Labia minora hypertrophy: pathologizing diversity?

INTRODUCTION: Labia minora hypertrophy can be characterized by the labial tissue extending beyond the labia majora; however, the exact definition of hypertrophy is a matter of debate. While the prevalence of labia hypertrophy is very common among women, taboo/controversial attitudes and surgical interventions still dominate. The recognition and study of labia minora hypertrophy will increase our knowledge of this underrepresented anatomic diversity. OBJECTIVES: To provide a report of the current literature on labia hypertrophy and discuss the definition, etiology, attitudes, management, and medicalization surrounding labia minora hypertrophy and the implications. METHODS: Comprehensive review of literature pertaining to labia minora hypertrophy. RESULTS: Labia minora appearance and measurements vary extensively, and hypertrophy is extremely prevalent in the population and largely nonpathologic. There remains a lack of standardized criteria to define labia hypertrophy. Attitudes surrounding labia hypertrophy differ globally, but in Western nations the overwhelming sentiment toward labia hypertrophy has largely been medicalized. CONCLUSION: Negative attitudes and unnecessary medicalization of nonpathologic instances of labia hypertrophy is unjustifiable and comes with potential risks. There remains an impending need to demedicalize nonpathologic elongated labia, educate the public on diverse genital appearance, and improve understanding of the long-term outcomes and risks of genital cosmetic surgery.

Examining the Morphology of External Genitalia in Iranian Women: A Labiagram-based Study in Iran and its Influence on Patients' Self-Satisfaction.

BACKGROUND: This study aims to document a woman's external genitalia data in the form of a labiogram and investigate whether variations in the size of specific components of a woman's external genitalia can influence her overall satisfaction with the esthetic appearance of her genitalia. METHODS: A cross-sectional observational study was carried out on a sample of 500 Iranian women. Socio-demographic information was collected for all participants, and they completed the Female Genital Self-Image Scale (FGSIS) questionnaire. Measurements of different external genitalia components were obtained for all participants. RESULTS: The findings revealed that there was no significant association between the measurements of the external genitalia and age or BMI. However, a significant negative correlation was observed between the total score on the FGSIS and specific parameters related to the width of different sections of the labia minora. The correlations were as follows: left lower third (r = - 0.305), lower right third (r = - 0.302), left middle third (r = - 0.365), right middle third (r = - 0.435), left upper third (r = - 0.397), and right upper third (r = - 0.407) (P value< 0.001). Moreover, cutoff points of 1.95 cm on the left side and 1.90 cm on the right side were identified through analysis as thresholds for predicting dissatisfaction among women. CONCLUSION: This study suggests that the width of the labia minora might influence certain women's motivation to undergo labiaplasty, a surgical procedure designed to modify the labia minora. To help women make informed decisions, it is crucial for those considering the procedure to have a comprehensive understanding of different labia minora types, potential benefits, and associated risks. By being well-informed, individuals can make choices that align with their personal preferences and priorities. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Beyond the tip of the iceberg: A meta-analysis of the anatomy of the clitoris.

An understanding of ranges in clitoral anatomy is important for clinicians caring for patients including those who have had female genital mutilation, women seeking genital cosmetic surgery, or trans women seeking reconstructive surgery. The aim of this meta-analysis is to investigate the ranges in clitoral measurements within the literature. A meta-analysis was performed on Ovid Medline and Embase databases following the PRISMA protocol. Measurements of clitoral structures from magnetic imaging resonance, ultrasound, cadaveric, and living women were extracted and analyzed. Twenty-one studies met the inclusion criteria. The range in addition to the average length and width of the glans (6.40 mm; 5.14 mm), body (25.46 mm; 9.00 mm), crura (52.41 mm; 8.71 mm), bulb (52.00 mm; 10.33 mm), and prepuce (23.19 mm) was calculated. Furthermore, the range and average distance from the clitoris to the external urethral meatus (22.27 mm), vagina (43.14 mm), and anus (76.30 mm) was documented. All erectile and non-erectile structures of the clitoris present with substantial range. It is imperative to expand the literature on clitoral measurements and disseminate the new results to healthcare professionals and the public to reduce the sense of inadequacy and the chances of iatrogenic damage during surgery.

Women's aesthetic perceptions of the genitalia and their association with anatomical measurements.

BACKGROUND: The purpose of this study is to determine women's perceptions of the vulva with the criteria defined in the literature for the ideal vulva and determine their relationship with anatomical measurements to determine the extent to which women's perceptions of normal align with our aesthetic standards of normality. METHODS: First of all, a questionnaire was given to all participants. The items of the data collection form included personal information, obstetric and gynecological information, their perceptions of their external genitalia and any physical, sexual, psychological, and hygiene problems they experience. Then examination and measurements of the external genitalia were performed. RESULTS: The majority of participants considered their genitalia normal (n = 101, 89.4%), while 12 participants (10.6%) considered them abnormal. Statistical analyses showed that women's perception of their genitalia as normal in appearance and size was associated with labia minora asymmetry (p = 0.023 and p = 0.006, respectively) and hyperpigmentation (p = 0.010 and p = 0.047, respectively) but not with labia minora measurements or protrusion (p > 0.05). CONCLUSIONS: Although there is a tendency in the field of aesthetic surgery to define ideals and aesthetic standards for all parts of the body, our definitions of normality do not always coincide with those of the individual. The appearance of the genitalia is as personal as the face, and an individual's self-perception is more important than our ideal. LEVEL IV: Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Cosmetic labiaplasty on minors: a review of current trends and evidence.

Cosmetic labiaplasty is a form of Female Genital Cosmetic Surgery (FGCS) that is performed with the deliberate intent to alter the appearance and morphology of the external genitalia in the absence of medical concerns. Over the last decade, there is an increasing demand for FGCS and the industry behind it is constantly growing. Adolescents comprise an extremely vulnerable population, with labiaplasties in this particular age group having also increased. However, labiaplasty has been widely contested due to the irrevocable alteration of a psychosexually significant body part on minors too young to consent. Besides, the changes that occur during pubertal development in the genital area can significantly alter pediatric surgical results. Genital anatomy is more diverse than we previously thought and there is evidence to suggest that the labia minora with their rich innervation play an important role in sexual arousal and pleasure. Education regarding the wide range of normal genital appearance suffices in most cases to dissolve concerns regarding body self-image. Mental health issues should always be explored and, if identified, the girl should be referred to an experienced professional for their resolution. Postponing labiaplasty until adulthood is strongly recommended to help adolescents achieve a well-informed decision regarding an irreversible procedure with possible adverse esthetic and functional outcomes.

The anatomical measurements of vulva in Indian women: A cross-sectional prospective study.

OBJECTIVE: To measure the anatomical dimensions of the vulva in adult Indian women. To analyze their correlations with age, body mass index (BMI), parity, and mode of delivery. METHODS: This cross-sectional study was conducted in a tertiary care university hospital in India, among 400 women aged 18 years and above. Various vulval measurements were taken, and Pearson's correction was applied to variables like age, BMI, parity, and mode of delivery. RESULTS: Mean length of glans of clitoris was 5.2 ± 1.43 mm, the labia minora width was 2.6 ± 0.74 cm, length of introitus was 1.3 ± 0.59 cm, and perineal body length was 2.3 ± 0.60 cm. The range of some measurements was extensive, for example labia minora width ranged from 0.7 to 4.9 cm. Normal centile curves were constructed for vulval measurements according to age groups. Statistically significant positive correlations of age, BMI, and obstetrical history were seen with labia minora width (r = 0.165, P = 0.001; r = 0.284, P < 0.001; r = 0.246, P < 0.001, respectively). CONCLUSION: The centile curves can be used as a reference for the Indian population of different ages. These can be used when counseling women coming for female genital cosmetic surgery.

Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair.

BACKGROUND: Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. METHODS: This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. RESULTS: At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. CONCLUSION: We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.

Shaping birth: variation in the birth canal and the importance of inclusive obstetric care.

Regional variation in pelvic morphology and childbirth has long occurred alongside traditional labour support and an understanding of possible normal courses of childbirth for each population. The process of migration and globalization has broken down these links, while a European model of 'normal' labour has become widespread. The description of 'normal' childbirth provided within obstetrics and midwifery textbooks, in fact, is modelled on a specific pelvic morphology that is common in European women. There is mounting evidence, however, that this model is not representative of women's diversity, especially for women of non-white ethnicities. The human birth canal is very variable in shape, both within and among human populations, and differences in pelvic shapes have been associated with differences in the mechanism of labour. Normalizing a white-centred model of female anatomy and of childbirth can disadvantage women of non-European ancestry. Because they are less likely to fit within this model, pelvic shape and labour pattern in non-white women are more likely to be considered 'abnormal', potentially leading to increased rates of labour intervention. To ensure that maternal care is inclusive and as safe as possible for all women, obstetric and midwifery training need to incorporate women's diversity. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Knowledge of Vulvar Anatomy and Self-examination in a Sample of Italian Women.

OBJECTIVE: The aim of the study was to investigate the knowledge of vulvar anatomy and vulvar self-examination (VSE) in a sample of Italian women attending a gynecology clinic. METHODS: For this original research from May to July 2019, 512 women attending the Lower Genital Tract Clinic at the Department of Surgical Sciences of the University of Torino were invited to participate in a 29-question survey about vulvar anatomy, VSE, and sociodemographic details. Data were analyzed using descriptive statistics. RESULTS: Of 512 patients, 500 completed the questionnaire (98% response rate). The mean age of respondents was 41 years (range = 17-77 years). Education level was evenly distributed between elementary, high school, and university graduates. Only 15% of interviewed women were able correctly sketching vulvar anatomy. Seventy-six percent of the women had not heard about VSE, and 61% of the women approach their genitalia with feelings of shame and embarrassment. Only 23% of the women would seek medical advice after identification of possible abnormalities during VSE. A majority (69%) of the women would like to have more information about VSE and vulvar health through educational videos and social media. CONCLUSIONS: Education about VSE may lead to earlier diagnosis of vulvar cancers and other pathologies. Further efforts are needed to disperse information about normal external female genital anatomy and VSE to achieve self-confidence among women.

Historical and Ethical Perspectives on Vulvoplasty.

INTRODUCTION: Surgical and other procedures to alter the shape of the female external genitalia, especially the labia minora, are increasingly popular and controversial worldwide. OBJECTIVES: This article aims to delineate and complicate the medical and moral controversy around these vulvoplasty procedures, by describing how female genital aesthetics, their interpretation, and alteration vary over time, space, and culture. METHODS: The history of the Hottentot Venus is used as a pivot about which to consider current biomedical, anthropological, and ethical literatures regarding female genital appearance and its manipulation. Intersectionality describes how different systems influence each other to affect the agency of certain individuals or groups, and is therefore an ideal analytic method for biopsychosocial concerns of sex and informed consent. RESULTS: The 19th century anatomic study and display of Sarah "Saartjie" Baartman, the Hottentot Venus, defined a European vulvar ideal by demonstrating its opposite. Today, the ideal appearance of the labia minora is variable across cultures and nationalities, and various mechanical and surgical manipulations are sought or imposed upon women to bring their bodies into conformity with these ideals. CONCLUSION: For European audiences, Baartman exemplified a stereotypical association between genital appearance, sexual availability, and accessibility as a biomedical subject. These logical linkages were a by-product of sexist, racist, and colonial ideologies that have since fallen out of favor. However, their genital effects continue to influence bioethical considerations of genitoplasty into the present day. Chubak B. Historical and Ethical Perspectives on Vulvoplasty. Sex Med Rev 2020;8:542-547.

Perception of Labial Size and Objective Measurements-Is There a Correlation? A Cross-Sectional Study in a Cohort Not Seeking Labiaplasty.

INTRODUCTION: Poor genital self-image is a common phenomenon leading to an increasing interest in female genital surgery over the last years. AIM: The aim was to correlate objective measurements of the labia minora with the individual subjective perception of the labial size. METHODS: In a cross-sectional study with 200 premenopausal women (median age 33.5 years) presenting for gynecological issues other than vulvar diseases, labial width and length were measured, and psychological and physical complaints were assessed. Multivariable logistic regression analyses were performed to identify factors that influenced self-reported complaints and subjective perception of labia size. MAIN OUTCOME MEASURE: The main outcome measure was labial appearance (width and length in mm, color), subjective perception of the labial size, and complaints. RESULTS: The median width of the labia minora was 19.0 mm (interquartile range = 12.6-27.5), and the median length was 35.5 mm (interquartile range = 27.8-48.9). The objective size of the labia was significantly associated with womens' subjective perception of the labial size, but not with self-reported complaints. Nearly one-third of the women (n = 53, 27%) reported complaints of their labia minora which were mainly physical (n = 41, 77%) or a combination of physical and psychological problems (n = 9, 17%), while only a small group reported experiencing only psychological complaints (n = 3, 6%). Predictors of complaints were previous cosmetic surgery and the subjective perception of the labia size. The latter was significantly associated with discomfort during intercourse and when visiting a sauna and by labia minora that protruded over the labia majora. CLINICAL IMPLICATIONS: Cutoff values to define labial hypertrophy and to justify labial reduction surgery should be avoided. STRENGTH & LIMITATIONS: This is a large sample of labial measurements in women not seeking labiaplasty. Standardized and validated questions regarding quality of life, sexuality, and body image could have provided more insight into psychological aspects. CONCLUSION: These data demonstrate the variability of labial anatomy and its perception. Widschwendter A, Riedl D, Freidhager K, et al. Perception of Labial Size and Objective Measurements-Is There a Correlation? A Cross-Sectional Study in a Cohort Not Seeking Labiaplasty. J Sex Med 2020;17:461-469.

Vulvar malignancies: an interdisciplinary perspective.

Vulvar cancer represents the fourth most common gynecologic malignancy and is often encountered by the general Dermatologist or Gynecologist. Dermatooncologists and Gynecologic Oncologists share expertise in this field and the diagnosis and treatment should ideally be interdisciplinary. All subtypes are typically seen in the later decades of life, although all histologic subtypes have been described in women younger than 30 years. The diagnosis is often delayed. Exact mapping of biopsies is of high importance, as the location and distance from the midline guides the surgical approach depending on the underlying histology. Squamous cell carcinoma accounts for more than 76 % of vulvar cancer with vulvar intraepithelial neoplasia being an important precursor. Basal cell carcinoma is the second most common vulvar malignancy. Melanoma accounts for 5.7 % of vulvar cancer and has a worse prognosis compared to cutaneous melanoma. Most of the trials on checkpoint inhibitors and targeted therapy have not excluded patients with vulvar melanoma and the preliminary evidence is reviewed in the manuscript. Surgery remains the primary treatment modality of locally resectable vulvar cancer. In view of the rarity, the procedure should be performed in dedicated cancer centers to achieve optimal disease control and maintain continence and sexual function whenever possible.

Anogenital distance in children born of mothers with polycystic ovary syndrome: the Odense Child Cohort.

STUDY QUESTION: Are higher testosterone levels during pregnancy in women with polycystic ovary syndrome (PCOS) associated with longer offspring anogenital distance (AGD)? SUMMARY ANSWER: AGD was similar in 3-month-old children born of mothers with PCOS compared to controls. WHAT IS KNOWN ALREADY: AGD is considered a marker of prenatal androgenization. STUDY DESIGN, SIZE, DURATION: Maternal testosterone levels were measured by mass spectrometry at Gestational Week 28 in 1127 women. Maternal diagnosis of PCOS before pregnancy was defined according to Rotterdam criteria. Offspring measures included AGD from anus to posterior fourchette (AGDaf) and clitoris (AGDac) in girls and to scrotum (AGDas) and penis (AGDap) and penile width in boys and body composition (weight and BMI SD scores) at age 3 months. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study was part of the prospective study, Odense Child Cohort (OCC), and included mothers with PCOS (n = 139) and controls (n = 1422). The control population included women with regular menstrual cycles (<35 days) before conception and no signs of androgen excess (hirsutism and/or acne). MAIN RESULTS AND THE ROLE OF CHANCE: AGD measures were comparable in offspring of women with PCOS compared to controls (all P > 0.2) despite significantly higher maternal levels of total testosterone (mean: 2.4 versus 2.0 nmol/l) and free testosterone (mean: 0.005 versus 0.004 nmol/l) in women with PCOS versus controls (both P < 0.001). In women with PCOS, maternal testosterone was an independent positive predictor of offspring AGDas and AGDap in boys. Maternal testosterone levels did not predict AGD in girls born of mothers with PCOS or in boys or girls born of women in the control group. LIMITATIONS, REASONS FOR CAUTION: The diagnosis of PCOS was based on retrospective information and questionnaires during pregnancy. Women participating in OCC were more ethnically homogenous, leaner, more educated and less likely to smoke compared to the background population. Our study findings, therefore, need to be reproduced in prospective study cohorts with PCOS, in more obese study populations and in women of other ethnicities. WIDER IMPLICATIONS OF THE FINDINGS: Our finding of the same AGD in girls born of mothers with PCOS compared to controls expands previous results of studies reporting longer AGD in adult women with PCOS. Our results suggest that longer AGD in adult women with PCOS could be the result of increased testosterone levels in puberty, perhaps in combination with weight gain. STUDY FUNDING/COMPETING INTEREST(S): Financial grants for the study were provided by the Danish Foundation for Scientific Innovation and Technology (09-067180), Ronald McDonald Children Foundation, Odense University Hospital, the Region of Southern Denmark, the Municipality of Odense, the Mental Health Service of the Region of Southern Denmark, The Danish Council for Strategic Research, Program Commission on Health, Food and Welfare (2101-08-0058), Odense Patient data Explorative Network, Novo Nordisk Foundation (grant no. NNF15OC00017734), the Danish Council for Independent Research and the Foundation for research collaboration between Rigshospitalet and Odense University Hospital and the Health Foundation (Helsefonden). There is no conflict of interest of any author that could be perceived as prejudicing the impartiality of the research reported.

Comparative study of stress response, growth and development of uteri in post-weaning gilts challenged with zearalenone and estradiol benzoate.

The objective of this study was to evaluate the effects of zearalenone (ZEA) and estradiol benzoate (EB) on stress injury and uterine development in post-weaning gilts. Thirty healthy post-weaning female gilts (Duroc × Landrace × Large White) aged 28-32 days were randomly allocated to three treatments as follows: (a) basal diet (Control), (b) basal diet plus 1.0 mg/kg purified ZEA (ZEA) and (c) basal diet plus 0.75 ml (1.5 mg) EB per pig at 3-days intervals by intramuscular injection (EB). The serum estradiol (E2 ), the final and the increased vulvar area, uterine index, thickness of the myometrium and endometrium, and protein expression of heat shock protein 70 (HSP70) in ZEA group were higher than those in the control group (p < .05), but lower than those in the EB group (p < .05). The serum luteinizing hormone in ZEA group was lower than that of the control group (p < .05), but higher than that in the EB group (p < .05). Higher serum follicle-stimulating hormone and progesterone were observed in the ZEA and control groups than those in the EB group (p < .05). The serum glutathione peroxidase activity in the ZEA group was lower than that in the control and EB groups (p < .001), and the malondialdehyde in the ZEA group was higher than that in the control and EB groups (p < .001). Moreover, the relative mRNA and protein expression of growth hormone receptor (GHR) and relative mRNA expression of HSP70 in the ZEA and EB groups were higher than those in the control group (p < .05). In conclusion, both ZEA (1.0 mg/kg) and EB (1.5 mg at 3 days intervals by intramuscular injection) stimulated vulvar swelling and uterine hypertrophy by disordering serum hormones and up-regulating GHR expression, and induced stress by different mechanisms in this study. Furthermore, the observed up-regulating HSP70 expression challenged by ZEA or EB may be part of the mechanism to resist stress injury.

Anatomy, histology, and nerve density of clitoris and associated structures: clinical applications to vulvar surgery.

BACKGROUND: A precise understanding of structures comprising the female external genitalia is essential in obstetric and gynecologic practice. OBJECTIVE: To further characterize the anatomy, histology, and nerve density of the clitoris and associated structures, and to provide clinical correlations to vulvar surgery. MATERIALS AND METHODS: Unembalmed female cadavers were examined. The length and width of the body, glans, and crura of the clitoris were measured. Distances from the glans to the urethra and from the dorsal surface of the clitoral body to the mid pubic arch were recorded. The path of the dorsal nerve of the clitoris was examined, and the nerve width was measured as it emerged from the lateral surface of crura and at the distal clitoral body. Distances from where the dorsal nerve emerged from the perineal membrane to the posterior surface of the membrane and to mid pubic arch were measured. Connective tissue layers associated with the clitoris were examined. Tissue was harvested from additional unembalmed cadavers, and nerve density of the labia minora, glans, and clitoral body were analyzed. Histological examination was performed on vulvar structures to clarify tissue composition. Descriptive statistics were used for data analyses. RESULTS: A total of 27 cadavers (aged 48-96 years) were examined, 22 grossly and 5 histologically. The median length and width of clitoral body were 29 mm (range, 13-59 mm) and 9 mm (range, 5-14 mm), respectively. The glans was 8 mm (range, 5-12 mm) long and 4 mm (range, 3-10 mm) wide. The length of the crura was 50 mm (range, 25-68 mm), and the width at the anterior portion was 9 mm (range, 2-13 mm). The closest distance from the glans to the urethra was 25 mm (range, 14-37 mm) and from the clitoral body to the mid pubic arch was 29 mm (range, 14-46 mm). The widths of the dorsal nerve at the lateral crura and at the distal clitoral body were 3 mm (range, 2-4 mm) and 1 mm (range, 1-2 mm), respectively. The distance from the dorsal nerve as it emerged from the perineal membrane to the mid pubic arch was 34 mm (range, 20-48 mm) and to the posterior surface of the membrane was 20 mm (range, 8-31 mm). The dorsal nerve and artery of the clitoris coursed adjacent to the medial surface of the inferior pubic ramus surrounded by a dense fibrous capsule adherent to the periosteum. The nerve and artery then coursed deep to dense connective tissue layers, which were contiguous with the suspensory ligament and fascia of the clitoris. Histologic examination revealed the presence of erectile tissue in the clitoral body, crura, and vestibular bulbs, but such tissue was absent in the glans and labia minora. Nerve density analysis revealed statistically significant greater density in the dorsal compared with ventral half of the clitoral body. Although not statistically significant, there was increased nerve density in the distal compared to the proximal half of the labia minora. CONCLUSION: Precise knowledge of clitoral anatomy and associated neurovascular structures is essential to safely complete partial vulvectomies, clitoral and vulvar reconstructive procedures, anti-incontinence surgeries, and repair of obstetric lacerations. Understanding the range of anatomic variations and awareness of the areas of increased nerve density is important during counseling and surgical planning. Although the dorsal nerve of the clitoris courses deep to dense connective tissue layers, inadvertent injury may occur in the setting of deep dissection or suture placement. The dorsal nerve seems most vulnerable with surgical entry or lacerations that extend from the midline of the prepuce to the inferior pubic rami.

"I Don't See That as a Medical Problem": Clinicians' Attitudes and Responses to Requests for Cosmetic Genital Surgery by Adolescents.

Labiaplasty is a form of genital surgery to reduce large or protruding labia minora. Internationally, the rates of this surgery among women and girls is increasing and is viewed as a worrying trend. Currently, the main clinical strategy is to reassure adolescents that they are normal by talking about the variation of labia size and appearance and showing pictures demonstrating the wide range of normal female genital appearance. For the most part, policy documents recommend against labiaplasty in adolescents, claiming that it is medically non-essential surgery. In this paper, we contrast findings from our interviews with clinicians with the existing literature and policy documents and we point out areas needing more thought. This is qualitative research using semi-structured interviews. We set out to find out on what basis clinicians decide how to treat or manage adolescent patients seeking labiaplasty. We interviewed clinicians who are likely to be approached by under-eighteens requesting labiaplasty. We use interpretive content analysis and thematic analysis to analyse the data. Our findings support the emphasis on education and reassurance as the first step for all patients, but other issues that have not figured previously in the literature that would alter clinical strategies for managing patients emerge as well. Key findings are that reassurance does not always work and that the distinction between functional and appearance concerns is not a solid foundation in itself for deciding whether surgery is ethically appropriate. We conclude that the distinction between functional and appearance concerns is not ethically relevant. It is open to different interpretations and is not regarded by all clinicians as the definitive factor in relation to surgery. The focus of clinicians should be on relieving distress whatever the cause. Appearance reasons may sometimes justify surgery but, also, functional reasons may sometimes not be sufficient justification for surgery.

Anogenital distance is determined during early gestation in humans.

STUDY QUESTION: Does cord blood androgen level obtained at birth affect the AGD in human newborns? SUMMARY ANSWER: In human newborns, though males have a significantly longer AGD compared to females (as early as 22 weeks of gestation) the AGD is not affected by androgen levels at birth in both the sexes. WHAT IS KNOWN ALREADY: Animal studies have reported a critical time period in early fetal life, termed the masculinization programming window (MPW) during which AGD is fixed by in utero androgen action and is unaffected by testosterone levels later during gestation. Thus, AGD may serve as a lifelong biomarker of androgen exposure during this window. This MPW is hypothesized to occur in humans at 8-14 weeks of gestation during which AGD is fixed. The effect of androgens (testosterone) on AGD after the MPW in humans is not known. Furthermore, altered AGD has been associated with various human reproductive health disorders in both males and females. STUDY DESIGN, SIZE, DURATION: A prospective descriptive cohort study was performed using data from randomly selected neonates (n = 205) born at a single center over a period of 1 year (August 2015 to August 2016). PARTICIPANTS/MATERIALS, SETTING, METHODS: AGDs in male (n = 117) and female infants (n = 88) together with penile width, glans girth and stretched penile length were measured by trained caregivers. Gestation ranged from 22 to 41 weeks and infants were examined within 24 h of birth (within 48-72 h in very sick preterm infants after clinical stabilization). AGD-1 was measured from the center of the anus to the posterior base of scrotum in males or to the posterior fourchette in females. AGD-2 was measured from the center of the anus to the anterior base of the penis in males or to the clitoris in females. Sex steroid hormones (testosterone, 17-OH progesterone (17-OHP) and androstenedione) were measured in serum prepared from umbilical cord blood samples taken at birth, using liquid chromatography-tandem mass spectrometry. MAIN RESULTS AND THE ROLE OF CHANCE: Males had a significantly lower gestational age (mean ± SD; 34.6 ± 4.9 versus 36.1 ± 4.1 weeks, P = 0.04), and a significantly longer AGD-1 (mean ± SD; 21.6 ± 6.0 versus 12.7 ± 3.8 mm, P < 0.001) and AGD-2 (41.9 ± 8.7 versus 33.9 ± 7.1 mm, P = 0.004) compared to female infants, respectively. The cord serum testosterone levels were significantly higher for male than female infants [median, interquartile range; 13.0 (7.3, 20.5) versus 4.1 (2.5, 5.9), ng/dl, P < 0.001]. There was no difference in levels of 17-OHP (P = 0.697) or androstenedione (P = 0.601) between the two sexes. On multiple regression analysis after adjusting for potential confounders, none of the AGD's in both males and females correlated with any sex steroid hormonal levels. We also provide normative charts for penile length, penile width and glans girth in preterm and term infants. LIMITATIONS, REASONS FOR CAUTION: No data were collected on family history of genital malformation, infertility or hormonal disorders, parental endocrine-disrupting chemical exposure or diet pattern, any of which might have influenced the AGD and/or sex steroid hormone levels in the offspring. WIDER IMPLICATIONS OF THE FINDINGS: Our results suggest that AGD in humans, like animals, is fixed in early gestation (likely during the hypothesized MPW) and is unaffected by androgen levels thereafter. Thus, AGD can serve as a biomarker of in utero androgen action during early gestation (likely 8-14 weeks) in humans. As such, causes of human newborn and adult reproductive health disorders, such as endocrine disruptors, should be explored during early gestation. However, further larger studies are needed to help corroborate these findings. STUDY FUNDING/COMPETING INTERESTS: No specific funding was obtained for this study, and all authors have no conflict of interest to declare.

Ovarian response is associated with anogenital distance in patients undergoing controlled ovarian stimulation for IVF.

STUDY QUESTION: Is the length of the anogenital distance (AGD) a biomarker of ovarian reserve and response to controlled ovarian stimulation (COS)? SUMMARY ANSWER: Shorter AGD is associated with presence of poor ovarian response. WHAT IS KNOWN ALREADY: Organ development during prenatal life is influenced by the prevailing intrauterine environment, and it has been suggested that nutritional, environmental and toxic factors could affect ovarian reserve set prenatally. AGD is a biomarker of prenatal-hormonal environment and observational studies have shown an association between its length and reproductive parameters in both sexes. STUDY DESIGN, SIZE, DURATION: This was a prospective cohort study of 437 women treated with IVF/ICSI conducted in a tertiary-care university hospital between January and December 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: All women underwent their first COS for IVF/ICSI and reached criteria for oocyte retrieval. Based on the number of oocytes obtained, patients were divided into three groups: poor responders (≤3 oocytes) (n = 50), normoresponders (4-15 oocytes) (n = 332) and high responders (>15 oocytes) (n = 55). Before retrieval, the following patient data were recorded: age, body mass index (BMI), ovarian reserve markers (anti-Müllerian hormone [AMH], antral follicle count [AFC] and follicular stimulation hormone [FSH]), cause of infertility, total doses of gonadotropins used and ovarian sensitivity index (OSI). Patients with previous pregnancies, polycystic ovary syndrome (PCOS), endometriosis and previous ovarian or genital surgery were excluded. Anthropometric biomarkers of AGDAC (anus-clitoris) and AGDAF (anus-fourchette) were measured in all patients under sedation on the day of retrieval and before proceeding to oocyte pick-up. Multiple linear regression analyses were used to examine the association between both AGD and ovarian reserve markers, the total units of gonadotropins used, the number of oocytes obtained and the OSI. Logistic regression was used to predict poor response in COS for IVF/ICSI, while accounting for confounders such as age and BMI. MAIN RESULTS AND THE ROLE OF CHANCE: Baseline FSH, AMH, AFC and age were significantly different among the three groups of ovarian response, as were the units of gonadotropin used, and the ovarian sensitivity index (OSI) (P < 0.001). Both AGDAC and AGDAF measurements were positively correlated with AMH levels (r = 0.38 and r = 0.21; P < 0.05), AFC (r = 0.41 and r = 0.20; P < 0.05), the OSI (r = 0.24 and r = 0.19; P < 0.05) and the number of oocytes retrieved (r = 0.29 and r = 0.28, respectively; P < 0.05). Conversely, there was a negative correlation between both AGD measurements and the doses of gonadotropins used (r= -0.19 and r= -0.15; P < 0.05). The area under the curve (AUC) for prediction of poor response of AGDAC was 0.70 (95% CI 0.66, 0.75), which was comparable to the classic ovarian reserve markers, such as AFC and AMH. AGDAF showed a significantly worse predictive capacity for poor ovarian response (AUC 0.60 [95% CI 0.55, 0.60]) than AMH and AFC. LIMITATIONS, REASONS FOR CAUTION: The population used for the study was a highly selected group of infertile women who underwent COS for IVF, so the findings of this research may not be applicable for general population. Besides, measurement or selection biases might have been possible and must be considered. WIDER IMPLICATIONS OF THE FINDINGS: The findings of this study suggest that in utero exposure to certain hormonal environments could affect the ovarian reserve set prenatally. STUDY FUNDING/COMPETING INTEREST(S): None. The authors have no competing interests to declare.

Measurements of a 'normal vulva' in women aged 15-84: a cross-sectional prospective single-centre study.

OBJECTIVE: Accurate and detailed description of a 'normal vulva' is rare, even though a few studies have dealt with the topic of normal measurements of parts of the external female genitalia. This leads to a situation with a wide range of existing diagnoses concerning 'normal' vulvar morphology. DESIGN: Cross-sectional prospective single-centre study. SETTING: From August 2015 to April 2017, we included 657 women in our gynaecological and uro-gynaecological outpatient clinic of the Cantonal Hospital Lucerne. POPULATION OR SAMPLE: We recruited white women aged 15-84 years. METHODS: Standardised defined measurements were taken of the clitoral gland, distance from the base of the gland to the urethral orifice, length of introitus, length of perineum, length of labia majora, and length and width of labia minora. Furthermore, we recorded baseline characteristics. MAIN OUTCOME MEASURES: The length of labia minora (r = -0.364, P < 0.001, n = 657) as well as the length of the perineum (r = -0.095, P = 0.014, n = 657) are inversely correlated with age. A positive correlation between body mass index and the length of the labia majora (r = 0.150, P < 0.001, n = 657) and the length of the introitus (r = 0.097, P = 0.014, n = 657) was found. RESULTS: We provide detailed data on age-related dimensions and description of the external female genitalia in a homogeneous group of white women. CONCLUSION: With our data, we present a baseline for the appearance of a normal white vulva, which could be used to establish standards for indications for gynaecological cosmetic surgery. TWEETABLE ABSTRACT: This study presents data on the standard dimensions of the external female genitalia and is, to our knowledge, the biggest cohort presented on this topic by now.