tag:theconversation.com,2011:/au/topics/gynaecological-condition-19256/articlesGynaecological condition – The Conversation2016-06-02T02:13:55Ztag:theconversation.com,2011:article/550382016-06-02T02:13:55Z2016-06-02T02:13:55ZDoes your vulva hurt? You could have vulvodynia<figure><img src="https://images.theconversation.com/files/117070/original/image-20160401-6825-ecxuds.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vulvodynia can be brutal and is commonly described as stabbing, burning, cutting or knife-like pain.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>If you have pain in your vulva, you’re not alone. Around <a href="http://europepmc.org/abstract/med/12744420">16% of women</a> will have vulvar pain lasting longer than three months. They aren’t neurotic or promiscuous. It’s likely they are suffering from a condition called vulvodynia.</p>
<p>Only people with a vulva can develop vulvodynia, but that’s where the discrimination stops. The condition occurs in <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1431685/">women of all ages</a> and ethnicities, regardless of education, skin type, sexual preference or relationship status.</p>
<p>The pain can be brutal and is commonly described as stabbing, burning or knife-like. It might happen only when the vulva is provoked, as when it’s touched by clothing or attempted penetration, or it can be constant. Not surprisingly, vulvodynia <a href="http://www.tandfonline.com/doi/abs/10.1185/03007995.2012.666963#.VteCOJN95ds">can severely impact</a> a woman’s quality of life.</p>
<h2>Vulvodynia and its costs</h2>
<p>About half of our species has a vulva, yet <a href="https://www.eveappeal.org.uk/news-info/blog/the-vagina-dialogues/">surprisingly few know</a> what, or where, it is. The vulva refers to the external genitalia of females: the clitoris, labia, vaginal opening and Bartholin’s glands, which provide the natural lubricant for the vagina. It has a rich supply of specialised nerves and gives pleasure when properly stimulated. </p>
<p>The vulva doesn’t extend to the vagina itself, which, contrary to common parlance and high-profile <a href="http://www.greatwallofvagina.co.uk/home">art exhibitions</a>, is on the inside, not the outside. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=867&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=867&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=867&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1089&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1089&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121493/original/image-20160506-454-1ddokal.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1089&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The vulva refers to the external genitalia of females.</span>
<span class="attribution"><a class="source" href="http://www.labialibrary.org.au/anatomy/#labia-majora-labia-minora">The Labia Library/Women's Health Victoria</a></span>
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<p>Putting “-dynia” on the end of a word refers to pain. Vulva means, well, vulva. So <a href="http://www.vulvalpainsociety.org/vps/index.php/vulval-conditions/vulvodynia">vulvodynia literally means</a> “painful vulva”. If you have pain in your vulva anywhere from your clitoris to your anus and labia to very inner thigh, and there is no clear injury or ongoing infection, then you have vulvodynia. </p>
<p>Three out of every 20 women will develop vulvodynia at some point and the cost can be profound. Sufferers often <a href="http://www.sciencedirect.com/science/article/pii/S0301211505002083">struggle to wear underwear</a>, sit down or use tampons.</p>
<p>Women with vulvodynia often <a href="http://www.mamamia.com.au/life-without-sex/">suffer through sex</a>. Some find ways to end their relationships when the pain becomes too unbearable. They can be so embarrassed about their condition they don’t mention it to their partner or tell them it’s the reason they want to separate. </p>
<p>And when it comes to economic costs, extrapolating from a <a href="http://www.tandfonline.com/doi/abs/10.1185/03007995.2012.666963#.VteCOJN95ds">United States study</a>, vulvodynia costs Australia more than A$2 billion per year.</p>
<p>Unfortunately, we don’t know what causes vulvodynia, although we do know a few things that don’t. It used to be considered a result of a woman having too many sexual partners, for instance, but we now know <a href="http://www.tandfonline.com/doi/pdf/10.1080/713846829">there is no relationship</a> between the two.</p>
<h2>Suspected causes</h2>
<p>Women with vulvodynia are sensitive in all parts of their body, not just the vulva. They commonly have other painful conditions such as irritable bowel syndrome. This implies changes in the brain information-processing centres that produce pain in these women.</p>
<p>Women with vulvodynia also have higher levels of <a href="http://europepmc.org/abstract/med/26132928">inflammatory markers</a> in their blood – part of an immune response – than those without. They are more likely to report <a href="http://www.tandfonline.com/doi/pdf/10.1080/713846829">repeated thrush infections</a> and having had a <a href="https://www.researchgate.net/publication/26702804_Urogenital_Infections_in_Relation_to_the_Occurrence_of_Vulvodynia">sexually transmitted disease</a>. This makes some researchers think a possible association exists between the prior infections and inflammation.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/124884/original/image-20160602-3253-t3ndks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/124884/original/image-20160602-3253-t3ndks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=634&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124884/original/image-20160602-3253-t3ndks.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=634&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124884/original/image-20160602-3253-t3ndks.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=634&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124884/original/image-20160602-3253-t3ndks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=796&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124884/original/image-20160602-3253-t3ndks.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=796&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124884/original/image-20160602-3253-t3ndks.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=796&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Psychological factors play a part in vulvodynia.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>Inflammation can induce nerve growth in the vulva region – which might also explain why the vulva becomes hypersensitive in vulvodynia. But girls can have vulvodynia before they report thrush, so it is not as simple as that.</p>
<p>Psychological factors play a part, as they do in any pain state. But it’s difficult to know whether these issues came before or after the pain. The sexual dysfunction associated with vulvodynia may increase depression, which may lead to further <a href="https://www.researchgate.net/publication/51612277_The_Effect_of_Major_Depression_on_Sexual_Function_in_Women">sexual dysfunction</a>, for instance. However, some women report symptoms of vulvodynia for the first time following a <a href="http://europepmc.org/abstract/med/9109079">psychological trauma</a>, such as the death of a parent, partner or friend. </p>
<p>Many women develop vulvodynia <a href="http://www.webmail.socrei.org/uploadedFiles/ASRM_Content/News_and_Publications/Journals_and_Newsletters/Menopausal_Medicine/2010/SRM_MenMed_Final_0510.pdf">during menopause</a>, which indicates hormones may play a role. There may also be a <a href="http://www.tandfonline.com/doi/abs/10.3109/00016349.2010.528368">genetic component</a> as women are more likely to develop the condition if someone in their family has, or has had, it. </p>
<h2>What should you do if you have vulvar pain?</h2>
<p>If you suspect you have vulvodynia, your first step should be to see your GP and ask for a referral to a gynaecologist or vulvar specialist with an interest in treating painful conditions.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/117072/original/image-20160401-6820-1thz8x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/117072/original/image-20160401-6820-1thz8x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/117072/original/image-20160401-6820-1thz8x0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/117072/original/image-20160401-6820-1thz8x0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/117072/original/image-20160401-6820-1thz8x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/117072/original/image-20160401-6820-1thz8x0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/117072/original/image-20160401-6820-1thz8x0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Natural alternatives to regular lubricants are almond and coconut oil.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/mealmakeovermoms/6953785320/in/photolist-bPoBya-bPoBAx-bAtY7m-bPoBpt-oT1RPN-9AYAUQ-dHA5Kp-kyq9ST-7x51qZ-rptqeR-4UEk8V-8kSUrK-4PjMh4-bmV7uR-cvRJM7-bPoBC4-bPoBnD-bPoBwv-bPoBs8-bPMnxr-bPoBJx-bASHy1-bAtXWY-bPMnwM-feNdKp-5Ynkye-bC67CS-bKJhuB-bQfAt6-52iMNk-cCqKNh-9hBU57-e1d52m-ma12rM-g6zf3s-7HcVEH-oT2mxr-9hBUgf-5CcPMi-9hBTRS-9hBUts-8kSUet-paf2gx-4UEdsX-2GXPk-oT2mRH-ajcuEd-patD3N-5CcQwM-5CcQ5B">Meal Makeover Moms/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Research into understanding vulvodynia is way behind other chronic pain conditions such as back pain, meaning fewer treatment options are available. But your specialist will help you decide on some <a href="http://www.bethshelly.com/docs/Andrews-JC-2011.pdf">treatments</a> that are right for you. </p>
<p>A treatment plan will often include medications, advice on management strategies and referral to other health professionals such as physiotherapists or psychologists. Treatments such as massage of the pelvic floor muscles and training to help reduce the tightness in the area could also help.</p>
<p>Anecdotally, we know things you can do at home to reduce the pain. Many women find relief using cool packs or a fan directed towards their vulva. You can avoid using soaps or body washes to clean your vulva; instead, use something like Dermeze soap-free wash or just water. </p>
<p>Ensure you are well lubricated during sex, but some commercial lubricants could aggravate symptoms. Natural alternatives are almond oil and coconut oil. </p>
<p>No woman should suffer in silence or shame because of her symptoms. The <a href="http://www.pelvicpain.org.au">Pelvic Pain Foundation of Australia</a> is a great place to find more information on vulvodynia and other pelvic pain conditions.</p><img src="https://counter.theconversation.com/content/55038/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Chalmers receives funding from The Pelvic Pain Foundation of Australia. </span></em></p><p class="fine-print"><em><span>Lorimer Moseley consults to Pfizer Australia, Kaiser Permanente and Providence Healthcare. He receives author royalties for Explain Pain, Explain Pain Handbook: Protectometer, Painful Yarns: Metaphors and stories to help understand the biology of pain, and The Graded Motor Imagery Handbook. He receives speaker fees. Details available on request.
He is supported by a Principal Research Fellowship from the National Health & Medical Research Council of Australia and his research is supported by project grants from the National Health & Medical Research Council of Australia.</span></em></p>If you’ve ever experienced pain in your vulva, you’re not alone. Around 16% of women will have vulvar pain that lasts for longer than three months. They are likely suffering from vulvodynia.Jane Chalmers, Lecturer in Physiotherapy, Western Sydney UniversityLorimer Moseley, Professor of Clinical Neurosciences and Foundation Chair in Physiotherapy, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/490512016-02-07T19:06:49Z2016-02-07T19:06:49ZWhy women see their GP more than men<figure><img src="https://images.theconversation.com/files/101774/original/image-20151113-12377-17qrxj9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It’s important a woman has a good relationship with her general practitioner.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>This article is part of our series examining hidden women’s conditions. You can also read today’s pieces on <a href="http://theconversation.com/we-need-a-cure-for-bacterial-vaginosis-one-of-the-great-enigmas-in-womens-health-50850">bacterial vaginosis</a> and the need to empower women with <a href="http://theconversation.com/vulvas-periods-and-leaks-women-need-the-right-words-to-seek-help-for-conditions-down-there-53638">appropriate language</a> to seek help when their body “malfunctions”.</em></p>
<hr>
<p>Women go to the doctor more often than men, particularly in their reproductive years, between the ages of 15 and 44. This difference is partly due to management of gynaecological and reproductive issues.</p>
<p>Because of the frequency of visits, and the sensitive nature of many of these, it’s important a woman has a good relationship with her general practitioner.</p>
<h2>Why women go to the doctor</h2>
<p>In a recent study, we found <a href="http://www.racgp.org.au/afp/2015/july/obstetric-and-gynaecological-problems-in-australian-general-practice/">about 12% of problems</a> managed for women of all ages in primary care concerned their reproductive or genital system.</p>
<p>Australian women visited a GP on average nearly seven times a year in 2013-14. For men, this figure was just under five times. Among those between 15 and 24, 83% of women – but only 68% of men – saw a GP at least once in any given year. </p>
<p>The frequency and type of these problems varied across age groups.</p>
<p>Throughout their lives, women experience different health issues. For instance, about 20% of women of childbearing age <a href="http://www.australiandoctor.com.au/cmspages/getfile.aspx?guid=591d3bc7-5bd3-482f-a0af-0131a2f957c1_">experience heavy bleeding</a> during menstruation, and 15% have <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Mathias%20SD,%20Kuppermann%20M,%20Liberman%20RF,%20Lipschutz%20RC,%20Steege%20JF.%20Chronic%20pelvic%20pain:%20prevalence,%20health-related%20quality%20of%20life,%20and%20economic%20correlates.%20Obstet%20Gynecol%201996%20Mar;87:321%E2%80%9327">chronic pelvic pain</a>. These numbers drop in older age groups.</p>
<p><a href="http://ses.library.usyd.edu.au/bitstream/2123/11883/4/9781743324240_ONLINE.pdf">Our study</a> showed in the decade between 2004 and 2014, female-specific problems accounted for a quarter of all problems managed by GPs for women in childbearing years. This fell to only 10% of problems managed for those between 45 and 64 years, and 3% for those 65 and over. </p>
<p>Across all adult age groups, gynaecological check-ups involving pap smears were common. Other female-specific problems managed by GPs aligned with the life stages: pregnancy and contraception in younger women, menstrual problems and menopause in the middle and older age groups. </p>
<p>We found the most common problem managed overall for women between the ages of 15 and 64 was depression. </p>
<p>The most commonly prescribed medications were contraceptives and antidepressants. </p>
<p>Across all age groups, women were <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4125.0main+features3150Jan%202013">more likely to have depression</a> than men and this was reflected in higher management by GPs. </p>
<p>For women 65 years and over, depression dropped down the list of problems, overtaken by a number of physical conditions. Pelvic floor disorders, such as urinary and faecal incontinence, <a href="http://jama.jamanetwork.com/article.aspx?articleid=182572">affect about 50%</a> of women aged 80 and older.</p>
<p>There are various theories about why women have higher depression rates. Environmental and <a href="http://www.sciencedirect.com/science/article/pii/S0165032702004329">biological influences</a>, such as hormones, have been implicated, but <a href="http://www.sciencedirect.com/science/article/pii/S0165032702004263">studies on this aren’t</a> conclusive.</p>
<h2>Relationship with a GP</h2>
<p>Some women feel embarrassed talking about female-specific issues, even with a health professional. One <a href="http://bjgp.org/content/bjgp/51/471/801.full.pdf">study showed only 32%</a> of women aged 45 and over who had urinary incontinence actually mentioned this to their GP.</p>
<p>This is why having a regular GP is important. Studies show <a href="http://bjgp.org/content/bjgp/51/470/712.full.pdf">continuity of care in primary</a> care is associated with <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04169-6/fulltext">better health outcomes</a>.</p>
<p>Reassuringly, our study found women between 25 and 44 were more likely to attend a regular practice than men in the same age group. Across all age groups, <a href="http://racgpconference.com.au/wp-content/uploads/2015/10/ID004-Content-of-GP-consultations-in-RACGP-proposed-Medicare-time-tiers-AProf-Britt.pdf">more than 90% of women</a> said they had a regular GP practice. </p>
<p>This is likely because they need repeated cervical cancer screening (pap smears) and contraceptive prescriptions, and management of chronic diseases in later years. </p>
<p>We hope future changes to cervical cancer screening (to replace <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/future-changes-cervical">two-yearly Pap smears</a> with a five-yearly HPV test) and the <a href="http://www.sciencedirect.com/science/article/pii/S002072921500226X">push towards long-term contraception</a>, despite their benefits, will not affect the relationship between women and their GP.</p><img src="https://counter.theconversation.com/content/49051/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women visit the GP more than men, particularly between the ages of 15 and 44. This difference is partly due to the management of gynaecological and reproductive issues.Clare Bayram, Research Fellow, Family Medicine Research Centre, Sydney School of Public Health, University of SydneyAllan John Pollack, Research analyst in Family Medicine, University of SydneyHelena Britt, Associate professor, Director of the Family Medicine Research Centre, Sydney School of Public Health, University of SydneyJanice Charles, Senior Research Officer General Practice, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/456502015-08-06T04:45:30Z2015-08-06T04:45:30ZWhat’s normal, anyway? GPs should discourage women from unnecessary genital surgery<figure><img src="https://images.theconversation.com/files/90969/original/image-20150806-1969-1c47b0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are increasingly feeling embarrassed about their genital appearance.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/sophielovescute/4660990790/in/photolist-6mcyHt-7ZBJTA-6qgCYn-4K7LN3-86SNbb-7um8th-bEdZ6h-7jq1Nu-avokom-9PWDbR-58hvVT-7mq5Ex-fmM8c-nuPunk-nuPJf1-nM9fAm-nARVnZ-bUDgfr-runCRE-o6s6R7-nR1hy7-o8n94E-s9VFUB-bRRzL4-5v6X2B-dcCTRt-7fhPi2-isqYLk-kgdr3T-kgf8py-kgfcAj-avoto1-nuQcUg-nuPJw3-e5DY5p-pSGTox-oagEnp-o8n9i7-o8n913-7ftXHv-aNwLZK-7VZ6CD-rBYWf-7fhPiP-7TdEKU-9P7mwH-sfiWxa-ehTFHM-dsSiTH-6SGnjz">Sophie/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>General practitioners have an important role to play in alleviating women’s anxiety about their genital appearance and can help stop the rise in women going under the knife for cosmetic reasons.</p>
<p><a href="http://whv.org.au/static/files/assets/ca7e9b2f/Women-and-genital-cosmetic-surgery-issues-paper.pdf">Figures show</a> 640 Australian women made Medicare claims for genital cosmetic surgery in 2000. The number grew threefold over the next decade, with 1,565 claiming the same surgeries on Medicare in 2011. There was no accompanying rise in the incidence of congenital or acquired diseases that would need such surgery.</p>
<p>The Medicare statistics reveal surgeries are as common among women between the ages of 15 to 24 as they are among those between 25 to 44. These figures are only the tip of iceberg as most women seek out genital cosmetic surgery through the non-rebatable, private system.</p>
<p>In response, the Royal Australian College of General Practitioners this week <a href="http://www.abc.net.au/news/2015-08-03/world-first-guidelines-for-female-genital-surgery-requests/6669306">introduced</a> world-first guidelines to advise doctors how best to deal with women’s rising interest in having genital cosmetic surgery.</p>
<p>When women ask for surgical modification to their genital tissue, they often don’t know enough to describe what they want removed, nor do many understand the long-term implications. </p>
<h2>What is normal?</h2>
<p>As a GP with more than 20 years’ experience in women’s health, I have seen a marked increase in the number of women embarrassed about their genital appearance. They might hint at their shame during a routine gynaecological procedure, either as an apology for how they look “down there” or as a blatant statement such as: “It’s so ugly, I’m so embarrassed, I want it fixed.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=451&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=451&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=451&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">General practitioners are often the first medical professional to see a woman’s anxiety over her genital appearance.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/cane_rosso/2124744542/in/photolist-4eKSwA-aDDLUg-xNiWs-6wUHts-6wdZBD-bGCLJH-N6K2x-6SyALq-9p25xE-bPzRSZ-712Nbm-N6Kq6-J1G5Q-bndKvQ-8UMM2s-axeTfZ-baTtMe-2TQPPY-3MwcX-4uJwjV-5ES6ez-7aZeQT-5qy5Mo-eLg8N-kN5eGt-9SFC43-4PU8VU-9mtgE4-9mnUG5-7vMD8T-bvU3Se-xpQdo-biJpoZ-9y5ues-8FyXXg-9SCDiT-aCE5xn-5HbsX2-kN6S6g-kN7RFs-kN5Gga-kN5r96-kN7nzN-kN7ajq-kN54Rr-kN72iq-kN4T68-kN6LF9-kN6zsN-kN4r3M">Ludo/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>General practitioners are often the first medical professional to see a woman’s anxiety over her genital appearance. This embarrassment may be based on an idealised benchmark of stylised, hairless and prepubescent genitals, so often depicted and promulgated through media, pornography and fashion. In real life, though, women and men know very little about genital diversity. And little research has been conducted on what constitutes normal genital appearance.</p>
<p>Marketers of female genital cosmetic surgery make a genital tissue “trim” seem like a simple lifestyle choice. But trimming labia is not the same as trimming one’s hair. The labia minora (inner lips) isn’t made of ordinary skin but tissue rich with nerve fibres <a href="http://www.ncbi.nlm.nih.gov/pubmed/18564153">that developed</a> as part of the primordial phallus (what becomes the clitoris during fetal development). </p>
<h2>A lucrative industry</h2>
<p>Female genital cosmetic surgery comprises a suite of relatively new procedures. Labiaplasty – where the labia minora are “trimmed” to not extend beyond the margins of the labia majora (outer lips) – is the most common, accounting for about 50% of all such surgeries. </p>
<p>Genital-related anxiety seems to have increased over the past decade, along with the use of <a href="https://www.themedicalbag.com/bodymodstory/porn-star-surgeryaka-the-barbie">terms</a> such as “Barbie-plasty”, “designer vagina” and “vaginal rejuvenation”. Google these and you see a plethora of consumer websites touting “facts” <a href="http://www.aesthetica.com.au/treatments/labiaplasty/">such as</a>: “more than 30% of women have excess genital tissue”. </p>
<p>These websites reinforce existing social and cultural messages about the vulva and vagina but <a href="http://bmjopen.bmj.com/content/2/6/e001908.full">offer scant information</a> about the diversity of genital appearance. Nor do they talk about the long-term risks of the surgery, which have not yet been researched. </p>
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<a href="https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=789&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=789&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=789&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=991&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=991&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=991&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In female genital cosmetic surgery, the labia minora are ‘trimmed’ to not extend beyond the margins of the labia majora.</span>
<span class="attribution"><a class="source" href="http://www.labialibrary.org.au/anatomy/">The Labia Library/Women's Health Victoria</a>, <span class="license">Author provided</span></span>
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<p>Such advertisements tap into the dissatisfaction some women feel about not being “normal”. But their existence shows a new and lucrative area. Prices in Australia for labiaplasty vary from A$3,000 to A$9,000 and can be coupled with clitoral hood reduction or mons pubis reduction (the mounded area above the pubic bone) – specialties women are seeking in high numbers. </p>
<p>These surgeries can be performed by anyone with a medical degree. No formal training is required and there are currently no evidence-based guidelines to support the procedures.</p>
<p>Complications often arise. Surgeons may remove too much genital tissue, exposing the woman’s clitoral head to undergarments and causing pain in ordinary clothing. Another common complication is irregularity and scarring along the trimmed labia minora or change in pigmentation of the skin and hypersensitivity. </p>
<p>Worryingly, the complications are so common that one prominent, plastic surgeon in the United States has found a lucrative market for correcting them, dubbing them <a href="http://www.labiaplastyrevisionsurgeon.com/index.html">“botched labiaplasties”</a>.</p>
<h2>Guidelines for GPs</h2>
<p>While few Australian researchers have explored the GPs’ role in cosmetic surgery, UK studies <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020045/">have indicated</a> a need for GPs to educate women who express concern about their genital normality or appearance.</p>
<p>The recently launched doctors’ resource – the <a href="http://www.racgp.org.au/your-practice/guidelines/female-genital-cosmetic-surgery/">RACGP guidelines</a> for female genital cosmetic surgery, which I helped develop – address the lack of balanced information. The guidelines recommend doctors listen to and educate patients about genital normality. Doctors are encouraged to refer women to sites such as the <a href="http://www.labialibrary.org.au">Labia Library</a> to help them understand the diversity of genital appearance.</p>
<p>Guidelines also advise GPs to examine the woman respectfully and explore the reasons for her concern. This is an opportunity to consider the psychological or sexual reasons for her anxiety by discussing personal or relationship issues, past history of sexual abuse or even mental health issues. Anecdotal evidence from GPs and surgeons suggests coercion due to partner criticism is sometimes a factor for women’s genital shame.</p>
<p>GPs should refer a woman for a gynaecological opinion if they feel their advice is not sufficiently reassuring. If the patient is under 18, they should refer her to an expert adolescent gynaecologist. </p>
<p>Hopefully the RACGP guide will prompt GPs and other health professionals to take the time to discuss women’s concerns about their genital appearance and ultimately reduce the rate of unnecessary and potentially harmful surgery.</p><img src="https://counter.theconversation.com/content/45650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Magdalena Simonis is affiliated with
RACGP National standing Committee Quality Care
Women's Health Victoria, board member .</span></em></p>New guidelines launched by the Royal Australian College of General Practitioners aim to help doctors educate women about the variety of genital appearance and stop them having unnecessary surgery.Magdalena Simonis, Lecturer, General Practice and Primary Health Care Academic Centre, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.