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Guideline Summary
Guideline Title
Female genital cosmetic surgery.
Bibliographic Source(s)
Shaw D, Lefebvre G, Bouchard C, Shapiro J, Blake J, Allen L, Cassell K, Clinical Practice Gynaecology Committee, Leyland N, Wolfman W, Allaire C, Awadalla A, Best C, Dunn S, Heywood M, Lemyre M, Marcoux V, Menard C, Potestio F, Rittenberg D, Singh S, Ethics Committee, Shapiro J, Akhtar S, Camire B, Christilaw J, Corey J, Nelson E, Pierce M, Robertson D, Simmonds A. Female genital cosmetic surgery. J Obstet Gynaecol Can. 2013 Dec;35(12):1108-12. [19 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Perceived aesthetic or functional female genitalia abnormalities that fall well outside the traditional realm of medically-indicated reconstructions

Guideline Category
Counseling
Evaluation
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Plastic Surgery
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To provide Canadian gynaecologists with evidence-based direction for female genital cosmetic surgery (FGCS) in response to increasing requests for, and availability of, vaginal and vulvar surgeries that fall well outside the traditional realm of medically-indicated reconstructions

Note: Genital surgery for gender reassignment or for the repair of obvious anomalies are not considered cosmetic surgeries and are not addressed in this policy statement.

Target Population

Adult and adolescent females

Interventions and Practices Considered
  1. Complete medical, sexual, and gynaecologic history
  2. Counseling and the provision of information concerning:
    • The normal variation and physiological changes to female genitalia over the lifespan
    • The possibility of unintended consequences of female genital cosmetic surgery (FGCS) to the genital area
    • The lack of data on the impact of subsequent changes during pregnancy or menopause
    • The paucity of evidence to support FGCS in terms of improvement to sexual satisfaction or self-image
  3. The provision of additional expertise in counseling adolescents
  4. Avoidance of promoting FGCS for the enhancement of sexual function and the advertising of these procedures should be avoided
  5. Avoidance of non-medical terms such vaginal rejuvenation, clitoral resurfacing, and G-spot enhancement
Major Outcomes Considered
  • Improved sexual satisfaction or self-image
  • Genital maturity
  • Respect for individual anatomical variations

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in 2011 and 2012 using appropriate controlled vocabulary and key words (female genital cosmetic surgery). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The quality of evidence obtained in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (see the "Rating Scheme for the Strength of the Evidence" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Classification of Recommendations†

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D. There is fair evidence to recommend against the clinical preventive action

E. There is good evidence to recommend against the clinical preventive action

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This policy statement has been prepared by the Clinical Practice Gynaecology Committee and the Ethics Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Recommendations

Major Recommendations

The quality of evidence (I-III) and classification of recommendations (A-E, L) are defined at the end of the "Major Recommendations."

Anatomy and Function of the Vulva And Vagina

  1. The obstetrician and gynaecologist should play an important role in helping women to understand their anatomy and to respect individual variations. (III-A)

Requests for Vulvo-Vaginal Cosmetic Procedures

  1. For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecologic history should be obtained and the absence of any major sexual or psychological dysfunction should be ascertained. Any possibility of coercion or exploitation should be ruled out. (III-B)
  2. Counselling should be a priority for women requesting female genital cosmetic surgery. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of evidence regarding outcomes and the lack of data on the impact of subsequent changes during pregnancy or menopause should also be discussed and considered part of the informed consent process. (III-L)
  3. There is little evidence to support any of the female genital cosmetic surgeries in terms of improvement to sexual satisfaction or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function and advertising of female genital cosmetic surgical procedures should be avoided. (III-L)

Requests for Vulvo-Vaginal Cosmetic Procedures in Adolescents

  1. Physicians who see adolescents requesting female genital cosmetic surgery require additional expertise in counselling adolescents. Such procedures should not be offered until complete maturity including genital maturity, and parental consent is not required at that time. (III-L)

Advertising

  1. Non-medical terms, including but not restricted to vaginal rejuvenation, clitoral resurfacing, and G-spot enhancement, should be recognized as marketing terms only, with no medical origin; therefore they cannot be scientifically evaluated. (III-L)

Definitions:

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Classification of Recommendations†

A. There is good evidence to recommend the clinical preventive action.

B. There is fair evidence to recommend the clinical preventive action.

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D. There is fair evidence to recommend against the clinical preventive action.

E. There is good evidence to recommend against the clinical preventive action.

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate evaluation of female patients requesting genital cosmetic surgery

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Foreign Language Translations
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Shaw D, Lefebvre G, Bouchard C, Shapiro J, Blake J, Allen L, Cassell K, Clinical Practice Gynaecology Committee, Leyland N, Wolfman W, Allaire C, Awadalla A, Best C, Dunn S, Heywood M, Lemyre M, Marcoux V, Menard C, Potestio F, Rittenberg D, Singh S, Ethics Committee, Shapiro J, Akhtar S, Camire B, Christilaw J, Corey J, Nelson E, Pierce M, Robertson D, Simmonds A. Female genital cosmetic surgery. J Obstet Gynaecol Can. 2013 Dec;35(12):1108-12. [19 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2013 Dec
Guideline Developer(s)
Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society
Source(s) of Funding

Society of Obstetricians and Gynaecologists of Canada

Guideline Committee

Clinical Practice Gynaecology Committee and the Ethics Committee

Composition of Group That Authored the Guideline

Principal Authors: Dorothy Shaw, MBChB, Vancouver BC; Guylaine Lefebvre, MD, Toronto ON; Celine Bouchard, MD, Quebec QC; Jodi Shapiro, MD, MHSc, Toronto ON; Jennifer Blake, MD, Toronto ON; Lisa Allen, MD, Toronto ON; Krista Cassell, MD, Charlottetown PE

Clinical Practice Gynaecology Committee: Nicholas Leyland, MD (Co-chair), North York ON; Wendy Wolfman, MD (Co-chair), Toronto ON; Catherine Allaire, MD, Vancouver BC; Alaa Awadalla, MD, Winnipeg MB; Carolyn Best, MD, Toronto ON; Sheila Dunn, MD, Toronto ON; Mark Heywood, MD, Vancouver BC; Madeleine Lemyre, MD, Quebec QC; Violaine Marcoux, MD, Ville Mont-Royal QC; Chantal Menard, RN, Ottawa ON; Frank Potestio, MD, Thunder Bay ON; David Rittenberg, MD, Halifax NS; Sukhbir Singh, MD, FRCSC, Ottawa ON

Ethics Committee: Jodi Shapiro, MD (Chair), Toronto ON; Saima Akhtar, MD, London ON; Bruno Camire, MD, Quebec QC; Jan Christilaw, MD, Vancouver BC; Julie Corey, RM, St Jacobs ON; Erin Nelson, BScPT, LLB, LLM, JSD, Edmonton AB; Marianne Pierce, MD, Halifax NS; Deborah Robertson, MD, Toronto ON; Anne Simmonds, RN, Scotsburn NS

Financial Disclosures/Conflicts of Interest

Disclosure statements have been received from all authors.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Society of Obstetricians and Gynaecologists of Canada (SOGC) Web site External Web Site Policy. Also available in French from the SOGC Web site External Web Site Policy.

Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La société des obstétriciens et gynécologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 1, 2014. The information was verified by the guideline developer on April 28, 2014.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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