Guideline sources The following summarized guidelines for the evaluation and management of female genital cosmetic surgery are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022), the Japanese Society for Neonatal Screening (JSNS/JSPU/JES/JSPE 2022), and the American College of Obstetricians and Gynecologists (ACOG 2020; 2017). 1 2 3 4 Guidelines 1. Diagnostic investigations Clinical assessment: As per SOGC 2022 guidelines, elicit a complete medical, sexual, and gynecological history, and confirm the absence of any major sexual or psychological dysfunction, including body dysmorphic disorder, in females requesting vaginal cosmetic procedures. Rule out any possibility of coercion or exploitation. A As per ACOG 2020 guidelines, be aware to recognize sexual function disorders, depression, anxiety, and other psychiatric conditions. Assess females, if indicated, for body dysmorphic disorder. Refer for evaluation before surgery in case of suspected psychological concerns. E https://web.pathway.md/diseases/rec1Jt8ljLRNR2nWA 1/3 6/29/23, 4:03 AM Female genital cosmetic surgery Pathway 2. Therapeutic procedures Vaginal laser therapy: do not offer laser therapy for genitourinary syndrome of menopause or cosmetic genital indications. D 3. Surgical interventions Indications for surgery: insufficient evidence to recommend any female genital cosmetic surgery or procedure to improve sexual satisfaction and/or self-image. Do not promote these surgeries for the enhancement of sexual function or self-image when choosing to proceed with these cosmetic procedures. I Show 2 more 4. Specific circumstances Adolescent patients: As per SOGC 2022 guidelines, ensure that physicians seeing adolescents requesting female genital cosmetic surgery have additional expertise in counseling adolescents. B As per ACOG 2017 guidelines, educate and reassure regarding normal variation in anatomy, growth, and development as the first step in adolescents seeking medical treatment. E Show 3 more Patients with congenital adrenal hyperplasia: perform clitoroplasty in patients with cosmetic problems and clitoromegaly. Prefer a neurovascular bundle-preserving procedure as standard surgery. B 5. Patient education General counseling: As per SOGC 2022 guidelines, educate females about their anatomy and help them appreciate individual variations, including transitions through the reproductive life cycle. B Show 2 more As per ACOG 2020 guidelines, inform females that surgery or procedures altering sexual appearance or function (excluding procedures performed for clinical indications, such as clinically diagnosed female sexual dysfunction, pain with intercourse, interference in athletic activities, previous obstetric or straddle injury, reversing female genital cutting, vaginal prolapse, incontinence, or gender affirmation surgery) are not medically indicated, pose a substantial risk, and their safety and effectiveness have not been established. E Show 2 more 6. Quality improvement Advertising: https://web.pathway.md/diseases/rec1Jt8ljLRNR2nWA 2/3 6/29/23, 4:03 AM Female genital cosmetic surgery Pathway As per SOGC 2022 guidelines, be cautious in advertising female genital cosmetic surgeries, to ensure such advertising is factual and not misleading. A As per ACOG 2020 guidelines, ensure that advertisements in any media are accurate and not misleading or deceptive. Recognize that rebranding existing surgical procedures (many of which are similar to, if not the same as, the traditional anterior and posterior colporrhaphy) and marketing them as new cosmetic vaginal procedures is misleading. E References 1. Dorothy Shaw, Lisa Allen, Cynthia Chan et al. Guideline No. 423 Female Genital Cosmetic Surgery and Procedures. J Obstet Gynaecol Can. 2022 Feb;44 2 204 214.e1. Open 2. No authors listed. Elective Female Genital Cosmetic Surgery: ACOG Committee Opinion, Number 795. Obstet Gynecol. 2020 Jan;135 1):e36-e42. Open 3. Tomohiro Ishii, Kenichi Kashimada, Naoko Amano et al. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency 2021 revision). Clin Pediatr Endocrinol. 2022;31 3 116 143. Open 4. No authors listed. Committee Opinion No. 686 Breast and Labial Surgery in Adolescents. Obstet Gynecol. 2017 Jan;129 1):e17-e19. Open https://web.pathway.md/diseases/rec1Jt8ljLRNR2nWA 3/3