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What Is Cosmetic Gynecology Surgery?

Author Melissa Malena covers What Is Cosmetic Gynecology Surgery? on BackTable OBGYN

Melissa Malena • Jul 24, 2023 • 58 hits

Cosmetic gynecology is carefully defined as a procedure undergone with informed consent to alter the aesthetics of the genitalia, as to guarantee its separation from female genital mutilation practices. The marketing and popularization of costmetic gynecology often predates the scientific studies required to give credibility. Labiaplasty, laser techniques and clitoral innervation are examples of this phenomenon. Expert cosmetic gynecologist Dr. Cheryl Iglesia, urges other physicians to implement evidence-based techniques and foster a practice focused on patient safety and empowerment. This article features excerpts from the BackTable OBGYN podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

• In determining whether a procedure falls under cosmetic gynecology sugery, three key questions are considered: whether the procedure is medically indicated, if it is intended to cause injury or psychological harm, and if the patient is making a well-informed decision in the absence of external pressure or coercion.

• The marketing of certain cosmetic gynecology surgeries or devices often surpasses the scientific evidence supporting their efficacy and safety, such as various laser and energy-based devices promoted for conditions like vaginal dryness or urinary incontinence.

• Dr. Iglesia emphasizes that the advancement of cosmetic gynecology is crucial in fostering an evidence-based practice that prioritizes patient safety and focuses on the broader issues of female sexual health, body positivity, and promoting normal anatomical variance.

Cosmetic Gynecology Surgery: Considerations for OBGYNs and Cosmetic Surgeons

Table of Contents

(1) What is Cosmetic Gynecology?

(2) The Science & Ethics of Cosmetic Gynecology

(3) Cosmetic Gynecology Surgery Innovations

What is Cosmetic Gynecology?

Dr. Cheryl Iglesia clarifies that procedures under the domain of cosmetic gynecology are elective and aimed at altering the aesthetic appearance of the genitalia or functional aspects without any existing pathology. Procedures range from improving sexual function to enhancing quality of life. The perspectives of OBGYNs contrasts that of cosmetic surgeons, as OBGYNs' long-term patient relationships influence their perspective on elective interventions. Dr. Iglesia recommends usage of a flowchart to determine if a procedure is cosmetic, beginning with whether it is medically indicated, and then assessing intent and patient autonomy. A key consideration for practitioners is the potential harm of culturally motivated genital mutilation. The field relies on practitioners helping patients make well-informed, autonomous decisions free of external pressure or coercion.

[Dr. Cheryl Iglesia]

Yes, and honestly, that term "vaginal rejuvenation", "designer laser vaginoplasties", that's not in these official terms. Because that is a marketing term, and you and I also know that the FDA recently, as of 2018, came down pretty hard on some companies, who were marketing for specific indications ahead of really having any robust data. However, I want to be clear that the definition of cosmetic gynecology has two different aspects of it.


It's the elective intervention to alter the aesthetic appearance of the external genitalia, or modify the genital organs, and for elective functional procedures in the absence of any pathology. I'm talking like you're not having incontinence. You're not having an episiotomy that didn't heal well, overt stage three prolapse. Anyway, it's elective with the goal of improving a person's quality of life, and that could be sexual function or whatnot, but it's a pretty broad definition that isn't specific to certain diagnosis.


People have the option of not liking the way their eyelids look, their nose looks, and I think people have the option of not liking the way their labia minora look. I think that in general, OBGYNs look at the full spectrum of normality. I think we may be less likely to do elective interventions than cosmetic surgeons, plastic surgeons who are trained, who don't really look at pathology.


At the same time, they're not following women longitudinally like we do, cradle-to-grave, and know what happens over time, as women age after you have children, after menopause hits, and so on. There's two different hats, in terms of aesthetics, functionality, and then the whole reconstructive realm. There's a flow chart in this document, which maybe we can add.


[Dr. Mark Hoffman]

We can put it in the show notes for sure.


[Dr. Cheryl Iglesia]

That'll be great, so that people can click onto it. I do like this flow chart. The first question is, is this, whatever procedure you're planning on doing, medically indicated, or does it address a pathology? If you have stress incontinence, that's not considered cosmetic surgery. If you have overt cystocele uterine prolapse surgery that's not considered. If you have abnormal labia, and it's getting in the way or discomfort with exercise.


[Dr. Mark Hoffman]

Which is a common one a lot of us hear, getting stuck in clothes, and things like that, or even pain during intercourse, or discomfort and things like that.


[Dr. Cheryl Iglesia]

That's right. Huge asymmetry. That's not necessarily considered cosmetic gynecology. If they answer, "No", to that, being medically indicated, or addressing a pathology, the next question on this flow diagram is: “ is the intent to cause injury or psychological harm?”
What we're getting at there, and I know the World Health Organization really comes out strongly on this, is the aspect of female genital mutilation or FGM for clitorectomies, infibulation, the gishiri cuts that are done in certain cultures. Again, that would not be considered cosmetic gynecology. There are cultural mores, and there are laws about doing some of these procedures in our own country, particularly, for adolescents under the age of 18.


Then, if the answer to that, in terms of causing psychological harm or causing injury is, "No", then the question is, is the patient making a well-informed autonomous decision in the absence of any external pressure or coercion? I think this is where this has exploded, because of what people are seeing, images that people are seeing on the internet, pornography.

Listen to the Full Podcast

Cosmetic Gynecology with Dr. Cheryl Iglesia on the BackTable OBGYN Podcast)
Ep 14 Cosmetic Gynecology with Dr. Cheryl Iglesia
00:00 / 01:04

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The Science & Ethics of Cosmetic Gynecology

Dr. Iglesia, as the President of the Society for Gynecologic Surgeons and a special government employee for the US FDA, is an expert on the ethical and scientific concerns around cosmetic gynecology surgery. Marketing often precedes robust scientific data in this area, causing potential issues with patient expectations and health outcomes. Rigorous investigation needs to precede wide usage of such devices in cosmetic gynecology. Dr. Iglesia emphasizes the need for fully informed patient decisions, the importance of medical providers staying updated with new developments, and the issues arising from medical spas performing procedures without sufficient medical expertise.

[Dr. Cheryl Iglesia]

That's where having the skill set, educating yourself, and surrounding yourself with other people who are looking at the technology but then also studying it. I will disclose, and I probably should have at the beginning of when I was describing where I'm from. Currently, I am the 49th president, only the fifth woman, and the first Filipino-American President of the Society for Gynecologic Surgeons.


[Dr. Mark Hoffman]

I should have put that in your intro, because it's one of your many titles. That's an amazing one.


[Dr. Cheryl Iglesia]

I'm excited about that. I'll tell you why, because it relates to cosmetic gynecology. The other thing is I am currently a special government employee for the US FDA. I've served on five panels, including some of the stuff that is controversial, like vaginal mesh, the morcellator, the Essure, and some other things. I like to look at technology.


I like to do the level one evidence, and I think that we need to do a better job in introducing new technologie. I'll be giving this TED talk at the AGL on this, how to do that ideally. Usually, you start with a small group to look at technology, work on the kinks, figure out the iterations, before things spread, and that's a little bit of what the concern is that, with cosmetic gynecology, some of that marketing got ahead of the science.


At the Society for Gynecologic Surgeons right now, I know that they've got some trials looking at laser, and laser with or without steroids for lichen sclerosus. I think there's a protocol right now on PRP, and whether or not that works. That's the kind of stuff that we see, which is platelet-rich plasma for sexual enhancements, that's the kind of stuff, so that needs to be done.


I know when I go to a lot of these cosmetic talks and they're like, "Patients don't really care. They just care about how it looks." At the same time, I get that because there's no objective criteria about that, but you can when it comes to functionality, and the patients do need to know what we have because we have an extremely good level one evidence for incontinence and prolapse procedures. And that's where it gets all muddied, and it's important to be able to ethically have that conversation, and match what you can deliver with those goals for the patient.


[Dr. Mark Hoffman]

No, and then you brought up the FDA, and you worked there, and I got to work with ACOG's Committee on Health Economics and Coding for a few years and chair that committee, and learned a lot about how the stuff comes through, but also the morcellator. And we talked a lot about that in my department, and what we're going to do with that, but how do these devices get put through the system?


Not just how they get value, but how the FDA, we talk about approval, but really it's not approval. If there's a predicate device that's similar enough, 510(k) process that just says it's close enough, we can let it through, so these devices can get through much more easily than a full FDA review and approval, and so the devices typically proceed the research, oftentimes, come before the research.


I think by being able to do what you're doing, and taking these devices and looking at them, because the alternatives, they come out, no one looks at them. Then we found out after the fact, like some of the mesh things that we shouldn't have been doing that. I think if, that's one of the big challenges that I feel with the ivory towers or the traditional academic sites to get these new devices reviewed, you almost have to prove that it works first, which defeats the purpose, because if we're trying as academicians and as researchers to study whether or something is safe or effective or beneficial, if I can't get it into my institution to look at, or I can't study it until it's been out there for a while, then what happens it's almost like the academic institutions are the last ones.


They may do the RCTs once it's been out for a decade, but they're not the ones at the front of the line doing the work early on. I applaud that very much, and I think-- I'm excited to hear you talk, because that's something that I agree with. It's something we're missing.


[Dr. Cheryl Iglesia]

Yes. Specific to cosmetic gynecology, so what the FDA back in 2018, and then there were probably over 40 different laser radiofrequency energy-based devices available to the United States, and they were people saying, "Use this laser, it's going to fix your dry vagina." "Use this it's going to cure your stress urinary incontinence." "Use this one, it's going to make it tighter for you and for your partner."


They called this out, even the term "vaginal rejuvenation" because they didn't have the data. One of the most recent trials that just came out, and it was in October of 2021 on JAMA was from Australia, a study that did look at a Sham versus, the Li article, versus a CO2 laser for GSM, and it was at a year follow-up showed no difference. Something people can criticize is that study looking at the power, and the settings of the lasers, and the way that some of these patients, 50% of them I think, had breast cancer.


Maybe these people need to be primed, because these lasers focus on targeting the chroma for water in the tissue, and so particularly, breast cancer patients, but the bottom line is, it's not good to have patients have an expectation. I'm going to spend $2,000, and I'm so afraid of estrogen, because they have breast cancer, when we have some evidence that some of the estrogens are safe with the formulations that are FDA-approved in the doses that are recommended, and in conjunction with speaking with the patient's oncologist.


They go to this, just because they see the marketing, and that's where you can get some harm. Maybe not so much harm in terms of burns and stuff like that, but it's significant harm because that's a whole chunk of change out of one's pocket, and I see it. I had a urologist that did laser and charged $2,000 to this woman, who was middle class.


She worked at a bank, and had stage street prolapse, and there was just no way that laser was ever going to help that prolapse, and that's not ethical. We did her robotic colpopexy and her sling, and then she sent her daughter and then she sent all of her friends from the bank, and it was all covered by insurance.


Again, it goes down to the goals and I think that we do have to have real conversations, and I think a lot of doctors, particularly, board-certified MIGs and OBGYN specialists, and urogynecologists do that very ethically. Sometimes I wonder what happens in some of these medical spas though, where you have estheticians just doing it, and putting a wand in there, or a probe, not even doing a speculum exam to check for any type of pathology, or wipe out the lubrication that's in there, that's going to fog up the mirrors, so that laser is never going to do anything.


Anyway, there's just a bunch of stuff and it's really refreshing when I see the multidisciplinary work that's being done at, I'll say IUGA, and studies being done at SGS, and the collaboration with the ASLMS specialists, who are thought leaders, and people like Macrene Alexiades, who's a real guru on radio frequency, dermatologist from Yale.


It's nice to be able to have these conversations and then to put a pause on it for people who, if you're going to do it, let's make sure we do the right thing, and collaborate with the right people.


[Dr. Mark Hoffman]

I agree with you, because as someone who needs to know more, which is why I was personally interested in having you on, I think a lot of us who are OBGYNs or GYN surgeons don't know what's out there, because it's like, "Well, it's cosmetic. That's not what I do, so I'm not going to know about it," but the fact is, our patients are looking for it.


They're searching for it, they're looking online, and what they find is a spa, or someone who's not trained, or doesn't know the data and the research, and then they come to see me and I go, "Well, that's not really what I do." That's on me, that's not an excuse for me not to know, and so I need to be able to tell folks what's available, what the options are.


[Dr. Cheryl Iglesia]

What the limited outcome data is.


[Dr. Mark Hoffman]

Yes, exactly. Thank you.


[Dr. Cheryl Iglesia]

Buyer beware.

Cosmetic Gynecology Surgery Innovations

There are a range of procedures in cosmetic gynecology, from labiaplasty to laser treatments, radiofrequency ablation, and potential interventions on the clitoris for enhancing sexual function. Lasers can stimulate tissue growth factors, leading to new collagen and blood vessels' formation. While different lasers have varied depths of penetration, it is also important to note the lack of high-quality, evidence-based studies and randomized trials to fully endorse these treatments. There also are potential risks associated with procedures like clitoral manipulation, emphasizing the importance of understanding these risks before patients choose to undergo such procedures. Dr. Iglesia stresses the need for more rigorous studies and caution potential patients to carefully research and consider all factors before deciding on any cosmetic gynecological procedure.

[Dr. Mark Hoffman]

Yes, so we've talked a little bit about labiaplasty, and I think many of us are familiar with that.


[Dr. Cheryl Iglesia]

Yes. You can do a labia minoraplasty, or you can do things with labia majora with fat grafting and augmentation.


[Dr. Mark Hoffman]

I was reading about that, like liposuction of the labia majora.


[Dr. Cheryl Iglesia]

Yes.


[Dr. Mark Hoffman]

You mentioned lasers and RF ablation, what's being done, what's out there? What does the data show about those technologies, and how should we be counseling our patients?


[Dr. Cheryl Iglesia]

Yes, so for the laser, which most of these are fractioned, we're all OBGYNs who are really familiar with lasers. We use it for CO2, for HPV, and we use it for like zapping endometriosis intraperitoneally, which is cool, particularly, if you're near a vessel, or the ureters, but these are fractionated lasers, and when you do that, the lasers are divided into much smaller laser beams with normal tissue between, and the temperatures, the power and fluency is a lot lower, so that you're not burning tissue, you're supposedly, stimulating the tissue growth factors, and to make new collagen and new blood vessels, and that's how it works.


There have been a lot of histological studies that are published for the vagina, and for the vulva. So lasers are being used for resurfacing, it's known very well in Fraxel for the face that different kinds of lasers have different depths of penetration. Most of the ones that are used in cosmetic gynecology are in that far infrared spectrum with a very low depth of penetration, not the Argon beam or Pico lasers which go a lot deeper.


Argon beam, we use for cancers, and around the liver, and Pico is used for tattoo ink. But this stuff is like, doesn't even get down past the dermis to the lamina propria, so it's very superficial. The good news is, the types of burns are pretty low. The bad news is that, I think that, again, it needs that water, and so if it's super, super dry, particularly, in people who are with their aromatase inhibitors, just don't think we're going to have that tissue effect.


[Dr. Mark Hoffman]

What tissue effect are you looking for? What are the indications for these procedures, what are the outcomes we would have?


[Dr. Cheryl Iglesia]:

Again, none of these have been cleared because the FDA has defined processes, has only cleared it for incision, ablation, coagulation of tissue, including gynecological, vulvar skin, and vaginal skin. It's not been cleared for indication, but what it's been used for is GSM, which is Genitourinary Syndrome of Menopause and lichen sclerosus. That's for the CO2, and the Erbium lasers.


There's been a little bit on incontinence, a stress urinary incontinence, none of which has panned out, but the radiofrequency, laser is light energy, and radiofrequency is more current. For radiofrequency, that's been used more so with, I even liken it to shrinky-dink. They used it on the outside to get rid of wrinkles until the labia shrink down. It's more labor-intensive, you're there wondering for a much longer time.


They used it at the introitus, at the level of the perineal body to help with vaginal laxity. There's a couple of studies that are out there looking at level one evidence, Sham versus active radiofrequency for that. It's also been used for stress incontinence, and there's even intraurethral, but many of us know that there were some former products that were used using radiofrequency devices that never really panned out, in terms of that.


The bottom line is, the data is low-level evidence. We don't have big randomized trials. In fact, I think that's what the FDA is trying to get at. We need for our GSM, both vaginal atrophy, dyspareunia, I think that's one of the big ones. We need level one evidence for looking at laser versus sham. We did a small pilot study looking at laser. It's called the velvet trial with us, Haven Clinic. There were seven sites looking at laser versus estrogen for GSM and dyspareunia, and they were pretty much equivalent. The study was very under power.


[Dr. Mark Hoffman]

That's a big deal, though.


[Dr. Cheryl Iglesia]

It was equivalent.


[Dr. Mark Hoffman]

That's not nothing.


[Dr. Cheryl Iglesia]

It's not nothing. We had the Vaginal Maturation Index, which was better with the estrogen, but pretty much all the other objective factors, Vaginal Health Index, and the female sexual function was pretty much equivalent. We need larger trials, we need multi-site trials. I think the FDA probably wants to look at more of these Sham-controlled studies, specifically, before you start marketing and having been paid thousands of dollars, because each of these treatments range from $500,000 a pop.


You need three or four of them to get the desired effect several weeks apart. That's a biophysics of that. That literally is more on the energy-based side. I guess laxity, GSM, lichen sclerosus, stress urinary incontinence. I think people are even looking at urgency, incontinence, dyspareunia. Those are some of the major diagnoses that people are looking at.


In terms of the other anatomical aesthetic stuff, it gives me pause a little bit, because there's been a lot of cosmetic surgery that's based on what they're doing to the clitoris. There's the clitoral, you can get a frenulum reduction, called a frenulectomy. You can do surgery to affect the prepuce.


[Dr. Mark Hoffman]

Is that with the intent of increasing sexual arousal?


[Dr. Cheryl Iglesia]

Some people feel there's exposing the glans for an enhancement of sexual function, orgasmic dysfunction, but there's a clitoral hood lift with the prepuce, they call it, hoodectomy. Some people will resect that, lichen sclerosus, if there's adhesions around it.


[Dr. Mark Hoffman]

Any data on any of that?


[Dr. Cheryl Iglesia]

Rachel Rubin just recently did a little study on clitoral adhesiolysis. She's got some stuff out there, not a lot. Then, there's a clitoral amplification with the platelet-rich, the PRP, platelet-rich factor, a plasma, and the injections, like the O-Shot and stuff. Again, not a lot. A lot of this is proprietary. I'm just letting you know what's out there.


[Dr. Mark Hoffman]

Well, no, because our patients are going to be interested in it. They're going to be searching for it, and we talked about the internet. They're going to find it, and the question is if they come to us, and we give them nothing, they're going to go somewhere else and find it. If we can all educate ourselves, and It's very concerning, because you do damage, and it's irreversible.


[Dr. Cheryl Iglesia]

That's right. I worry about the clitoris, right? Particularly, in a young woman, it's highly innervated. Thousands of nerve endings. The clitoris itself with arousal can engorge 50% to 300%. I don't like to mess with it. Anyway, that gives me pause a little bit, but obviously, people are doing it.


[Dr. Mark Hoffman]

If they're doing it, we should know about it a little more.


[Dr. Cheryl Iglesia]

We should know about it, and buyer beware, yes, really. Particularly for young people, I think, lichen sclerosus is a bit different. Then, there are other options that, in addition to the tightening, which is more on the radiofrequency energy-based side, that's that whole vaginal rejuvenation.


[Dr. Mark Hoffman]

Is that just basically, in a sense, heating up? When we talk about RF ablation in gynecology, we think more about endometrial ablation.


[Dr. Cheryl Iglesia]

The shrinky-dink effect.


[Dr. Mark Hoffman]

Shrinky-dink effect of the vagina. Tightening. Any data on that?


[Dr. Cheryl Iglesia]

Vaginoplasty. No, there's not. It's proprietary. Which we can just do. I can do an anterior and posterior repair. Now, is there a randomized trial? That would be very interesting to see. The question is, Mark, and this is where, again, the gray goes. Again, remember the first question is, is this addressing a significant pathology? What people who do this stuff as marketing, and again, it's very, very gray.


They're going to be marketing for the not significant pathology, just a little bit of, they call laxity. I just want it to be a little bit tighter without having to have an incision over what we do for overt prolapse. Again, I think we just need some more data on it because it is a problem. The International Incontinence Society or whatever, the IUGA does have a terminology called vaginal laxity. How do we define it? It's a sensation of looseness.

Podcast Contributors

Dr. Cheryl Iglesia discusses Cosmetic Gynecology on the BackTable 14 Podcast

Dr. Cheryl Iglesia

Dr. Cheryl Iglesia is the Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center in Washington, D.C.

Dr. Mark Hoffman discusses Cosmetic Gynecology on the BackTable 14 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, February 16). Ep. 14 – Cosmetic Gynecology [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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