Cosmetic Gynecology: Balancing Societal Pressures & Patient Goals

[Dr. Mark Hoffman]
What year was that roughly?

[Dr. Cheryl Iglesia]
Mid-2000s. I don't know, 2006 or so. At the time, there was the opportunity to go out to Hollywood, and do a weekend course. I remember it was three days. It was $54,000 to learn about laser vaginal rejuvenation, and designer laser vaginoplasties, and these were trademarked terms. I remember inquiring about it, and I sent this to them, my chair, because at this point, after graduating fellowship, I ended up here and started the division at MedStar Health and Georgetown University School of Medicine. Showed this to my chairman, who quickly said, "Are you crazy, Cheryl? I'm not sending you to Hollywood for $54,000 to learn this."

[Dr. Mark Hoffman]
Then, you were fully expecting him to say, "Oh, that sounds great. Let me get out the checkbook."

[Dr. Cheryl Iglesia]
Well, I said, "Listen, Dr. Muduvnick, we'll get the return on this, because, look, you can charge these people. You can charge these people $12,000 for those little anterior/posterior repairs, which we're getting pretty much like 23 RVUs, if you add the hysterectomy on the sling, and it's just cash basis. I just do five of these, and I've made my money on this course." He's like, "You're crazy."

Anyway, I'm in academic medicine, and I'm still curious. I had to go and talk to people, including Urogyns that had done this, and I remember talking to John Nicholas. He was like, "Yes, you got to pay to play if you want that diode laser," but actually, the person who was very generous with his knowledge, and I have written some things with, published some articles, with Red Alinsod.

I actually did end up going out to Long Beach, and seeing what Red was doing, and learning about radio frequency and techniques, and laser technologies and other energy-based technologies. I just followed it, but I have to say, joining the American Society of Laser Medicines and Surgery and hanging out with some of the cosmetic dermatologists. It really helped me understand biophysics, and then helped me get a better awareness of what was missing, in terms of, I don't want to poo-poo all of this.

What kind of studies can we do for people who have serious issues like genitourinary syndrome of menopause, and the very bad lichen sclerosus? Clearly, being a fellowship-trained and double board certified urogynecologist, where does this fit in the armamentarium, cosmetic gynecology versus reconstructive pelvic surgery? I've given a lot of talks, and in my mind, have what you can charge insurance for, and what is maybe considered aesthetic. It really wasn't until this past year when I was asked, it's probably been about two years, honestly, Mark.

To be on a committee with them, I was on a combo committee to develop a consensus document on what cosmetic gynecology is, which was just published. It was published jointly in the Blue Journal this year, IUJ's journal, the International Urogyn Journal, as well as the Gold Journal with the American Urogyn Society Journal Urogynecology. It's been changed from FPMS to urogynecology, and we basically, did a consensus document on cosmetic oncology, gave the mini state-of-the-art lecture at the past Congress, which was in June in Austin on cosmetic terminology.

[Dr. Mark Hoffman]
For our listeners, can you give us a little brief summary of that? Because I think a lot of us have heard the term "cosmetic gynecology", and I asked you what year it was, because I remember I was a resident from 2006 to 2010, and that's when E Entertainment Television had the plastic surgeons on, and they had guys coming on talking about the G-Shot.

[Dr. Cheryl Iglesia]
Designer-- DLV. Beverly Hills, 90210.

[Dr. Mark Hoffman]
Yes, all of that, and it became?

[Dr. Cheryl Iglesia]
The O-Shot.

[Dr. Mark Hoffman]
Yes, exactly, and it became part of pop culture, more so than anything I think that we'd ever seen before. We can talk a little bit about that in a bit, too, and how this has become more popular, but let's maybe start from what the official definitions are, and then we go back into the pop culture stuff.

[Dr. Cheryl Iglesia]
Then, people feel really bad about themselves. The bottom line is, it should be autonomous. There shouldn't be any external pressure, even societal, social media pressure, or coercion. If that's the case, and everything's hunky-dory, you've been educated, you've been shown images of what is the range of normal, then there's the aesthetic tier that if you want your labia minora to be reduced, and undergo a labiaplasty, then that's considered cosmetic.

Then, there's a functional tier, and that's like you want your vagina tightened surgically. Now, that brings up this whole new concept of vaginal laxity. Me as a urogynecologist, I don't know where to draw the line, because why do I want to subject someone to some $2,000 radio frequency procedure, when I know how to treat you with reconstructive surgery that has ICD-9 or ICD-10, and CPT codes.

[Dr. Mark Hoffman]
I really appreciate how you've taken this topic, where people are very passionate about it on both sides like, "This is terrible, we should not be exposing these women to these procedures. We just need to tell the normal is normal." The other side is, "Hey, look, people are allowed to do what they want with their bodies and we don't. People get nose jobs, people get breast implants, all these things, and so how is this different? We should give people the choice."

What I so appreciate about what you've written and what you speak about, and why I wanted you here is because you found that gray in the in between, where you can say, "Life is gray. There is no black and white."

[Dr. Cheryl Iglesia]
Oh, yes.

[Dr. Mark Hoffman]
Where you can say, "Listen, this is here. This is what people are asking about. Let me become the expert. I'm someone who's worked really, really hard at becoming a surgeon and becoming good at it. If they're going to have these procedures, let me talk to them. Let me make sure they're not being pushed into it." Like you said, this is coming from the individual, and that we feel like they're making a well-informed decision.

Let me be the expert. If they're going to get these things done, it's done in a way that is as safe as possible, that is as well-informed as possible. A lot of what we get in the ivory tower, and I'll say, this is what I hear from people within my own department is, if you talk about it, people are just immediately passing judgment. Assuming that you're just trying to either get rich, or you're completely in line with, we should sculpt this perfect non-existent ideal, as opposed to just trusting people to decide what's best for themselves.

That's something maybe we could do about our job. I love that you've found this very patient-centered way of addressing this topic that we ought to be taking seriously, because a lot of people want to know about it.

[Dr. Cheryl Iglesia]
I think the key question is: First of all, just some principles when you're operating on someone, never operating on a stranger. You need to know who you're operating on. The second thing is, where they're coming from. The major thing that we have to ask is, what are the patient's goals? What is it that you want to achieve? "Well, I want to not make a lot of noises when I'm making love with my partner. I don't want to be wetting myself."