Extreme Makeover: Vagina Edition

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Throughout history, women have adorned or altered their appearance to appear more attractive and desirable The genitals are no exception to this rule of adornment. Hair removal, piercings, tattoos, and yes, even surgery are all things that many women choose to do in the interest of making their private parts more attractive.

But it’s one thing to glue a few crystals on your mons or dye your pubic hair pink for kicks. It’s quite another thing to undergo plastic surgery to change the appearance of your genitals.

Along with the “less is more” pubic hair trend comes the ability to clearly see what things look like, and as with every other part of the body, women tend to be really critical of their appearance.  I’ve even had a few patients who were so self-conscious about the appearance of their labia that they avoided sexual intimacy altogether and requested  a trim even when reassured that their labia were perfectly normal.

Beyond appearance, many women do have lengthy labia that simply are uncomfortable or "get in the way" . lengthy labia can also obstruct the flow of urine, a situation known as urinary splaying. .

  I never realized just how many women were dissatisfied  with their labia  until I mentioned it in my book, The Essential Guide to Hysterectomy. Suddenly, women were coming out of the woodwork telling me that they wanted to have their labia shortened but they had never before asked because they were too embarrassed. While some women are motivated by being tired of cleaning urine off the toilet seat, others requested a labioplasty because they experience discomfort and irritation during sexual or athletic activities. And then there are those that simply don’t like the way their labia look.

Women who requested labioplasty in one study gave the following motivations for desiring surgery:

           Aesthetic dissatisfaction 87 % 

           Discomfort in clothing 64%

           Discomfort in playing sports 26%

           Uncomfortable sex 43 %

 

Another disturbing trend is the increasing number of teenagers requesting labial reduction surgery. In  May  2016, The American College of Obstetricians and Gynecologists (ACOG)  released  the following  position statement:

"When adolescents seek medical treatment, the first step is often education and reassurance regarding normal variation in anatomy, growth, and development. Nonsurgical comfort and cosmetic measures may be offered, including supportive garments, personal hygiene measures (such as use of emollients), arrangement of the labia minora during exercise, and use of form fitting clothing. If emotional discomfort or symptoms persist, then surgical correction can be considered."

 In other words, labial surgery should be a last resort. The very last resort.  So, whether  you a teen or an adult, when opting for surgery, it’s important to keep in mind that there is always the risk of complication. And, like any cosmetic procedure, sometimes the result isn’t exactly what you had in mind, Unlike the minimalist pubic hair style which is all the rage today, there is no going back from surgery. My advice, love your labia as they are and only go for the 'designer vagina" if discomfort, not appearance is the issue. 

Hand-On-The-Door Questions

Hand on the Door Questions

I refer to them as the "hand-on-the-door" questions. They go something like this: One of my patients will come in for her annual visit.  After the exam we chat about her irregular periods, the occasional hot flash and her daughter’s new boyfriend. Finally, I ask, “Is there anything else you’d like to discuss?” “No,” she'll say assuredly."  “Ok, see you next year.”  Then, just as I'm about to leave the room, my patient blurts out a question– Do you think that bump on my labia might be herpes? How do you know I don’t have ovarian cancer?  Does my vagina smell? Her “hand-on-the-door” question is typically the most important one she'll ask during her appointment and is probably the reason she came to see me in the first place.

Who is a candidate for labiaplasty?

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Labiaplasty is a type of plastic surgery to shorten labia minora. This certainly isn't in the top 10 surgical procedures I perform, but it does come up at least a few times a year. The real question is, when are labia so long that they require surgery? While there's a huge range of what's considered normal, the average labia measures about one inch from base to tip. Most of my patients with excessively long labia request a labiaplasty not because they care about the cosmetic appearance, but because they experience discomfort and irritation during sexual or athletic activities. Certainly there are those women who desire "a trim" based on their idea of what's attractive, even when reassured that their labia are perfectly normal. I have had a few patients who were so self-conscious about the appearance of their labia that they avoided sexual intimacy altogether.

Labiaplasty is an outpatient procedure that can be performed by a gynecologist or plastic surgeon. Most women are sore for a couple of weeks and develop an affinity for boxer shorts. Bike riding and sex are generally out of the question for about a month. Most women who have this procedure are highly motivated and say that the end result was worth it.

What causes postmenopausal vaginal bleeding?

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A bloody vaginal discharge after menopause is commonly due to dryness and thinning of vaginal tissue from lack of estrogen. Vaginal infections such as yeast or bacterial vaginosis are another culprit. Bleeding originating from the cervix can occur if there is a benign cervical polyp or cervical inflammation. Many sexually transmitted infections can cause cervical bleeding; if there is a new partner in your life, it is a good idea to be screened for chlamydia, gonorrhea and trichomonas. Cervical and vaginal cancers can also cause bleeding, but are less common.

Abnormal bleeding from the cavity of the uterus is caused by hormonal imbalances, benign growths such as polyps or fibroids, pre-cancer or cancer.

Can I bring my own gown with me to my gynecologic exam?

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It would be nice if every office provided roomy cloth gowns. But there's no rule that says you can't provide your own exam gown. Call prior to your appointment and inquire if your doctor prefers gowns that open in the front or the back. Keep in mind that your gown may get stained, especially if you are having a procedure. Bring something that you won't care if it gets ruined. A wrap around robe or loose dress with a front zipper is fine.

What is vaginismus?

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Vaginismus is a condition in which vaginal muscles spasm when you attempt to have intercourse. There are many reasons why women suffer from vaginismus, but it's particularly common in women who have a history of sexual abuse or trauma. The brain will send a "no" message to the vaginal muscles, causing them to spasm. In fact, if a woman had pain with intercourse in the past for any reason, her body and mind can remember that, causing her vagina to clamp down in an attempt to protect itself from further pain.

What is hysteroscopic myomectomy?

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Myomectomy is an alternative to hysterectomy that surgically removes fibroids and leaves the uterus behind. Most women that undergo myomectomy get an abdominal incision and require a six-week recovery. Hysteroscopic myomectomy is an underutilized uterus-sparing technique that removes problematic fibroids without an incision. This procedure is performed as an outpatient, takes less than an hour, and requires essentially no recovery. A hysteroscopic myomectomy can treat a uterine fibroid without the need for surgery, or even an incision. In this video, obstetrician and gynecologist Dr. Lauren Streicher explains more about hysteroscopic myomectomy.

How is the cause of postmenopausal vaginal bleeding determined?

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An ultrasound combined with a sample of tissue from the inside of the uterus will generally identify the cause of postmenopausal vaginal bleeding. Years ago, a surgical dilatation and curettage was the only way to obtain tissue. Now, a quick office procedure is usually performed in which a thin flexible catheter is threaded through the cervical opening into the uterine cavity. The catheter has a suction device on it such that a tiny amount of tissue can be aspirated and sent to the lab for analysis. Most uterine samples yield reassuring results, but on occasion uterine cancer, the most common gynecologic malignancy and the fourth most common cancer to occur in women, is detected.

How should I prepare for a gynecological exam?

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Unlike a trip to the dentist, where brushing and flossing is essential, women need not do anything to prepare for an exam with their gynecologist. Truly, the only expectation is basic hygiene -- a shower or bath within 24 hours is always appreciated. In some cases, a woman’s efforts to “prepare” for an exam could actually diminish a gynecologist's ability to get accurate test results. If a Pap test is on the agenda, it’s important that a woman hasn’t done anything to wash away or obscure the cervical cells that need to be screened for pre-cancerous changes. It is also impossible to evaluate an abnormal discharge or odor if the environment has been altered. That means no spermicide, no medications, no lubricants and no douching (you should never douche under any circumstance!) for 24 hours before your appointment.

And, ideally, no sex. Having intercourse without a condom the night before a Pap will not make a normal Pap smear abnormal, but it might obscure cervical cells so that it cannot be accurately read.

Should you cancel if you “forgot” the night before? Realistically, after waiting two months for an appointment, asking for the afternoon off work or desperately needing a refill on your birth control pills, it may not be practical to take a pass. Be sure to mention to your gynecologist that you had sex, and be aware that you may get a call back if the Pap can’t be read accurately.

On the other hand, if you are coming in specifically to check out an abnormal discharge or odor, you should probably reschedule. It’s pretty much impossible to figure out what is going on if you had intercourse hours before your visit.

If you are coming in for another problem, say abnormal bleeding, an STD check or pelvic pain, it really doesn’t matter.

Is it Okay to Have Sex the Night Before my OB-GYN Appointment?

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Having intercourse without a condom the night before a Pap will not make a normal Pap smear abnormal, but it might obscure cervical cells so that it cannot be accurately read. Should you cancel if you “forgot” the night before? Realistically, after waiting two months for an appointment, asking for the afternoon off work or desperately needing a refill on your birth control pills, it may not be practical to take a pass. Be sure to mention to your gynecologist that you had sex, and be aware that you may get a call back if the Pap can’t be read accurately.

On the other hand, if you are coming in specifically to check out an abnormal discharge or odor, you should probably reschedule. It’s pretty much impossible to figure out what is going on if you had intercourse hours before your visit.

If you are coming in for another problem, say abnormal bleeding, an STD check or pelvic pain, it really doesn’t matter.

Is it ever a good thing to have sex before your appointment? Actually, yes. If someone tells me they bleed every time they have sex, it is helpful to see where it is coming from -- the uterus, cervix or vagina.

What are the symptoms of lichen sclerosus?

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Lichen sclerosus (LS) usually occurs on the skin around the clitoris and/or labia, which appears white, thin and slightly wrinkled. In addition to intense itching, there can be cracks in the skin, bleeding and pain. No surprise, in the most severe cases intercourse is pretty much out of the question -- the skin not only splits, but scarring causes a narrowing and tightening of the opening of the vagina.

How often should I get a Pap test?

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Most women have it drilled into them that they must get a Pap smear every year but now the annual ritual of getting a Pap smear is not necessarily annual. Initiation of Pap smears and recommendation for frequency of Pap smears have changed and a lot of women are confused by how often they need to get one. The American College of Gynecologists has issued very specific guidelines, which are as follows:

  • Pap tests should begin at age 21
  • From 21-30, it is fine to get a pap every 2 years instead of annually as long as you have had 3 normal pap tests in a row and are low risk, meaning you have never had moderate or severe dysplasia, cervical cancer, Human Immunodeficiency Virus (HIV) or have a severe medical illness that compromises your immune system.
  • After age 30, every 3 years is fine, but only if you are low risk.
  • After age 70, you can cross Pap smears off your "to do" list as long as you have had a normal test for at least 10 years.