Guideline No. 423: Female Genital Cosmetic Surgery and Procedures.

OBJECTIVE: To provide Canadian surgeons and other providers who offer female genital cosmetic surgery (FGCS) and procedures, and their referring practitioners, with evidence-based direction in response to increasing requests for, and availability of, vaginal and vulvar surgeries and procedures that fall outside the traditional realm of medically indicated reconstructions. TARGET POPULATION: Women of all ages seeking FGCS or procedures. BENEFITS, HARMS, AND COSTS: Health care providers play an important role in educating women about their anatomy and helping them appreciate individual variations. Most women requesting FGCS and procedures have normal genitalia, and up to 87% are reassured by counselling. At this time, due to lack of rigorous clinical or scientific evidence of short- and long-term efficacy and safety, FGCS and procedures for non-medical indications cannot be supported. FGCS and procedures are typically provided in the private sector, where costs are borne by the patient. EVIDENCE: Literature was retrieved through searches of MEDLINE, Scopus, and The Cochrane Library using appropriate controlled vocabulary and keywords. The selected search terms represented keywords for FGCS (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening, vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal cosmetic procedures) combined with female genital counselling, consent, satisfaction, follow-up, adolescent, and body dysmorphic or body dysmorphia. The search was restricted to publications after 2012 in order to update the literature since the previous guideline on this topic. Results were restricted to systematic reviews, randomized controlled trials, and observational studies. Studies were restricted to those involving humans, and no language restrictions were applied. The search was completed on May 20, 2020, and updated on November 10, 2020. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Gynaecologists, primary care providers, surgeons performing FGCS and/or procedures.

Directive clinique no 423 : Interventions chirurgicales et thérapeutiques esthétiques génitales féminines.

OBJECTIF: Fournir aux chirurgiens et autres fournisseurs de soins canadiens qui réalisent des interventions chirurgicales ou thérapeutiques esthétiques génitales féminines, et tout praticien demandeur, des directives fondées sur des données probantes en réponse à l'augmentation des demandes et de la disponibilité des interventions chirurgicales et thérapeutiques vaginales et vulvaires sortant du cadre traditionnel de la reconstruction avec indication médicale. POPULATION CIBLE: Les femmes de tous âges qui consultent pour subir une intervention chirurgicale ou thérapeutique esthétique génitale. BéNéFICES, RISQUES ET COûTS: Les professionnels de la santé qui prodiguent des soins aux femmes jouent un rôle important en renseignant les femmes sur leur anatomie et en les aidant à prendre conscience des variations individuelles. La plupart des femmes qui demandent une intervention chirurgicale ou thérapeutique esthétique génitale féminine ont des organes génitaux normaux, et jusqu'à 87 % d'entre elles sont rassurées par des conseils. À l'heure actuelle, étant donné le manque de données probantes cliniques et scientifiques rigoureuses sur l'efficacité et l'innocuité à court et à long terme, il n'y a aucune base pour se prononcer en faveur des interventions chirurgicales ou thérapeutiques esthétiques génitales féminines sans indication médicale. Les interventions chirurgicales ou thérapeutiques esthétiques génitales féminines sont généralement réalisées dans le secteur privé, où les coûts sont assumés par la patiente. DONNéES PROBANTES: La littérature publiée a été rassemblée par des recherches dans les bases de données Medline, Scopus et Cochrane Library au moyen de termes et mots clés pertinents et validés. Les termes de recherche sélectionnés se composaient de mots clés sur les interventions chirurgicales ou thérapeutiques esthétiques génitales féminines (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening, vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal cosmetic procedures) combinés à female genital counselling, consent, satisfaction, follow-up, adolescent et body dysmorphic or body dysmorphia. La recherche a été limitée aux articles publiés après 2012 afin de mettre à jour la documentation depuis la dernière directive à ce sujet. Les résultats ont été restreints aux revues systématiques, aux essais cliniques randomisés et aux études observationnelles. Les études ont été limitées à celles menées chez l'humain seulement, et aucune restriction linguistique n'a été appliquée. La recherche a été effectuée le 20 mai 2020 et mise à jour le 10 novembre 2020. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Gynécologues, fournisseurs de soins primaires, chirurgiens réalisant des interventions chirurgicales et/ou thérapeutiques esthétiques génitales féminines. RECOMMANDATIONS.

The worldwide epidemic of female obesity.

The rapidly rising number of individuals who are overweight and obese has been called a worldwide epidemic of obesity with >35% of adults today considered to be overweight or obese. Women are more likely to be overweight and obese than their male counterparts, which has far-reaching effects on reproductive health and specifically pregnancy, with obese women facing an increased risk of gestational diabetes, preeclampsia, operative delivery, fetal macrosomia, and neonatal morbidity. The etiology of obesity is highly complex encompassing genetic, environmental, physiologic, cultural, political, and socioeconomic factors, making it challenging to develop effective interventions on both a local and global scale. This article describes the extent and the cost of the obesity epidemic, which, although historically seen as a disease of high-income countries, is now clearly a global epidemic that impacts low- and middle-income countries and indigenous groups who bear an ever-increasing burden of this disease.

Today's evidence, tomorrow's agenda: implementation of strategies to improve global reproductive health.

The Alliance for Women's Health deliberated on critical gaps and emerging issues related to women's health, focusing on contraception, safe abortion care, HIV, and cervical cancer prevention. Despite the health, socioeconomic, and development benefits of family planning, up to 222 million women have an unmet need for modern contraception. The number of unsafe abortions increased globally, 98% of which occurred in low-resource countries. Fragmentation of services for HIV and cervical cancer prevention and treatment fail to maximize opportunities to reach women within reproductive, maternal, and child health services. The FIGO 2012 PreCongress Workshop elaborated the role of societies of obstetricians-gynecologists in implementation of actions to increase access to modern methods of contraception to help individuals meet family planning intentions. Human rights principles underpin the imperative to ensure equitable access to a wide range of modern methods of contraception. The role of task shifting/sharing in different models of service delivery was elaborated. Actions from the International Conference on Population and Development on safe abortion care and integration of effective contraception were reaffirmed. A call was made to increase access to integrated HIV and cervical cancer prevention, screening, and management. Cross-cutting strategic approaches to accelerate progress include evidence-based information to stakeholders and continued education in these areas at all levels of training. A call was made to advocate for a budget line item for sexual and reproductive health, including family planning and engaging the demand side of family planning, while involving men to enhance uptake and continuation.

Female genital cosmetic surgery.

OBJECTIVE: To provide Canadian gynaecologists with evidence-based direction for female genital cosmetic surgery in response to increasing requests for, and availability of, vaginal and vulvar surgeries that fall well outside the traditional realm of medically-indicated reconstructions. 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. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. The obstetrician and gynaecologist should play an important role in helping women to understand their anatomy and to respect individual variations. (III-A) 2. 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) 3. 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) 4. 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) 5. 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) 6. 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).

Objectif : Fournir aux gynécologues canadiens des directives factuelles en matière de chirurgie esthétique génitale chez la femme, en réponse au nombre grandissant de demandes (et d'interventions) de chirurgie vaginale et vulvaire se situant bien au-delà des reconstructions traditionnellement indiquées sur le plan médical. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed ou MEDLINE, CINAHL et The Cochrane Library en 2011 et en 2012 au moyen d'un vocabulaire contrôlé et de mots clés appropriés (« female genital cosmetic surgery ¼). Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune restriction n'a été appliquée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en mai 2012. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Recommandations 1. Un des rôles importants des obstétriciens-gynécologues devrait consister à aider les femmes à comprendre leur anatomie et à en respecter les variantes qui leur sont propres. (III-A) 2. Lorsqu'une femme demande la tenue d'interventions esthétiques vaginales, une anamnèse médicale, sexuelle et gynécologique exhaustive devrait être obtenue et l'absence de tout dysfonctionnement sexuel ou psychologique majeur devrait être établie. La présence possible de coercition ou d'exploitation devrait également être écartée. (III-B) 3. Le counseling devrait constituer une priorité dans le cas des femmes qui demandent la tenue d'une chirurgie esthétique génitale. Les sujets abordés dans le cadre du counseling devraient comprendre les variations normales et les modifications physiologiques qui se manifestent au cours de la vie, ainsi que la possibilité de connaître des conséquences imprévues à la suite de la tenue d'une chirurgie esthétique visant les organes génitaux. Le manque de données en ce qui concerne les issues de la chirurgie et les effets des modifications subséquentes attribuables à la grossesse ou à la ménopause devrait également faire l'objet de discussions et être considéré comme faisant partie du processus de consentement éclairé. (III-L) 4. Peu de données soutiennent l'amélioration de la satisfaction sexuelle ou de l'image de soi qui serait attribuable aux interventions de chirurgie esthétique génitale chez la femme. Les médecins qui choisissent de procéder à de telles interventions esthétiques ne devraient pas en faire la promotion à des fins d'amélioration de la fonction sexuelle; de surcroît, le recours à la publicité pour promouvoir les interventions de chirurgie esthétique génitale chez la femme devrait être évité. (III-L) 5. Les médecins qui reçoivent des demandes de chirurgie esthétique génitale de la part d'adolescentes doivent chercher à obtenir des compétences additionnelles en ce qui a trait à l'offre de services de counseling aux adolescentes. De telles interventions chirurgicales ne devraient pas être offertes avant l'atteinte de la pleine maturité physiologique (y compris la maturité génitale); le consentement parental n'est alors pas requis. (III-L) 6. Les termes non médicaux (y compris, entre autres, le rajeunissement vaginal, le resurfaçage clitoridien et l'augmentation du point G) devraient être reconnus comme n'étant que des termes de marketing, sans aucune origine médicale; ainsi, ils ne peuvent faire l'objet d'une évaluation scientifique. (III-L).

"Screening" for domestic violence.

Domestic violence has been recognized as a public health concern worldwide with serious social and health consequences, including adverse pregnancy outcome. Although health-care professionals are becoming better informed about domestic violence, and women accept being questioned in this regard, studies have shown that fewer than 10% of physicians ask women routinely about domestic violence, even during pregnancy. Further, based on traditional criteria for screening, reviews have not supported screening programs for domestic violence. This purist approach to screening is inconsistent with what we know about domestic violence and provides a rationale for health-care professionals who are personally uncomfortable with routinely asking women about domestic violence to avoid such an approach. Biomedical models are inadequate to measure the "success" of screening for complex psychosocial health issues. Recent studies suggest that merely asking about violence and providing validation and support reduces violent incidents. The term "screening" in this context may be a misnomer better replaced by "routine enquiry." Published systematic reviews and guidelines about domestic or relationship violence acknowledge the seriousness of the problem from a health perspective and the justification to include routine enquiry about domestic violence as part of health care, even when concluding that the evidence is lacking to justify screening programs as traditionally defined. Continued education and support for health professionals is essential in ensuring that women are not unknowingly left at greater risk due to a non-systematic approach.

RETIRED: Cystic fibrosis carrier testing in pregnancy in Canada.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.