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Female genital cosmetic surgeries (FGCSs) and procedures are increasingly being advertised as common, simple, and complication-free, capable of not only improving aesthetic appearance but also increasing self-esteem and sexual pleasure.Guidelines for physicians and clear, scientifically correct information for patients must be made available, to minimize the number of ineffective or deleterious procedures.The International Society for the Study of Vulvovaginal Disease positions/recommendations regarding FGCS are as follows:1. There is a wide variation regarding genital normalcy; providers must be able to explain this to women.2. There are no data supporting FGCS including, G-spot augmentation, hymenoplasty, vulvar and perianal bleaching/whitening, vaginal tightening procedures, and other procedures aimed at increasing sexual function.3. Women should not be offered FGCS before the age of 18 years.4. Women undergoing FGCS should be evaluated by a provider with expertise in vulvovaginal diseases, including attention to their psychological, social, and sexual context. Evaluation by an experienced mental health provider should be considered when the motivation for seeking surgery and/or expectations are not clear or realistic.5. Female genital cosmetic surgery is not exempt from complications.6. Informed consent must always be obtained.7. Surgeons performing FGCS should refrain from solicitous advertising or promoting procedures without scientific basis, including on Web sites.8. Surgeons should not perform surgery that they do not agree with and explain their rationale/position when pressured by patients.9. The genital surgeon must be adequately trained in performing FGCS including knowledge of the anatomy, physiology and pathophysiology of the vulva, vagina and adjacent organs.

The concept of genitourinary syndrome of menopause (GSM) was recently introduced and has been gaining widespread use. While some justifications for its introduction are straightforward, others may be questionable. Numerous unspecific symptoms and signs were included in the definition of the syndrome, but the minimum number required for diagnosis was not established. While the GSM definition is designed to facilitate identifying vulvovaginal and urinary estrogen-deprivation-associated symptoms and signs, several concerns have evolved: (1) the syndrome may result in the underdiagnosis of vulvar and urinary pathology; and (2) serious conditions (e.g., high-grade squamous intraepithelial lesions of the vulva or vulvar intraepithelial neoplasia, differentiated type) may be missed while others may not receive appropriate treatment (e.g., lichen sclerosus, overactive bladder). In addition, the transformation of urogenital symptoms and signs into a syndrome may create an iatrogenization of menopause, which, consequently, can lead to demand for (and offer of) a panacea of treatments. This can be detrimental to the care of women who require focused therapy rather than global treatment addressing a variety of genitourinary conditions, not all of which even require any form of intervention. Women's needs may be better served by having a more precise urogenital diagnosis.

The 21st century brought along a number of discoveries and medical advances. With the advances, we can mention the following: target therapies for cancer, genomics and molecular biology, pharmacogenomics, minimally invasive and robotic surgery, immunosuppressive therapies in transplant patients, human papillomavirus in the era of vaccination, and aesthetic vulvovaginal procedures. All of them have greatly influenced medicine. As a scientific society, we have several challenges. In the past, you had to go to a library to get information. Now, we have readily available, accessible information. Thus, here comes the debate; we are facing a change in our educational paradigm, which needs to be approached from an integral and holistic perspective. New historical and cultural circumstances call for a deep reflection on the current social validity of scientific societies. They should be open to new ideas and allow dissent, work in teams, and speak a common language. They must be organized and, in constant communication with its members, support and organize research developing well-designed clinical trials and observational studies. We should work for our patients, recognizing the importance of the whole woman. We all have a great scientific and humanitarian challenge; to succeed, we must not lose sight of who we are working for. We work for them, our patients, and not for us. Our mission is to take care of our them!

Background The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology is controversial. Aims In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Materials & methods This project was developed between January and September 2018. The development of this document followed the ICS White Paper Standard Operating Procedures. Results Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and studies are industry sponsored. Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. Discussion The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Conclusion At this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

OBJECTIVE In a series of cases of high-grade vaginal intraepithelial neoplasia (VaIN) at our institution, to analyze its clinicopathologic characteristics, diagnostic methodology, and therapeutic results obtained with the use of CO2 laser vaporization. MATERIALS AND METHODS Between January 2003 and December 2009, 28 patients with a diagnosis of high-grade VaIN were treated in our department using CO2 laser vaporization. Of the 28 patients, 7 were lost to follow-up; 21 patients were followed up with cytological examination and colposcopy for therapeutic response. Median follow-up was 25 months (range = 12-78 months). The setting is an urban referral center, a private hospital with a high-grade complexity. RESULTS Of the 21 patients evaluated, 18 are currently disease free after having undergone a single application of CO2 laser vaporization with a cure rate of 86% (95% CI = 63.7%-97%). Three patients (14%) presented with persistence/recurrence and required a second application. Of these 3 patients, 2 are currently disease free, whereas 1 patient progressed to invasive carcinoma 11 months after a second procedure and was managed with partial colpectomy and pelvic lymphadenectomy. CONCLUSIONS CO2 laser vaporization was effective for the initial treatment of high-grade VaIN. However, a long-term follow-up is required due to the recurrent character of this disease.

To evaluate what the appropriate indications are for vulvovaginal (VV) plastic surgeries in our environment.This is a retrospective study of 73 consecutive patients who were seen on consultation at the gynecologic aesthetic unit between January 2008 and January 2009 asking for a VV aesthetic surgery.All patients completed the Female Sexual Function Index questionnaire and received information on sexuality.Of the 73 patients seen on consultation, 32 (43.8%) underwent surgery, and the main reason for this was reduction labioplasty in 19 patients, widening vaginoplasty in 6, reduction vaginoplasty in 1, and resection of asymmetries in 6 patients. None of the patients seen on consultation for vulvar bleaching, G-spot amplification, or augmentation labioplasty underwent surgery. Postoperative complications included wound dehiscence in 3 patients (9.3%) and a vulvar hematoma in 1 patient (3.1%).Postoperative sexual satisfaction was optimal for 30 patients; only 2 complained of dyspareunia.Most patients seen on consultation for VV plastic surgery had no need for it and only received information regarding female anatomy and sexuality. Reduction labioplasty owing to hypertrophy of the labia minora represented the most frequent reason for consultation and surgery. Indications for VV plastic surgeries should be based not only on surgical results but also on the reported satisfaction achieved by those patients who did not undergo surgery and only received appropriate information during consultation.

A workshop on updates on intraepithelial neoplasia of the vulva was held at the 2009 World Congress of the International Society for the Study of Vulvovaginal Diseases in Edinburgh, Scotland, September 2009. This is a review of the information presented.

Vulvar intraepithelial neoplasia (VIN) is a high-grade intraepithelial squamous lesion and precursor of invasive squamous cell carcinoma (SCC). The 2004 International Society for the Study of Vulvovaginal Disease (ISSVD) classification distinguished two types of VIN: usual type (human papillomavirus (HPV)-related) and differentiated type (not HPV-related). The incidence of usual-type VIN is higher in younger women, while differentiated-type VIN is more common in older patients with chronic dermatologic conditions. Differentiated-type VIN has a greater invasive potential and shorter time between diagnosis and SCC than usual-type VIN. The diagnosis of VIN is carried out by identifying a lesion by visual inspection and confirming by performing a biopsy. Screening tests are not available. Patients with usual-type VIN are at a higher risk of developing another HPV-related malignancy of the anogenital tract; therefore, examination from the cervix to the perianal area is mandatory. The therapeutic approach to VIN balances the invasive potential with the need to be as conservative as possible. Current prophylactic HPV vaccines offer protection against usual-type VIN and related invasive carcinoma.

To evaluate the effectiveness and safety of imiquimod 5% for the treatment of bowenoid and basaloid vulvar intraepithelial neoplasia (VIN) and to evaluate recurrences following treatment.Eight patients55 years old (range, 32-51; mean, 39.7), with bowenoid or basaloid VIN 2/3 diagnosed by biopsy were treated with imiquimod 5%. Women with other types of intraepithelial neoplasia of the lower genital tract, immunosuppressed women, pregnant women and women with other types of vulvar pathology were excluded. Two patients previously treated for VIN 3 (surgical resection, resection by loop electrosurgical excision procedure) had recurrences. Patients applied imiquimod cream 3 times a week until total clearance of the lesions or up to a maximum of 16 weeks. Responses were categorized as total when there was no colposcopic evidence of a lesion, partial when the lesion area diminished50% and progressive when there was an increase in the lesion area. A biopsy was performed at the end of treatment. Follow-up was carried out monthly (10-30 months).Total clearance of lesions was observed in 6 patients after 10-16 weeks. Two patients had a partial response (1 with 75% and the other with 50% reduction of the lesions). Posttreatment histopathology showed the absence of precancerous lesions in 7 patients (87.5%). Biopsy was positive for VIN 3 (12.5%) only in the patient showing a clinical response of 50%. Of the 7 patients with biopsies negative for VIN, 2 (25%) were positive for viral infection; 1 gave a negative reading after 2 months after treatment, and the other 1 remained positive for human papillomavirus. The patient with persistent VIN received surgical treatment. The side effects were as follows: erythema in 8 patients (100%), erosions in 1 patient (12.5%) and edema in 1 patient (12.5%). No relapses occurred after treatment during 10-30 months of follow-up.In this initial series, imiquimod proved to be effective for the treatment of bowenoid and basaloid VIN 2/3 in a group of young women and was less aggressive treatment than surgical ones. The treatment was well tolerated, causing local reactions that enabled the therapy to be completed.