BJOG Editor's Choice

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The evidence-based management of vulval ‘disorders’ has often been neglected by academic and clinical experts. In this edition of BJOG, we focus on vulval cancer and vulval plastic surgery.

In 1998, we published a large audit of 411 women with vulval cancer managed in the Midlands region of the UK in the 1980s (Rhodes et al. Br J Obstet Gynaecol 1998;105:200–5). At that time, vulval cancer management often occurred in low-volume general hospitals and, as a result, management, including surgical practice, was disparate with many older women having suboptimal treatment and outcomes. In the last 14 years there has been a UK policy of centralising the management of vulval cancer. This has resulted in more uniform practice and improved outcomes, demonstrated when practice was re-audited (Yap et al. J Obstet Gynaecol 2011;31:754–8). In this month's BJOG, we have included two papers, one from England by Lai and colleagues on page 728 and one from the USA by Rauh-Hain and colleagues on page 719, that have used national registries to evaluate trends in incidence and outcomes during similar time periods up to 2009. In both countries, the trends are very similar. The English study demonstrates that vulval cancer has increased in incidence over the last decade across all age ranges by 18% (Figure 1) and mortality across all age ranges has decreased by 25%. In both studies, younger women presented with earlier-stage disease and their survival from vulval disease was a lot greater than for older women (Figure 2). In the US study, older women were more likely to have primary radiotherapy and, if surgery was performed, lymphadenectomy was more often omitted. These are similar findings to the trends found by Rhodes and colleagues before the centralisation of cancer care in the UK. In both papers it is clear that older women present with later-stage disease and have a poorer prognosis. Strategies to improve women's awareness of vulval symptoms and lesions, and their importance, should be considered by primary-care providers.

Figure 1.

Trends in incidence in vulval cancer for different age groups in England. Source: Lai et al., p 728.

Figure 2.

Adjusted hazard ratios for vulval cancer specific disease comparing different age groups in the USA. Source: Rauh-Hain et al., p 719.

In contrast to trends in incidence and outcomes in vulval cancer, vulval plastic surgery is becoming one of the ‘hot’ topics in gynaecological practice and the issue is receiving lots of media attention. Certainly in my own unit, the demand for labiaplasty has risen dramatically over the last decade and a specialist service has been designed to accommodate the needs of the women requesting such surgery. Women's perceptions of the normal vulval appearance is being modified by the influence of plastic surgery publicity, pornography and the desire to look ‘perfect’. The most common request for vulval plastic surgery is to reduce the size of the labia minora so that they are smaller than the labia majora and are symmetrical. In a study from Australia by Moran and Lee, a group of women were exposed to images of natural external genitalia and vulvas that had undergone labiaplasty. Women who viewed vulvas that had undergone labiaplasties first were more likely to consider normal genitalia abnormal than if they had seen photographs of normal genitalia first. Accompanying this research study, we have four short ‘perspective’ opinion papers on pages 767–8 giving polarised views on the issues of vulval cosmetic surgery. They make interesting reading; I thought I had fixed views on the subject but now I am not so sure!

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