Aesthetic gynecology

Yana Yutskovskaya , MD, professor, doctor of the highest category, owner of the clinic chain LLC “Professor Yutskovsky Clinic” (Vladivostok) and LLC “Professor Yutskovsky Clinic” (Moscow), member of the board of directors of NADC (Russia)

Alexander Yutskovsky , MD, professor, doctor of the highest category, honorary director of the Yutskovsky Professor Clinic LLC (Vladivostok), chairman of the Primorsky branch of RODVIK (Russia)

Evgeniy Leshunov , urologist, andrologist LLC "Professor Yutskovskaya's Clinic" (Moscow), "Professor Yutskovskaya's School" (Moscow), Department of Urology, State Budgetary Educational Institution of Further Professional Education, IPK FMBA, Secretary of the International Society of Gender Medicine Specialists (Russia)

Interest in human sexuality and its manifestations has always been quite great. At the same time, the change in social and moral norms towards greater tolerance in this area, which has occurred in the last 20 years, has not at all reduced the level of interest, and perhaps even contributed to its growth. The importance of sexual health for a woman’s quality of life and overall health cannot be overestimated, but this topic is too often ignored by first-line doctors: gynecologists, dermatovenerologists and therapists

RELEVANCE OF THE PROBLEM

There has been a noticeable change in attitudes towards female sexuality: the denial of the significance of sexual relationships has been replaced by recognition of the sexual-erotic sphere as exclusively important for women [1]. Moreover, sexuality as a significant, “core aspect of human existence” [2] is today becoming a sphere of commercial interests [3]. Increasing attention to issues of sexuality and sexual behavior on the part of the media, the identification of sexual and personal success of women, on the one hand, and the preservation of contradictory attitudes towards female sexuality, on the other, naturally lead to an increase in internal tension when interacting with the sexual-erotic sphere and , as a consequence, to an increase in the number of functional sexual disorders [4]. Research conducted in Canada indicates that among patients over 25 years of age, 85% (out of 850 respondents) would like to discuss sexual problems with a doctor, but more than 70% believe that the doctor will ignore these questions [5]. This article is intended to help overcome certain barriers that exist for physicians, making the topic more accessible to “first-line” doctors who are able to correctly diagnose and treat manifestations of sexual dysfunction.

FEMALE SEXUAL DYSFUNCTIONS

Female sexual dysfunction (FSD) is a disorder of sexual desire, arousal, and orgasm directly related to sexual activity, as well as pelvic pain [6]. The appearance of any of these symptoms or their combinations causes anxiety in patients, negatively affecting the quality of life and interpersonal relationships. Considering that one of the most important areas of modern medicine is to improve the quality of life of people with various diseases, from this point of view, sexual dysfunction becomes a significant problem in modern medicine.

The classification of female sexual dysfunctions was created by the International Commission for Unification in 1998. In 2003, the classification of FSD was revised and adopted on the recommendation of the International Consensus Conference with the participation of the American Urological Association, based on the theory of sexual response proposed by Masters and Johnson, which describes the four phases of the female sexual response cycle (desire, arousal, orgasm, satisfaction).

For clinical practice, the best option is the FSD classification, approved in 2003.

Classification of female sexual dysfunctions

So, they distinguish:

1. Sexual desire disorders causing personal distress:

• • low sexual desire disorder (actually decreased libido) (hypoactive sexual desire disorder) – persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts and/or desire or receptivity to sexual activity;
• • sexual aversion disorder (sexual aversion disorder) – persistent or recurrent phobic aversion and avoidance of sexual contact with a sexual partner.

2. Sexual arousal disorder – a persistent or recurrent inability to achieve or maintain sufficient sexual arousal, resulting in personal distress. May be expressed as a lack of subjective arousal, lack of lubrication or other somatic reactions.

3. Orgasmic disorder – persistent or recurrent difficulty, delay or failure to achieve orgasm after sufficient sexual stimulation and arousal, resulting in personal distress.

4. Sexual pain disorder:

• • dyspareunia – recurrent or persistent pain in the genitals during or before sexual intercourse;
• • vaginismus (vaginismus) – recurrent or persistent involuntary spasms of the muscles of the outer third of the vagina, preventing penetration and leading to personal distress;
• • non-coital sexual pain disorder – recurrent or persistent pain in the genitals caused by non-coital sexual stimulation.

The proposed classification includes organic and psychogenic forms of sexual dysfunction. It is generally accepted that many functions in women are not strictly psychologically or organically determined. For example, objective signs of hypersensitivity or allodynia of the vestibular margin in some patients with dyspareunia, as well as increased muscle tone of the perivaginal muscles, are often associated with vaginismus and may be due to significant central or psychological determinants. The advantage of this classification option is that it identifies four main categories of sexual dysfunction, as they are necessary to maintain continuity in research into clinical practice.

Epidemiological studies

Current literature suggests that 40% of women worldwide suffer from sexual disorders [7].

According to R. Rosen, 43% of women complain of one sexual problem, while 11–33% of those surveyed fall within a specific problem category [8].

According to the National Health and Social Life Survey, 43% of women experience some kind of sexual dysfunction during the year [9]. An anonymous survey showed that among women aged 18 to 59 years:

• • 27–32% report a lack of interest in sex;
• • 22–28% – anorgasmia (every fourth);
• • 17–22% of women do not enjoy sex;
• • 18–21% experience pain during intercourse;
• • 18–27% report insufficient vaginal hydration during sexual intercourse.

Insufficient lubrication, according to research, occurs in 10-15% of the adult female population in Europe, reaching its peak at 25-35% among women aged 50 years. According to a survey conducted in Northern Europe, women aged 61 years have problems with so-called “vaginal dryness” in 43% of cases [10].

A common problem is dyspareunia. Two studies showed a prevalence of dyspareunia of up to 10% among European women. Danielsson et al. conducted a study including 3,024 respondents aged 20–60 years. They found that symptoms of dyspareunia were most common in those aged 20–29 years – 13%, and in the age group 50–60 years – in 7% of cases [11]. In Germany, Great Britain and Sweden, according to studies, dyspareunia occurs in 14–18% of cases [12, 13, 14].

According to epidemiological studies conducted in European countries, vaginismus varies from 5 to 1% of cases, depending on its form (sporadic or constant) [15]. These data are quite consistent with the data of another large epidemiological study conducted by Kadri et al., which showed the prevalence of vaginismus among women in Morocco to be up to 6% [16]. Similar results were obtained in a web-based survey conducted May 24–June 6, 2002, in which 730 white women and 364 African American women volunteered (94.5% completion rate). During the study, 288 (27.9%) women reported pain in the vulva, of which 80 (7.8%) noted that pain had bothered them over the past six months [17].

According to our study, conducted for the first time in Russia, including a study and survey of 540 healthy women in the Southern Federal District, the prevalence of FSD was distributed as follows:

• • sexual dysfunction in the form of problems with desire were identified in 179 women (33.1%);
• • problems of arousal – 248 (46%);
• • problems with lubricant release – in 245 (45.4%);
• • problems with orgasm – 227 (42%);
• • problems with satisfaction – 230 (42.6%);
• • problems with pain – in 239 women (44%).

There were statistically significant differences between different age groups in scores characterizing desire (p = 0.005), arousal (p = 0.001), orgasm (p = 0.001) and satisfaction (p = 0.0011) [18].

If only a small number of women consider sexual dysfunction to be a problem, this may partly explain the fact that only a proportion of them seek medical help for the condition.

Rice. 1. Prevalence of female sexual dysfunctions. Research results

MEDICINE SOLUTION TO THE PROBLEM OF FEMALE SEXUAL DYSFUNCTIONS

The drug Flibanserin was developed by specialists from the German pharmaceutical company Boehringer-Ingelheim. It was originally intended to combat depression. In Europe, 1,946 women aged 18 years and older took part in testing the new drug. The effect of the drug was also tested on 5 thousand North American women. Flibanserin has been shown to be effective and safe in the treatment of sexual arousal disorders. The drug is a 5-HT1A agonist and a 5-HT2A antagonist and is called “female Viagra” based on its mechanism of action.

TREATMENT OF ANORGASMIA WITH INJECTION PLASTIC METHOD

Today, there are methods of intimate injection plastic surgery that can solve the problem of orgasmic dysfunction. Augmentation of the projection zone of the female prostate gland is the method of choice in the treatment of female orgasmic dysfunction of both organic and psychogenic nature when psychotherapy fails or in combination with it.

At the creation stage, this procedure was subject to modifications; in particular, the volume-forming drug was replaced. The first fillers used for G-spot augmentation were autologous adipose tissue and collagen, but due to frequent cases of migration, organization (lipofilling) and inflammation (collagen) in the injection site, these drugs are now used less and less. Hyaluronic acid is a polysaccharide, a high-molecular carbohydrate compound, found in the skin of animals and humans, and is part of the intercellular basic substance of the connective tissue of vertebrates, which determines its use in various fields of medicine.

For intimate contouring, drugs are used that are developed and registered for administration in the anogenital area. The drug is used to increase the “G-spot”, clitoris, volume of the labia majora and minora, as well as to moisturize the vestibule of the vagina, clitoris, and clitoral mantle.

In the area of the “G-spot” and the space between the anterior wall of the vagina and the urethra, hyaluronic acid gel is injected into the submucosal layer using a drip, linear-retrograde or “fan” technique. The volume of the administered drug is 0.5–1.0 ml. A 25–27 G needle is used. In this case, not only does the projection area of the “G-spot” increase, but also a slight decrease in the volume of the vagina, which is especially noticeable during sexual intercourse at the time of the formation of the so-called orgasmic cuff (Fig. 1).

Rice. 1. “G-spot” area after the augmentation procedure

As a result of the intervention, the “G-spot” projection zone becomes the most protruding part of the anterior vaginal wall, more accessible to tactile influence, which increases its sensitivity and thereby improves intimate life. The introduction of the gel into the “G-spot” area can also reduce urethral hypermotility - the main cause of urinary incontinence, which occurs as a result of involutional changes in tissue. Thus, this procedure can solve two serious problems at once.

Research conducted at the Professor Yutskovskaya Clinic LLC proves the effectiveness of the procedure for sexual arousal disorders and orgasmic dysfunction. The study involved 40 women of reproductive age, average age 36 years. Women who did not have regular sex life and did not have a regular partner were excluded.

All patients were examined by specialists: a gynecologist, a plastic surgeon, and a psychologist. The intimate filling procedure with augmentation of the “G-spot” and the head of the clitoris was carried out under local application anesthesia; in none of the cases did any adverse events or complications arise. All patients were surveyed using the international FSFI (Female Sexual Function Index) questionnaire (Table 1). Outcomes were assessed prospectively before and 2 months after the procedure. Significantly higher mean FSFI values (29.4 ± 1.1) were found after intimate correction compared to baseline values (24.5 ± 2.2) (P < 0.05). Based on this, we can conclude that the method used is highly effective and safe and recommend it as an alternative to psycho- and drug therapy for orgasmic dysfunctions.

LASER VAGINAL REJUVENATION

This technique is based on the use of high-intensity laser energies to solve various problems associated with involutional processes occurring in the urogenital area. Considering the high social significance of the problem of rehabilitation of patients with problems of vaginal prolapse, stress urinary incontinence, and vaginal relaxation syndrome, laser techniques are gaining high popularity and are being actively introduced into clinical practice.

The main advantages of the new technology:

• ● minimally invasive intervention without incisions and bleeding;
• ● fast and simple outpatient procedure;
• ● does not require anesthesia;
• ● does not require special preparation and post-operative care;
• ● does not require consumables.

Today, the aesthetic medicine market has a large selection of various laser devices that can be used in aesthetic gynecology. Basically, either an erbium (Er:YAG) or a CO2 laser is used for this purpose.

There are a number of publications where A. Gaspar et al. evaluated the effects of two fractional laser systems - CO2 and erbium - in combination with local application of platelet-rich plasma and pelvic gymnastics. An improvement in the condition of the vaginal wall and a narrowing of the vaginal diameter was observed in both groups, but more complications were recorded in the group of patients who received CO2 laser treatment. Side effects include burning and excessive narrowing of the vagina.

The use of an Er:YAG laser with variable pulse duration (100, 300, 600, 1,000 μs) allows for procedures combining ablative and coagulation components, and rejuvenating non-ablative procedures based on coagulation effects leading to a reduction in mucosal area and super-powerful stimulation of collagenosis in the submucosal layer.

At Professor Yutskovskaya Clinic LLC, to realize this effect, we, together with Asclepion Laser Technology, have developed a new method of laser vaginal rejuvenation, which is based on the use of an Er:YAG laser (2,940 nm) of the 6th generation MCL-31 (Asclepion Laser Technologist, Germany) and Juliet vaginal attachment.

A special feature of this method is the 2-stage technique of performing the procedure and the combination of ablative and thermal modes, which allows a stepwise effect on both the lamina propria (submucosal layer), causing collagenogenesis, and on the vaginal mucosa, triggering neoangiogenesis, while eliminating the possibility of damage to the muscular layer of the vagina and overheating of the tissue.

Juliet is a unique tool, which is essentially a 3rd generation attachment, in which we were able to take into account all the advantages and correct all the shortcomings of previous generations of attachments for vaginal rejuvenation. The main advantages of the 3rd generation are the ability to use a vaginal attachment without special dilators and the ability to sterilize both in an autoclave and in antiseptic solutions.

Today, our clinic has accumulated enormous experience in conducting vaginal rejuvenation procedures, which exceeds 400 clinical cases. We have developed protocols for using the Juliet technique to solve the following problems:

• • vaginal relaxation syndrome;
• • vaginal prolapse grade 1–2 according to POP-Q;
• • stress urinary incontinence of the 1st–2nd degree;
• • vaginal atrophy;
• • vaginal dryness syndrome (post-radiation, postmenopausal, metabolic).

In 2014, at the annual European Congress on Anti-Age Medicine (AMEC), a new method of treating vulvar lichen sclerosus using an Er:YAG laser in combination with the Plasmolifting method was presented and appreciated (a prize for the best clinical case in aesthetic gynecology). .

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Today, the “Clinic of Professor Yutskovskaya” is one of the leading centers dealing with the problems of aesthetic gynecology. Since 2008, a special course on aesthetic correction of the anogenital area has been available at the training center. Every month, about 50 doctors are trained within the walls of the educational center “Professor Yutskovskaya’s School”. At the same time, the course program changes every 6 months due to modern trends and the emergence of new techniques. So we invite everyone to our training course who wants to get acquainted with modern trends in aesthetic gynecology, including laser vaginal rejuvenation (detailed information is presented on the website of the training center “School of Professor Yutskovskaya”).

The list of references is in the editorial office.

Table 1

First published: Nouvel Aesthetic 4 (92)/2015