The Quest for the Perfect Vagina: What You Should Know About Cosmetic Genital Procedures

Pam Harrison


August 27, 2018

Vaginal Rejuvenation and the Quest for the Ideal Vagina

"Vaginal rejuvenation" is really a thing. And companies who promote the use of energy-based devices (primarily lasers) for these unapproved cosmetic genital procedures have now been read the riot act by the US Food and Drug Administration.

Let's back up. The first reaction for many clinicians is most likely something like: "They're doing what? Where?"

The term "vaginal rejuvenation" is intentionally vague, but it implies that the vagina will be "perkier" afterward—tighter, with better muscle support and renewed vaginal tissue that will enhance both appearance and performance, explained Cheryl Iglesia, MD, director, section of female pelvic surgery, MedStar Washington Hospital Center, Washington, DC. (The medical term for vaginal rejuvenation is "vaginal reconstruction" or "vaginoplasty/perineoplasty," but the device-makers really loved the term "rejuvenation" and it stuck). Vaginoplasty has even been called "revirgination."

Other popular procedures include labiaplasty reduction surgery or labia minora plasty, in which surgeons reduce the size of the labia and/or remove loose and unsightly tissue for a more aesthetic look or for functional concerns, such as chafing or irritation of the labia during cycling and other activities.

The American College of Obstetricians and Gynecologists (ACOG) also singled out G-spot amplification, or what others refer to simply as the "O-Shot®." The O-Shot involves injecting the patient's own platelet-rich plasma into the general area of the G-spot, purportedly promoting orgasm. ACOG categorically frowns on all cosmetic vaginal procedures, including vaginal rejuvenation, stating that they are neither medically indicated nor proven to be safe and effective, as reflected in their 2007 committee opinion on vaginal rejuvenation and cosmetic vaginal procedures (reaffirmed in 2017).[1] They emphasize that these procedures are not without potential adverse sequelae, such as infection, adhesions, dyspareunia, scarring, and loss of sensation,[1] concerns echoed in the recent FDA safety warning about the safety risks associated with energy-based devices.

Who Performs Cosmetic Genital Procedures?

Make no mistake—women are asking for these procedures, and many practitioners, including ob/gyns, plastic and cosmetic surgeons, and even dermatologists are only too happy to oblige. ACOG does not collect statistics on how many of its members are offering these types of vaginal procedures—so there is no way of knowing how many ob/gyns perform them, Iglesia observes.

Statistics provided by the American Society of Aesthetic Plastic Surgeons[2] suggest that slightly more than one fourth of plastic surgeons offered vaginal and cosmetic genital procedures in 2017, although the number of labiaplasties being performed by plastic surgeons is apparently dropping. Paul Pin, MD, chief of the Division of Plastic Surgery at Baylor University Medical Center in Dallas, Texas, who also teaches plastic surgery at the University of Texas Southwestern Medical School, said that at least in Dallas, more ob/gyns than plastic surgeons are dedicating their entire practices to these procedures—"although looking at the operating room schedules, it seems that a lot of ob/gyns only dabble in this arena," he added.

The precise number of cosmetic vaginal surgeries performed in the United States is likewise impossible to pin down because they often take place in ambulatory settings, appearing only as a footnote in a patient's electronic medical record. And health insurance doesn't cover them. "Most labiaplasties are self-paid, costing between $3000 and $10,000. They are usually done as outpatient procedures, under local anesthesia, and take less than an hour," Pin explained.

"There is a huge incentive for surgeons to encourage these procedures, especially ob/gyns, who would be lucky to make $3000 for delivering a baby—and that includes all pre- and postnatal care," he added.

Why Do Women Want These Procedures?

Even with financial inducements to offer these procedures, the question remains: Why do so many women want them? As is true perhaps for all cosmetic surgeries, it comes down to body image and a desire to look different from how they look now. And that desire might follow from having taken a closer look at one's external genitalia.

In a study published in 2016, Rowen and colleagues[3] found that more than 80% of women surveyed admitted to pubic hair grooming, although it was most common among younger women. "When you groom your pubic hair, you get a better view of what's underneath," Iglesia noted—"and a lot of women don't like what they see." This was made quite clear by a more recent study that found a high degree of genital dissatisfaction among middle-aged women in the United States.[4] Of note, the frequency of sexual activity was negatively correlated with genital dissatisfaction, an observation that is not surprising to practitioners who have direct experience in women's sexual health.

"Celebrities and others in the public eye are talking about this," Iglesia noted, explaining that women have been heard to say, "I'm in a new relationship, so I got my vagina rejuvenated." Women are also increasingly exposed to images of female genitalia on the Internet and through other sources of pornography. "Everybody wants to have the perfect vagina," said Sheryl Kingsberg, PhD, chief of behavioral medicine, University Hospitals Cleveland Medical Center in Cleveland, Ohio.

"Laser manufacturers are preying on the desire for a perfect vagina, and their marketing targets every age group with the idea that women can restore tissue to some youthful state and achieve that perfect 'Barbie doll' look," she observed. (By the way, it's not only girls and women who are falling prey to societal pressure to have perfect genitalia. According to Kingsberg, young boys are exploring a practice called "jelqing," in which they carry out a series of twists and jerks and all kinds of weird manipulations of their penis in a misguided attempt to turn themselves into porn stars. Needless to say, this can permanently damage the penis.)

Kingsberg, who is also president of the North American Menopause Society (NAMS), does not flat-out condemn the therapeutic potential of laser devices. She points out, for example, that there is some evidence that laser treatment to "resurface" the vagina can significantly improve vaginal atrophy in women who suffer from extreme vaginal dryness. Furthermore, laser treatment offers women a nonhormonal alternative to intravaginal estrogen and gives clinicians another tool to provide relief for postmenopausal women and breast cancer survivors with vaginal atrophy who can't take estrogen.

"These nonhormonal devices hold tremendous promise—let me make that clear," Kingsberg said. "I just want to make sure the right research is done and, as the FDA pointed out, that these devices are used only for conditions for which they have shown safety and efficacy. At NAMS, we're speeding ahead trying to make sure that clinicians are up to date on ethics, standards, and evidence-based treatments," she emphasized.

Other gynecologists have come to the defense of one technology—–the fractional CO2 laser—maintaining that it isn't simply cosmetic and shouldn't be lumped together with the full range of technology and treatments being marketed to women who are dissatisfied with genital appearance.[5] Many gynecologists have found the fractional CO2 laser to be useful in alleviating the vulvovaginal atrophy, dryness, and other symptoms of the genitourinary syndrome of menopause that lead to painful intercourse and an unsatisfying sex life.[5] Although pilot studies are promising,[6] to date, no sham-controlled randomized controlled trial has been conducted to establish the safety and effectiveness of this device.

'You're Normal, Just Live With It'

With probably more procedures under his belt than just about anybody else in the United States (800 labiaplasties alone and counting), gynecologist and genital plastic/cosmetic surgeon Michael Goodman, MD, clinical assistant professor of obstetrics and gynecology at California Northstate University School of Medicine, Elk Grove, California, and the author of You Want to Do What? Where? Everything You Ever Wanted to Know About Women's Genital Plastic & Cosmetic Surgery knows a thing or two about the use—and misuse—of cosmetic vaginal procedures and has strong opinions on who should be offering them and why.

"One of my responsibilities is doing the right things for the right reasons on the right patients," Goodman said. "And if a woman comes in and says, 'I've got to have a vaginal tightening operation for my boyfriend,' that is a person I need to counsel and not necessarily just operate on," he added. On the other hand, Goodman and like-thinking cosmetic genital surgeons feel that if a woman wants a cosmetic vaginal procedure to enhance her self-esteem and possibly her sexual enjoyment, who are they to tell her that she is "normal" and she should just live with a part of her body she doesn't like, as ACOG recommends its members do? "If a woman goes to see her ob/gyn and says, 'I've always been small and I don't have a good self-image and would like a breast augmentation,' or if she says, 'I've always been large and I'd like a breast reduction,' the ob/gyn will refer her to a plastic surgeon. The same holds true for abdominoplasty and rhinoplasty," Goodman maintained.

But if a woman says, 'My labia have always been large and I'm self-conscious about it,' her ob/gyn might say, 'You are normal and you should just accept it," Goodman added. "It's a combination of paternalism (I don't think you should do this') and dismissiveness," he believes. Goodman also maintains that too few surgeons are trained specifically in these procedures. He often trains other clinicians at his high-volume practice focusing on cosmetic genital procedures and menopausal medicine in Davis, California, and is very involved in the academic worlds of both sexual medicine and plastic surgery. As a leader in this field, Goodman is highly critical of ACOG's stance to not provide training in the area of cosmetic genital procedures, even though he has offered to hold courses at their annual meetings to teach ob/gyns the right techniques to minimize the risk for unintentional—but avoidable—mistakes. (The same is not true for plastic surgeons, who do offer courses in cosmetic vaginal techniques at many of their meetings, and at least some residents in plastic surgery are now being exposed to these procedures during their training.)

However, as Goodman also observed, "The basics are not just techniques; the basics are understanding what women are saying and understanding their sexuality, and then deciding what procedure would be best for them, in light of their goals," he emphasized. At the same time, he continued, "Many of my patients say that they know they are normal, but they are still embarrassed and don't want to make love with the lights on."

He added, "Female genital plastic surgery is improving their self-image and self-esteem; it can offer functional improvement in terms of being more comfortable in exercise clothes and during certain activities, and can greatly improve sexual enjoyment. All I can say is, what's wrong with that?"


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