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.

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).

• The Great Wall of Vulva (website with images of plaster casts of over 500 labia)
• So what's a vulva anyway? (pdf information leaflet from Brook)
• The Labia Library (website, Women's Health Victoria with information and photographs)

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).

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 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.