Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guideline Platform
  3. Gynaecology
  4. Back
  5. Gynaecology guidelines
  6. Female genital cosmetic surgery, Gynaecology (626)
Announcements and latest updates

Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Female genital cosmetic surgery, Gynaecology (626)

Warning

Objectives

To provide guidance to health professionals involved in the care of those requesting surgery to change the appearance of their vulva

Audience

Healthcare professionals working in primary and secondary care involved in the care of individuals with a vulva

Please report any inaccuracies or issues with this guideline using our online form

Female genital cosmetic surgery (FGCS) describes a group of surgical procedures designed to change healthy female genitalia for perceived improvement in cosmetic appearance (1).  Labiaplasty is the most common FGCS procedure, and describes a surgical procedure involving partial removal and reduction in the size of the labia minora.  Commonly, there will be reduction bilaterally to both labia minora, but may also be carried out to reduce asymmetry when one is longer than the other. Removal or reduction of the clitoral hood may also be performed ‘hoodectomy’.

Other FGCS procedures include vaginaplasty, liposuction of the labia majora, fat injection to the labia minora and mons pubis, hymenal reconstruction, hair transplantation, and laser therapy. (2)

Why is FGCS requested?

The reasons that FGCS are requested are often to alleviate perceived functional discomfort, improve appearance and increase self-esteem.  It is thought there is pressure on those with a vulva to appear ‘neater’, with a younger, pre-pubescent look being more desirable (3).  Vulvodynia (pain without a clear identifiable cause) is not an indication for FGCS.

What is a normal Vulva?

The size range and symmetry of the adult labia shows a wide variation. It is often useful to support a patient presenting with concerns and discuss the range of ‘normality’. The RCOG ethical paper opinion outlines clinicians have a duty of care to provide this information (1).

It is also essential to discuss the anatomy of the vulva including demonstrating the mons pubis, labia majora, minora, clitoris and hood, urethra, vaginal vestibule, perineum and perianal areas (1). A recent study suggesting up to 40% of patients are unable to correctly identify genital structures, with implications for health care seeking and shared decision making (4).

Implications of FGCS

The implications of FGCS can stem from unrealistic expectations, with many women being disappointed with the outcome.  Surgery can be marketed as helping urinary function and sexual functioning, however there is a lack of high quality evidence.

Additionally, there can be scarring affecting functioning and appearance.  Importantly, there can be issues with residual pain, change in sensation and altered sexual functioning.  In the short term there can be complications with wound dehiscence (up to 30%) and infection (1).

When can FGCS be offered?

Overall, FGCS should be considered as medically non-essential surgery.  The RCOG recommends   that FGCS should not be undertaken within the NHS unless it is medically indicated, and should not normally be offered to individuals below 18 years of age, due to continued anatomical development during puberty. 

All surgeons who undertake FGCS must be aware that the procedure may be prohibited unless it is necessary for the patient’s physical or mental health, and they must take appropriate measures to ensure compliance with the FGM Acts. (5)

As such, within Greater Glasgow and Clyde Health Board, FGCS is not offered as a cosmetic only procedure.

Exceptions may include where surgery is medically necessary and secondary to another underlying medical conditions.  Examples may include

  • Anatomical Implications secondary to genital Cancer
  • Significant congenital malformations e.g. secondary to congenital adrenal hyperplasia
  • Repair after significant trauma, e.g. secondary to severe adhesions from Lichen Sclerosus

Referrals

Referrals should initially be made to general gynaecology.

Links to educational and supportive information as above should be made available to patients and those working in primary care prior to review in clinic.

The RCOG recognises that often, the ‘desire for labial reduction is a type of displacement for other forms of anxiety or lack of feelings of self-worth, and thus whether counselling may be more appropriate than surgery’.  To this end, psychology referral should be considered in primary care prior to referral to gynaecology.

The patient may then be seen by any gynaecologist. If that gynaecologist is of the opinion that there are no abnormalities of the external genitalia, and there is no evidence of a dermatosis requiring treatment, then the patient should be reassured and discharged from gynaecology.

Women should be directed to the information above if they have not already accessed.  Advice should be regarding general vulval care.

Where surgery may be required (see indications above), an opinion and/or input from the Plastic Surgery Service may be required. Where there are complications arising from previous FGCS, plastic surgery should be involved and consideration given to clinical photography as part of clinical notes.

Editorial Information

Last reviewed: 14/11/2023

Next review date: 31/10/2027

Author(s): Claire Higgins.

Version: 2

Approved By: Gynaecology Clinical Governance Group

Document Id: 626