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BackTable / OBGYN / Podcast / Transcript #14
Podcast Transcript: Cosmetic Gynecology
with Dr. Cheryl Iglesia
In this episode, Dr. Mark Hoffman invites Dr. Cheryl Iglesia to shed light on the topic of cosmetic gynecology. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Origins of Cosmetic Gynecology
(2) Cosmetic Gynecology: A Definition
(3) Why Do Patients Want Cosmetic Gynecological Procedures?
(4) Patient Autonomy in Cosmetic Gynecology
(5) Technological Advancements in Cosmetic Gynecology
(6) The Surgical Techniques of Cosmetic Gynecology
(7) The Rise of Social Media and its Influence on Cosmetic Gynecology
(8) The Intersection of Science and Trends: Meeting Patients Where They Are
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Dr. Mark Hoffman] Hello, everyone, and welcome to The BackTable OBGYN Podcast, your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com. Welcome back to The BackTable OBGYN Podcast. This is Mark Hoffman, and we have a very special guest today, Dr. Cheryl Iglesia. Welcome, Dr. Iglesia. [Dr. Cheryl Iglesia] Thank you, Dr. Mark Hoffman. [Dr. Mark Hoffman] Mark, please, and we were talking earlier, and you had asked that I call you Cheryl, so I appreciate that. Dr. Iglesia or Cheryl is a Professor of OB-GYN and Urology at Georgetown University, the Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center. She's also the Director of the National Center for Advanced Pelvic Surgery, and we are very excited to have you here to talk about cosmetic gynecology. Welcome to the show. [Dr. Cheryl Iglesia] Thank you, Mark. [Dr. Mark Hoffman] We always like to let our listeners know a little bit about our guests, not just their expertise, but also where you're from, how you got into the work you're doing, and more specifically, how you came to become an expert in cosmetic gynecology. [Dr. Cheryl Iglesia] Oh, okay. Well, let's see. I actually haven't gotten very far, because I actually was born and raised in Baltimore, Maryland, and I went to Hopkins for undergrad, and then for med school, I was at the University of Maryland, and because my significant other was down in Florida, I ended up doing my OB-GYN residency down in Florida. He was in anesthesia at USF, and I ended up doing OB-GYN at University of Florida at Jacksonville. Our chairman, Robert Thompson, who's now deceased, was very active in both the American Urogyn Society, and it introduced me to the site for gynecologic surgeons, so much so that I ended up doing a fellowship with Debru Baker and Dee Fenner, and I think we both know Dee. We shared Dee together, since you were at Michigan. [Dr. Mark Hoffman] That's right. [Dr. Cheryl Iglesia] Chicago, and then after that, I actually did a stint with the late Tom Benson, close to you in Indiana on a neuro-urology and the neurodiagnostic studies for pelvic floor disorder. I learned a lot about neuroanatomy, and how to do nerve conduction studies and EMGs for sexual dysfunction and incontinence and fecal incontinence, urinary, and whatnot. That's how I came to this. It's specifically for cosmetic gynecology when I was on the Patient Education Board, as well as a Chair of the Committee for Gynecologic Practice. Now, they're the committees that write those committee opinions and the technology assessments. This came across the desk, because there were a lot of advertisements for the term "vaginal rejuvenation".
(1) The Origins of Cosmetic Gynecology
[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.
(2) Cosmetic Gynecology: A Definition
[Dr. Cheryl Iglesia]
Yes, and honestly, that term "vaginal rejuvenation", "designer laser vaginoplasties", that's not in these official terms. Because that is a marketing term, and you and I also know that the FDA recently, as of 2018, came down pretty hard on some companies, who were marketing for specific indications ahead of really having any robust data. However, I want to be clear that the definition of cosmetic gynecology has two different aspects of it.
It's the elective intervention to alter the aesthetic appearance of the external genitalia, or modify the genital organs, and for elective functional procedures in the absence of any pathology. I'm talking like you're not having incontinence. You're not having an episiotomy that didn't heal well, overt stage three prolapse. Anyway, it's elective with the goal of improving a person's quality of life, and that could be sexual function or whatnot, but it's a pretty broad definition that isn't specific to certain diagnosis.
People have the option of not liking the way their eyelids look, their nose looks, and I think people have the option of not liking the way their labia minora look. I think that in general, OB-GYNs look at the full spectrum of normality. I think we may be less likely to do elective interventions than cosmetic surgeons, plastic surgeons who are trained, who don't really look at pathology.
At the same time, they're not following women longitudinally like we do, cradle-to-grave, and know what happens over time, as women age after you have children, after menopause hits, and so on. There's two different hats, in terms of aesthetics, functionality, and then the whole reconstructive realm. There's a flow chart in this document, which maybe we can add.
[Dr. Mark Hoffman]
We can put it in the show notes for sure.
[Dr. Cheryl Iglesia]
That'll be great, so that people can click onto it. I do like this flow chart. The first question is, is this, whatever procedure you're planning on doing, medically indicated, or does it address a pathology? If you have stress incontinence, that's not considered cosmetic surgery. If you have overt cystocele uterine prolapse surgery that's not considered. If you have abnormal labia, and it's getting in the way or discomfort with exercise.
[Dr. Mark Hoffman]
Which is a common one a lot of us hear, getting stuck in clothes, and things like that, or even pain during intercourse, or discomfort and things like that.
[Dr. Cheryl Iglesia]
That's right. Huge asymmetry. That's not necessarily considered cosmetic gynecology. If they answer, "No", to that, being medically indicated, or addressing a pathology, the next question on this flow diagram is: “ is the intent to cause injury or psychological harm?”
What we're getting at there, and I know the World Health Organization really comes out strongly on this, is the aspect of female genital mutilation or FGM for clitorectomies, infibulation, the gishiri cuts that are done in certain cultures. Again, that would not be considered cosmetic gynecology. There are cultural mores, and there are laws about doing some of these procedures in our own country, particularly, for adolescents under the age of 18.
Then, if the answer to that, in terms of causing psychological harm or causing injury is, "No", then the question is, is the patient making a well-informed autonomous decision in the absence of any external pressure or coercion? I think this is where this has exploded, because of what people are seeing, images that people are seeing on the internet, pornography.
(3) Why Do Patients Want Cosmetic Gynecological Procedures?
[Dr. Mark Hoffman]
That's what we talked about. Again, I had a member of my faculty. I was considering even giving a grand round on this, just because it was something that I feel like prior to pornography becoming just ubiquitous on the internet, just so easily accessible before you probably had to go to some store on the other side of town. You had to physically go somewhere.
Now, anybody with an internet connection can see things that you couldn't see without someone either exposing you to it, or having to go somewhere to get it. In the past, when we thought of cosmetic surgery, it was things that were easy to see, noses, or breast size and things like that. Now, there was a whole new world of what was normal, or what was considered attractive.
Where before the only external genitalia you might have seen was either your own, or maybe a sibling or a parent, who probably had pretty similar-looking anatomy. Now, we had exposure to endless amounts of anatomy, in a way that didn't exist before. People started looking in the mirror and saying, "Maybe I look different," and this is something that.That was our theory.
Actually, we did some very quick looks and Google searches. You can go back and look at Google history searches, and look back. It was around the time of those shows, the number of searches went up exponentially. It became hugely popular to learn about that.
[Dr. Cheryl Iglesia]
It sounds really intriguing to say that. Who doesn't want to get their vagina rejuvenated? A lot of Hollywood stars ending relationships, and then, "I went to clean that all up, and got my vagina rejuvenated." Let's just be real that women are all already-- Many people are very insecure when it comes down to sexual health. There's so much airbrushed stuff.
[Dr. Mark Hoffman]
We see people online, a lot of these Instagram stars that are being caught manipulating their own photos. Not only are they professionally manicured in a certain way, they're even digitally altering the after, just to make it look right. We have a whole image issue in this country to address.
[Dr. Cheryl Iglesia]:
Let's not forget that with, particularly the millennials, 83%-- We did a paper on this, just a survey, literally on the street survey. 80% do some type of pubic hair grooming. It's a huge multimillion-dollar industry for laser hair removal. Anyway, once you remove all the hair, you do have a different view of what's down there, and there's a lot of pressure for these girls.
In the locker rooms, they're like, "Oh my God--," I remember seeing the Sex and the City show, Samantha telling-- I forget which of the other women, "I wouldn't be caught dead looking like that," on the beach with her bathing suit on, some pubic hair showing. There's a lot of shame. Let's just say, when there's a lot of shaming going on, and whether it be on your sexual debut, and you're like, "That's not what-- What is that? Oh my gosh."
(4) Patient Autonomy in Cosmetic Gynecology
[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."
(5) Technological Advancements in Cosmetic Gynecology
[Dr. Cheryl Iglesia]
That's where having the skill set, educating yourself, and surrounding yourself with other people who are looking at the technology but then also studying it. I will disclose, and I probably should have at the beginning of when I was describing where I'm from. Currently, I am the 49th president, only the fifth woman, and the first Filipino-American President of the Society for Gynecologic Surgeons.
[Dr. Mark Hoffman]
I should have put that in your intro, because it's one of your many titles. That's an amazing one.
[Dr. Cheryl Iglesia]
I'm excited about that. I'll tell you why, because it relates to cosmetic gynecology. The other thing is I am currently a special government employee for the US FDA. I've served on five panels, including some of the stuff that is controversial, like vaginal mesh, the morcellator, the Essure, and some other things. I like to look at technology.
I like to do the level one evidence, and I think that we need to do a better job in introducing new technologie. I'll be giving this TED talk at the AGL on this, how to do that ideally. Usually, you start with a small group to look at technology, work on the kinks, figure out the iterations, before things spread, and that's a little bit of what the concern is that, with cosmetic gynecology, some of that marketing got ahead of the science.
At the Society for Gynecologic Surgeons right now, I know that they've got some trials looking at laser, and laser with or without steroids for lichen sclerosus. I think there's a protocol right now on PRP, and whether or not that works. That's the kind of stuff that we see, which is platelet-rich plasma for sexual enhancements, that's the kind of stuff, so that needs to be done.
I know when I go to a lot of these cosmetic talks and they're like, "Patients don't really care. They just care about how it looks." At the same time, I get that because there's no objective criteria about that, but you can when it comes to functionality, and the patients do need to know what we have because we have an extremely good level one evidence for incontinence and prolapse procedures. And that's where it gets all muddied, and it's important to be able to ethically have that conversation, and match what you can deliver with those goals for the patient.
[Dr. Mark Hoffman]
No, and then you brought up the FDA, and you worked there, and I got to work with ACOG's Committee on Health Economics and Coding for a few years and chair that committee, and learned a lot about how the stuff comes through, but also the morcellator. And we talked a lot about that in my department, and what we're going to do with that, but how do these devices get put through the system?
Not just how they get value, but how the FDA, we talk about approval, but really it's not approval. If there's a predicate device that's similar enough, 510(k) process that just says it's close enough, we can let it through, so these devices can get through much more easily than a full FDA review and approval, and so the devices typically proceed the research, oftentimes, come before the research.
I think by being able to do what you're doing, and taking these devices and looking at them, because the alternatives, they come out, no one looks at them. Then we found out after the fact, like some of the mesh things that we shouldn't have been doing that. I think if, that's one of the big challenges that I feel with the ivory towers or the traditional academic sites to get these new devices reviewed, you almost have to prove that it works first, which defeats the purpose, because if we're trying as academicians and as researchers to study whether or something is safe or effective or beneficial, if I can't get it into my institution to look at, or I can't study it until it's been out there for a while, then what happens it's almost like the academic institutions are the last ones.
They may do the RCTs once it's been out for a decade, but they're not the ones at the front of the line doing the work early on. I applaud that very much, and I think-- I'm excited to hear you talk, because that's something that I agree with. It's something we're missing.
[Dr. Cheryl Iglesia]
Yes. Specific to cosmetic gynecology, so what the FDA back in 2018, and then there were probably over 40 different laser radiofrequency energy-based devices available to the United States, and they were people saying, "Use this laser, it's going to fix your dry vagina." "Use this it's going to cure your stress urinary incontinence." "Use this one, it's going to make it tighter for you and for your partner."
They called this out, even the term "vaginal rejuvenation" because they didn't have the data. One of the most recent trials that just came out, and it was in October of 2021 on JAMA was from Australia, a study that did look at a Sham versus, the Li article, versus a CO2 laser for GSM, and it was at a year follow-up showed no difference. Something people can criticize is that study looking at the power, and the settings of the lasers, and the way that some of these patients, 50% of them I think, had breast cancer.
Maybe these people need to be primed, because these lasers focus on targeting the chroma for water in the tissue, and so particularly, breast cancer patients, but the bottom line is, it's not good to have patients have an expectation. I'm going to spend $2,000, and I'm so afraid of estrogen, because they have breast cancer, when we have some evidence that some of the estrogens are safe with the formulations that are FDA-approved in the doses that are recommended, and in conjunction with speaking with the patient's oncologist.
They go to this, ust because they see the marketing, and that's where you can get some harm. Maybe not so much harm in terms of burns and stuff like that, but it's significant harm because that's a whole chunk of change out of one's pocket, and I see it. I had a urologist that did laser and charged $2,000 to this woman, who was middle class.
She worked at a bank, and had stage street prolapse, and there was just no way that laser was ever going to help that prolapse, and that's not ethical. We did her robotic colpopexy and her sling, and then she sent her daughter and then she sent all of her friends from the bank, and it was all covered by insurance.
Again, it goes down to the goals and I think that we do have to have real conversations, and I think a lot of doctors, particularly, board-certified MIGs and OB-GYN specialists, and urogynecologists do that very ethically. Sometimes I wonder what happens in some of these medical spas though, where you have estheticians just doing it, and putting a wand in there, or a probe, not even doing a speculum exam to check for any type of pathology, or wipe out the lubrication that's in there, that's going to fog up the mirrors, so that laser is never going to do anything.
Anyway, there's just a bunch of stuff and it's really refreshing when I see the multidisciplinary work that's being done at, I'll say IUGA, and studies being done at SGS, and the collaboration with the ASLMS specialists, who are thought leaders, and people like Macrene Alexiades, who's a real guru on radio frequency, dermatologist from Yale.
It's nice to be able to have these conversations and then to put a pause on it for people who, if you're going to do it, let's make sure we do the right thing, and collaborate with the right people.
[Dr. Mark Hoffman]
I agree with you, because as someone who needs to know more, which is why I was personally interested in having you on, I think a lot of us who are OB-GYNs or GYN surgeons don't know what's out there, because it's like, "Well, it's cosmetic. That's not what I do, so I'm not going to know about it," but the fact is, our patients are looking for it.
They're searching for it, they're looking online, and what they find is a spa, or someone who's not trained, or doesn't know the data and the research, and then they come to see me and I go, "Well, that's not really what I do." That's on me, that's not an excuse for me not to know, and so I need to be able to tell folks what's available, what the options are.
[Dr. Cheryl Iglesia]
What the limited outcome data is.
[Dr. Mark Hoffman]
Yes, exactly. Thank you.
[Dr. Cheryl Iglesia]
Buyer beware.
(6) The Surgical Techniques of Cosmetic Gynecology
[Dr. Mark Hoffman]
Yes, so we've talked a little bit about labiaplasty, and I think many of us are familiar with that.
[Dr. Cheryl Iglesia]
Yes. You can do a labia minoraplasty, or you can do things with labia majora with fat grafting and augmentation.
[Dr. Mark Hoffman]
I was reading about that, like liposuction of the labia majora.
[Dr. Cheryl Iglesia]
Yes.
[Dr. Mark Hoffman]
You mentioned lasers and RF ablation, what's being done, what's out there? What does the data show about those technologies, and how should we be counseling our patients?
[Dr. Cheryl Iglesia]
Yes, so for the laser, which most of these are fractioned, we're all OB-GYNs who are really familiar with lasers. We use it for CO2, for HPV, and we use it for like zapping endometriosis intraperitoneally, which is cool, particularly, if you're near a vessel, or the ureters, but these are fractionated lasers, and when you do that, the lasers are divided into much smaller laser beams with normal tissue between, and the temperatures, the power and fluency is a lot lower, so that you're not burning tissue, you're supposedly, stimulating the tissue growth factors, and to make new collagen and new blood vessels, and that's how it works.
There have been a lot of histological studies that are published for the vagina, and for the vulva. So lasers are being used for resurfacing, it's known very well in Fraxel for the face that different kinds of lasers have different depths of penetration. Most of the ones that are used in cosmetic gynecology are in that far infrared spectrum with a very low depth of penetration, not the Argon beam or Pico lasers which go a lot deeper.
Argon beam, we use for cancers, and around the liver, and Pico is used for tattoo ink. But this stuff is like, doesn't even get down past the dermis to the lamina propria, so it's very superficial. The good news is, the types of burns are pretty low. The bad news is that, I think that, again, it needs that water, and so if it's super, super dry, particularly, in people who are with their aromatase inhibitors, just don't think we're going to have that tissue effect.
[Dr. Mark Hoffman]
What tissue effect are you looking for? What are the indications for these procedures, what are the outcomes we would have?
[Dr. Cheryl Iglesia]:
Again, none of these have been cleared because the FDA has defined processes, has only cleared it for incision, ablation, coagulation of tissue, including gynecological, vulvar skin, and vaginal skin. It's not been cleared for indication, but what it's been used for is GSM, which is Genitourinary Syndrome of Menopause and lichen sclerosus. That's for the CO2, and the Erbium lasers.
There's been a little bit on incontinence, a stress urinary incontinence, none of which has panned out, but the radiofrequency, laser is light energy, and radiofrequency is more current. For radiofrequency, that's been used more so with, I even liken it to shrinky-dink. They used it on the outside to get rid of wrinkles until the labia shrink down. It's more labor-intensive, you're there wondering for a much longer time.
They used it at the introitus, at the level of the perineal body to help with vaginal laxity. There's a couple of studies that are out there looking at level one evidence, Sham versus active radiofrequency for that. It's also been used for stress incontinence, and there's even intraurethral, but many of us know that there were some former products that were used using radiofrequency devices that never really panned out, in terms of that.
The bottom line is, the data is low-level evidence. We don't have big randomized trials. In fact, I think that's what the FDA is trying to get at. We need for our GSM, both vaginal atrophy, dyspareunia, I think that's one of the big ones. We need level one evidence for looking at laser versus sham. We did a small pilot study looking at laser. It's called the velvet trial with us, Haven Clinic. There were seven sites looking at laser versus estrogen for GSM and dyspareunia, and they were pretty much equivalent. The study was very under power.
[Dr. Mark Hoffman]
That's a big deal, though.
[Dr. Cheryl Iglesia]
It was equivalent.
[Dr. Mark Hoffman]
That's not nothing.
[Dr. Cheryl Iglesia]
It's not nothing. We had the Vaginal Maturation Index, which was better with the estrogen, but pretty much all the other objective factors, Vaginal Health Index, and the female sexual function was pretty much equivalent. We need larger trials, we need multi-site trials. I think the FDA probably wants to look at more of these Sham-controlled studies, specifically, before you start marketing and having been paid thousands of dollars, because each of these treatments range from $500,000 a pop.
You need three or four of them to get the desired effect several weeks apart. That's a biophysics of that. That literally is more on the energy-based side. I guess laxity, GSM, lichen sclerosus, stress urinary incontinence. I think people are even looking at urgency, incontinence, dyspareunia. Those are some of the major diagnoses that people are looking at.
In terms of the other anatomical aesthetic stuff, it gives me pause a little bit, because there's been a lot of cosmetic surgery that's based on what they're doing to the clitoris. There's the clitoral, you can get a frenulum reduction, called a frenulectomy. You can do surgery to affect the prepuce.
[Dr. Mark Hoffman]
Is that with the intent of increasing sexual arousal?
[Dr. Cheryl Iglesia]
Some people feel there's exposing the glans for an enhancement of sexual function, orgasmic dysfunction, but there's a clitoral hood lift with the prepuce, they call it, hoodectomy. Some people will resect that, lichen sclerosus, if there's adhesions around it.
[Dr. Mark Hoffman]
Any data on any of that?
[Dr. Cheryl Iglesia]
Rachel Rubin just recently did a little study on clitoral adhesiolysis. She's got some stuff out there, not a lot. Then, there's a clitoral amplification with the platelet-rich, the PRP, platelet-rich factor, a plasma, and the injections, like the O-Shot and stuff. Again, not a lot. A lot of this is proprietary. I'm just letting you know what's out there.
[Dr. Mark Hoffman]
Well, no, because our patients are going to be interested in it. They're going to be searching for it, and we talked about the internet. They're going to find it, and the question is if they come to us, and we give them nothing, they're going to go somewhere else and find it. If we can all educate ourselves, and It's very concerning, because you do damage, and it's irreversible.
[Dr. Cheryl Iglesia]
That's right. I worry about the clitoris, right? Particularly, in a young woman, it's highly innervated. Thousands of nerve endings. The clitoris itself with arousal can engorge 50% to 300%. I don't like to mess with it. Anyway, that gives me pause a little bit, but obviously, people are doing it.
[Dr. Mark Hoffman]
If they're doing it, we should know about it a little more.
[Dr. Cheryl Iglesia]
We should know about it, and buyer beware, yes, really. Particularly for young people, I think, lichen sclerosus is a bit different. Then, there are other options that, in addition to the tightening, which is more on the radiofrequency energy-based side, that's that whole vaginal rejuvenation.
[Dr. Mark Hoffman]
Is that just basically, in a sense, heating up? When we talk about RF ablation in gynecology, we think more about endometrial ablation.
[Dr. Cheryl Iglesia]
The shrinky-dink effect.
[Dr. Mark Hoffman]
Shrinky-dink effect of the vagina. Tightening. Any data on that?
[Dr. Cheryl Iglesia]
Vaginoplasty. No, there's not. It's proprietary. Which we can just do. I can do an anterior and posterior repair. Now, is there a randomized trial? That would be very interesting to see. The question is, Mark, and this is where, again, the gray goes. Again, remember the first question is, is this addressing a significant pathology? What people who do this stuff as marketing, and again, it's very, very gray.
They're going to be marketing for the not significant pathology, just a little bit of, they call laxity. I just want it to be a little bit tighter without having to have an incision over what we do for overt prolapse. Again, I think we just need some more data on it because it is a problem. The International Incontinence Society or whatever, the IUGA does have a terminology called vaginal laxity. How do we define it? It's a sensation of looseness.
(7) The Rise of Social Media and its Influence on Cosmetic Gynecology
[Dr. Mark Hoffman]
Right. It's not something any woman can measure, necessarily. At least, they don't at the moment. I think people can get it in their head that maybe one person told them that once, and it's in their head forever, that that's their problem. I think it is the other big part of the two, because people are very self-conscious, and it's an area that people aren't as comfortable talking about, which is why, again, having a show like this, having you one to allow us to shine a light on it.
[Dr. Cheryl Iglesia]
So that you know what's going on there.
[Dr. Mark Hoffman]
This is what's out there. If you're not on Instagram. That's how people find stuff out.
[Dr. Cheryl Iglesia]:
Or listening to goop.
[Dr. Mark Hoffman]
Yes, we could do a whole other show on that.
[Dr. Cheryl Iglesia]
TikTok. A lot of the stuff on TikTok. The other thing that's out there on the vagina side is, vaginal augmentations with fillers, which is called vaginal augmentation. This is for sexual enhancement. The O-Shot, the G-Shot, the G-Spot amplification, PRP injections, including hyaluronic acid injections into the anterior vaginal wall, the high whatever the G-spot is, they feel like, behind the clitoris, along that anterior vaginal wall. Again, you're paying hundreds, if not thousands of dollars for this, which is very limited evidence.
[Dr. Mark Hoffman]
And not risk-free. These are procedures.
[Dr. Cheryl Iglesia]
Yes. I've heard of cases where people are having a major reaction to that hyaluronic acid. I understand that there are issues. I mean that people use a lot in the orthopedic literature. That's why we have this trial going on with PRP versus placebo, but they use it in the knees. There might be something there.
Again, how we introduce these things, let's do it in a small group of well-trained surgeons, and have very specific outcomes, and outcomes that matter with a patient, whether it be like, "Is this is going to help me with my orgasm? I'm having problems with an orgasmic dysfunction."
[Dr. Mark Hoffman]
It'd be nice to give them an actual answer.
[Dr. Cheryl Iglesia]
It really would be nice.
(8) The Intersection of Science and Trends: Meeting Patients Where They Are
[Dr. Mark Hoffman]
Of these, anything you've incorporated into your practice? You talked about, you went out to California, you learned how to do some of these things.
[Dr. Cheryl Iglesia]
Obviously, yes. We are doing, in addition to laser for GSM, I actually have done a lot. We published the CURLS Trial in 2021, which was clobetasol versus steroid versus fractionated CO2 for lichen sclerosus. That's the CURLS Trial. Then, clobetasol versus steroid, and it showed equivalence, which was a really good sign, which is right now.
[Dr. Mark Hoffman]
That's huge. What period of time is that? Because when I do that, we're talking months, years, how long are we doing this?
[Dr. Cheryl Iglesia]
We presented six-month follow-up, and they got three treatments, and people were able to cross over. We followed it up, and it hasn't been published, but we are presenting it at the meeting, and I think at a dermatology meeting. We recently did a study looking at the laser in people with lichen sclerosus, and we did the histology. There was one study, I think, out of the Ukraine, or Croatia, or something.
I think it was Bulgaria, honestly, but there wasn't a lot. We were pleasantly surprised. We have a dermatopathologist that we worked with that actually showed, not only the difference in the histology, but it correlated with the objective findings. That kind of stuff, honestly, Mark, we're doing these kinds of studies because this isn't cosmetic. There's been nothing new for lichen sclerosus in 40 years since they realized that testosterone didn't work. This is something that, obviously, it affects 3% of women, can lead to cancer, squamous cell cancer, it can lead to significant architectural damage to young women, where lichen sclerosus can prepubertal and postmenopausal make really, really big changes. If we have this information and we can-- That's important, right? It'd be nice for insurance to cover that too.
[Dr. Mark Hoffman]
No, it's amazing. We typically think of older patients with lichen sclerosus, but we also all have those younger women that are dealing with it, and it's extremely disruptive, and that architectural change is irreversible mostly, right? Having a solution for that beyond just clobetasol and good luck is, it'd be nice to at least think of some other opportunities.
[Dr. Cheryl Iglesia]
The whole purpose of this cosmetic gynecology terminology was really to establish a framework, so that people who are doing this, and particularly investigators. We can have something, so we can advance this, and practice evidence-based medicine, and improve safety. There's a whole thing on there about reporting complications.
At the same time, it's not really wanting to just promote cosmetic oncology, we still, and it's our almost moral obligation to emphasize that, there are many anatomic variants of normal, and it's normal, unless it's causing distress, discomfort, or bother.
[Dr. Mark Hoffman]
You're doing the work of meeting patients where they are though. I think when we say, "It doesn't matter what it looks like, it's all normal." If patients don't feel that way, we are, in a sense, passing judgment, or we're telling them that their feelings about their bodies don't matter, and that's where the whole cosmetic side of surgery for the whole body is,
we can ignore it, or we can understand that that's where the patients are, that's where their interests are.
I think that's, again, filling that gray and being the President of SGS and having all the accolades you have, and being an expert in so many areas, but to be the one to also say like, "I'm going to talk about this, I'm going to be the expert, so we can teach others, because our patients are going to find that either way." Speaking of which, where do you see-- You've given a talk, I think what's called, "The Quest for the Perfect Vagina." Right?
[Dr. Cheryl Iglesia]
Yes. That was actually an editorial in the Green Journal. It has followed me and they bring that editorial back up.
[Dr. Mark Hoffman]
I'll make sure this podcast is heard by as many people as possible, so they always ask you about it.
[Dr. Cheryl Iglesia]
Right. It was a great editorial, and I loved it because it did just what we're talking about today, which is talking about these things, and putting it in the Green Journal, right? The journal we all think of as, from all of our subspecialties in OB-GYN, we all come back to that, and so it could reach a wide audience to talk about this topic that all of us need to hear about.
[Dr. Mark Hoffman]
Since you are now,we're making you the expert on this forever. Where is the quest for the perfect vagina going? What's on the horizon? What else are our patients reading about? What else are those that make the technologies, and those that make the devices, and the doctors who are trying to do this, where's it headed? What else are we going to see going forward?
[Dr. Cheryl Iglesia]
Well, I think what we are hoping, and I think there are a lot of people down under, I think there are a lot of pediatric gynecologists in England, gynecologists in Australia. I think there's a better awareness that, what's normal is not this narrow definition of the labia, like no camel toe have to be kissy-kissy, I think that's coming out there, but there are a lot of social media forces, and pornographic images that we have to play into.
I think we're going to see some trials coming out that are the IND-like trials. I'm specifically interested in some of the trials coming out on breast cancer survivors in our own country, because there's a couple on clinicaltrials.gov right now that are coming out, and I think that'll be really important. We just have to keep spreading the word, so that people feel very comfortable, and promote body positive images that sexual health is healthy, and that's the only thing that we can do, understanding where this is coming from? I don't know. We could talk a lot more about shame.
[Dr. Mark Hoffman]
A lot of people, a lot of cultures, a lot of this country is built on shame, I mean the history of this country, and a lot of that without getting political, there are a lot of people in this country, who think talking about sex, or talking about the sexual organs is a shameful enterprise, and I think that it's the kind of thing that we can pretend that these things don't exist, but they do.
They're a huge part of most people's lives, and I think that, like you said, making it something we can all talk about, making it something that we're more comfortable understanding what normal is. Again, I know in the mid-2000s, there weren't any of our societies that were promoting on social media what normal labia looked like, right? It was pornography, it was E-Entertainment Television and those things.
We may not be first, but if we're not the voice, if we can't be a voice to compete with those other voices, with those other media, then that's where they're going to find out, that's where they're going to learn. I guess we're a little behind as always, right?
[Dr. Cheryl Iglesia]
I think you need to have a show on orgasm, Mark. Orgasm and masturbation.
[Dr. Mark Hoffman]
Are you going to come back, and do it? You are an expert on that too?
[Dr. Cheryl Iglesia]:
No, I'm going to give you some names.
I honestly feel like what's happening is that people, they're not educated and they're going to these other sources, because they see that as a problem. Now, you've got other things like the OSHA to help, but I think we need to talk about the clitoris, have something specific to the anatomy and the physiology and of the sexual response, so, arousal.
[Dr. Mark Hoffman]
It's this big mystery, not because no one cares, but because not enough work has been done to study this stuff, and understand it. Most of the work was done, it's been decades, and, yes, there's a huge need for it, and the expectations about arousal and orgasm, and those things don't follow the science, so, yes.
[Dr. Cheryl Iglesia]
See how there's so much of this functional aspect that we need to do, but that's where a lot of these marketing things have come across, because of the dearth of information that's solid.
[Dr. Mark Hoffman]
Somebody will fill the void, somebody will answer that question, but do you want it to be the person who's the most educated in those areas, who's done the most work, or do you want it to be the person who can potentially profit off it? I think that we have, so kudos to you, thank you for coming on the show. I know you're a very busy person, and we know that you made extra efforts to be here today, and so we're very grateful for that, this has just opened up a whole bunch of new stuff for us.
[Dr. Cheryl Iglesia]
Keep a conversation going.
[Dr. Mark Hoffman]
Yes, that's what this is.
[Dr. Cheryl Iglesia]
This is a fantastic podcast I've listened to. You have a great voice, I think the ideas are great.
[Dr. Mark Hoffman]
Oh, thank you so much.
Podcast Contributors
Dr. Cheryl Iglesia
Dr. Cheryl Iglesia is the Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center in Washington, D.C.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2023, February 16). Ep. 14 – Cosmetic Gynecology [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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