Feminine Wellness Podcast

Almost every woman who sits down with me about labiaplasty asks some version of the same question.

If you trim the labia, or reduce the extra skin over the clitoris, will I lose feeling? Will I stop having orgasms? Will orgasm be less intense?

It is a fair question. The internet is full of scare stories. Some of them come from poorly done surgery. Most of them come from a misunderstanding of where the nerves actually live.

I have spent more than thirty years operating on this anatomy, teaching it, recording it, and then repairing it when someone else has taken too much or when nature’s healing was not symmetric or smooth. I can tell you what the operating room shows. I can also tell you what the published numbers show. They agree more than the blogs do.

Done with respect for the nerves and knowledge of anatomy, labiaplasty and clitoral hood reduction — whether a trim, a wedge, a hybrid, or a rim — do not destroy clitoral sensation and do not cause long-term sexual dysfunction. In many women they do the opposite. Sex gets more comfortable. Orgasm gets easier. The extra fold of skin that used to bury the clitoris is no longer in the way.

That is not a slogan. That is what the best papers we have actually measured. The best paper was done by my Fellow Otto Placik, MD.

First, where the nerves really are

The clitoris is not only the little button you can see. It is a wishbone of erectile tissue that runs under the pubic bone and along the sides of the vaginal opening. The main clitoral nerves travel on top of that wishbone, deep, under a layer of tissue — not in the thin free edge of the inner lips, and not in the extra hood skin we usually remove.

A properly planned labiaplasty works on skin and the moist inner lining. A properly planned hood reduction works on extra folds of skin lying above or lateral of the clitoral nerve. Neither operation cuts the body of the clitoris. Neither operation chases those deep nerves. We know where they are and we stay away from them.

That is why a woman can have a generous trim or an extended wedge and still feel a light touch on the hood a year later. The nerve highway was never on the piece of tissue removed.

The inner lips themselves are sensitive. They have many small nerve endings along the edge. That is real. Numbness on those surgical edges does happen then the regrowth of small nerves occurs, and edge sensitivity goes back to normal.

The study that finally measured it

For years we had opinions. In 2015 we got a map.

Dr. Otto J. Placik — plastic surgeon in the Chicago area, the most prominent labiaplasty surgeon in the Midwest, and a proud Fellow and graduate of the Alinsod Institute — did what the field had not done. He did not just ask women if sex was “better.” Otto tested them. He has a very curious mind. He wrote the chapter on Clitoral Hood Reduction in my textbook.

With John P. Arkins he enrolled 37 women having reduction of the inner lips plus reduction of extra clitoral hood skin using the trim, or edge, method. At five mapped points — the hood and four spots on the lips — he used Semmes-Weinstein monofilaments. Those are the same fine nylon hairs a neurologist uses on a diabetic foot: you press until the hair bends, and the woman says whether she felt it. He tested before surgery, at two weeks, and at three, six, and twelve months.

That paper is:

Placik OJ, Arkins JP. A Prospective Evaluation of Female External Genitalia Sensitivity to Pressure following Labia Minora Reduction and Clitoral Hood Reduction. Plast Reconstr Surg. 2015;136(4):442e–452e.

* Journal page

* PubMed

* Author PDF

Here is what he found.

* No loss of feeling on the clitoral hood.

* No loss on the inner part of the lips, closer to the vaginal opening.

* At six months the cut edge of the lip was not numb. It was slightly more sensitive.

* At six months, 44 out of 100 women were having sex more often.

* 35 out of 100 were reaching orgasm more often.

* 35 out of 100 said those orgasms were stronger.

* 34 of the 37 women came back at six months. 28 were followed at least a year.

His conclusion, in the journal’s own words:

“Labia minora and clitoral hood reduction as performed by the trim/edge resection method does not result in diminished sensitivity.”

That sentence should be on every consult sheet in this country. It came from a prospective map, not a marketing brochure. I am proud it came from a surgeon I trained.

A year later, in the same journal, European colleagues wrote a letter about Otto’s paper. They did not attack it. They put it next to the two largest series in the world and said the same thing we tell patients: the nerves survive a careful operation.

Oranges CM, Largo RD, Garcia Nuñez D, Schaefer DJ. Letter on Placik and Arkins. Plast Reconstr Surg. 2016;137(4):758e.

* The letter

The two biggest series ever published

Before Otto’s touch-tests, we had two giants doing their diligent research. They asked women, in plain language, what sex felt like after surgery.

Dr. Gary Alter, 2008. A wedge removal of the inner lips plus reduction of extra hood skin on the sides. 407 women. 166 sent back questionnaires.

Alter GJ. Aesthetic Labia Minora and Clitoral Hood Reduction Using Extended Central Wedge Resection. Plast Reconstr Surg. 2008;122:1780–1789.

* PubMed

Among those who answered:

* About 23 out of 100 said sexual feeling improved — easier orgasm, more sensitive.

* About 5 out of 100 said sexual feeling changed for the worse — harder orgasm, or less feeling in the lips.

Read that twice. In the largest American wedge series, more than four times as many women felt more as felt less. The 5 out of 100 matters. I will come back to it. It is not the typical result. It is the tail you see when too much tissue comes off, or a scar pulls, or a woman is already struggling.

Prof. Stefan Gress, 2013. A “composite” operation: inner lips, hood, and a clitoris that sat too high brought a few millimeters closer to the vaginal opening. 812 operations.

Gress S. Composite Reduction Labiaplasty. Aesthetic Plast Surg. 2013;37:674–683.

* PubMed

* Author summary

Gress wrote that fears of lost sexual feeling were unfounded. None of his patients reported a problem getting sexually stimulated. About 35 out of 100 said they were easier to stimulate after surgery, especially the women whose clitoris had sat too high and came down a little. Three women had temporary pain with intercourse. It was gone by two months. No lasting numbness. No strange burning that stayed.

The 2016 letter put those two numbers on one page: Alter, about 23 better and 5 worse. Gress, about 35 more easily stimulated. Then it pointed at Otto’s touch-tests as the reason the questionnaires make sense.

Hood reduction is not “clitoral surgery”

Women hear “clitoral hood reduction” and picture a knife on the clitoris. That is not the operation. We are not cutting the clitoris.

The hood is a fold of skin. Extra folds bury the sensitive tip. Reduce the fold and more of that tip can meet touch. That is mechanics, not magic.

In 2010 a multicenter group that included Otto Placik and other experienced genital surgeons looked at 258 operations and separated hood work from vaginal tightening.

Goodman MP, Placik OJ, Benson RH III, Miklos JR, Moore RD, et al. A Large Multicenter Outcome Study of Female Genital Plastic Surgery. J Sex Med. 2010;7:1565–1577.

* ScienceDirect

* Open PDF

They simply asked women whether sex was better, the same, or worse.

* After labiaplasty and/or hood reduction alone, about 65 out of 100 said sex improved at least somewhat.

* When those operations were combined with vaginal tightening, about 93 out of 100 said sex improved.

* About 97 out of 100 were satisfied with the labiaplasty / hood result.

* The wedge had a slight edge over a straight trim for sexual improvement — 70 versus 56 out of 100 — but both groups improved.

A year later the same lead author reviewed the whole field and put sexual satisfaction after these operations in the 80 to 85 out of 100 range, and overall satisfaction in the 90 to 95 range.

* 2011 review

* Open PDF

That is not “everyone becomes a different person in bed.” It is “most women are the same or better, and the ones who came in hurting often stop hurting.”

What later studies mean when they talk about “sexual function scores”

After 2015, most papers stopped using nylon hairs and went back to questionnaires. The one you will see named in headlines is the Female Sexual Function Index.

That is not a medical test. Nobody draws blood. Nobody puts a probe on the clitoris. It is a written survey, usually 19 questions, that asks a woman about the last month of her sex life. It covers six ordinary things:

* Desire — do you want sex?

* Arousal — does your body turn on?

* Lubrication — do you get wet enough?

* Orgasm — can you get there, and how often?

* Satisfaction — is the experience worth having?

* Pain — does intercourse hurt?

Each area gets points. Those points are added into one total. A higher total means sex, on paper, is going better. A jump in the total does not prove a nerve grew back. It can mean less tugging, less self-consciousness, less pain at entry, more of the clitoris available to touch, or simply that a woman is no longer avoiding sex because she hated how she looked. It can show a trend towards improvement if there is one.

A 2025 review added up six studies that used this survey after labiaplasty. Together they included hundreds of women. The average total score rose by about 19 percent. In plain English: on that questionnaire, sex was better by roughly one-fifth.

* Nahidi et al., 2025

A second review, looking at papers from 2015 through 2025, found the same pattern: after labiaplasty, with or without hood reduction, women scored better on these surveys. No method — trim, wedge, or the more combined operations — clearly beat the others for sex. And the authors said, in one clean sentence, that the only study that actually mapped feeling with those nylon hairs found no loss of clitoral or labial sensitivity.

That study is Otto’s.

* 2015–2025 review

* PubMed

A careful British comparison from 2014, not written by surgeons, found a large improvement in how women felt about the look of their vulva and a smaller, still positive, change in sexual function. Appearance moved more than orgasm. That is honest. Comfort and confidence are part of sex.

* Veale et al., 2014

One older anatomy paper is still used against this surgery. It showed that the edge of the inner lip is full of nerve endings. That is true. Removing skin is not the same as cutting the main nerve of the clitoris. Those are different structures, different depths, different operations. Those small nerve endings would heal and function normally with time.

* Schober et al., 2010

A 2016 cadaver study of nerve density in the inner lips found the nerves scattered, not gathered in one “do not cut here” cable. That is why more than one technique can be safe in trained hands.

* Kelishadi, 2016

So can sensation get worse?

Yes. It can theoretically happen. I have not seen it.

Temporary numbness in the first weeks is common. Swelling sits on small fibers. Most of that fades as the swelling fades. Lasting loss of clitoral feeling after a standard labiaplasty or hood reduction is not what Placik, Gress, Goodman, or the newer reviews show.

What I tell a woman in the consult room

I tell her Otto’s Linear Excision numbers: the hood still felt the nylon hair; orgasms were more frequent in about 35 out of 100; stronger in about 35 out of 100.

I tell her Alter’s Wedge Labiaplasty numbers: about 23 out of 100 more sensitive, about 5 out of 100 less.

I tell her Gress’s number: about 35 out of 100 easier to stimulate, and no lasting numbness in 812 operations.

I tell her Goodman’s numbers: about 65 out of 100 better after labiaplasty or hood work alone, about 97 out of 100 glad they had it.

I tell her the later questionnaires still have not found a winner between wedge and trim for sex, which is another way of saying both can be done without wrecking the clitoris.

A Barbie Look, Hybrid Look, or Rim reduction in trained hands is not a nerve operation. Neither is a Wedge Labiaplasty.

Otto measured the results of surgery. The rest of us had been watching it in clinic for years. Now you know.

Dr. Red Alinsod is a urogynecologist in the Dallas–Fort Worth area, founder of the Alinsod Institute for Aesthetic Vulvovaginal Surgery, and editor of textbooks on female cosmetic genital surgery. Dr. Otto J. Placik of the Chicago area is a Fellow of the Alinsod Institute and the author of the 2015 study that mapped touch after labiaplasty and hood reduction.

This article is education, not a promise about any one operation. If you have pain, numbness, or a result you were not expecting, you deserve an examination by someone who revises this anatomy for a living.

The 2026 EJOG systematic review of FGCS sexual function says the same thing in one line: “One prospective cohort with standardized sensory testing found no reduction in clitoral or labial sensitivity after labiaplasty with CHR.” That cohort is Placik.

COSMETIC: ORIGINAL ARTICLES

A Prospective Evaluation of Female External Genitalia Sensitivity to Pressure following Labia Minora Reduction and Clitoral Hood Reduction

* Otto J. Placik

* John P. Arkins

Authors and Affiliations

Plastic & Reconstructive Surgery 136(4):p 442e-452e, October 2015. | DOI: 10.1097/PRS.0000000000001573

Abstract

Background:

Little research has been conducted into the effects of labiaplasty on sensitivity of external genitalia. This study aimed to determine the effect of labia minora and clitoral hood reduction using the edge resection technique on external genitalia sensitivity.

Methods:

Female subjects electing to undergo labia minora and clitoral hood reduction were enrolled. Subjects underwent sensitivity testing using monofilaments at five locations (one at the clitoral hood and four labial with each labium measured 0.5 cm from the leading edge and 1.5 cm distal to the hymen) at baseline; 2 weeks; and 3, 6, and 12 months postoperatively. Self-evaluations using the Sexual Function Questionnaire were performed at baseline and 3, 6, and 12 months postoperatively.

Results:

Thirty-seven subjects undergoing labia minora and clitoral hood reduction were enrolled. Subjects experienced a median increase in sensitivity at month 6 of 0.118 mN at the 0.5-cm right labial location (p = 0.027) and 0.059 mN at the 0.5-cm left labial location (p = 0.046) compared with baseline. No change in sensitivity was demonstrated at the clitoral hood or either of the 1.5-cm labial locations. At 6 months, an increase in the number of sexual relations was observed in 44.1 percent of subjects (p = 0.011), an improvement in orgasm frequency was exhibited by 35.3 percent of subjects (p = 0.013), and an increase in orgasm strength was observed in 35.3 percent of subjects (p = 0.006).

Conclusion:

Labia minora and clitoral hood reduction as performed by the trim/edge resection method does not result in diminished sensitivity.

Sexual function after female genital cosmetic surgery: A systematic review and meta-analysis

Ebru Zulfikaroglu a, Didem Kurban b

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10.1016/j.ejogrb.2025.114894

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Sexual function after female genital cosmetic surgery: A systematic review and meta-analysis

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* Abstract

* Introduction

* Section snippets

* References (35)

Highlights

* •

Decade-long systematic review (2015–2025) of 11 FGCS studies on sexual function and PROs.

* •

FGCS is associated with moderate improvements in FSFI-based sexual function and satisfaction.

* •

Complications are uncommon and mostly minor; revision or reoperation is infrequent in available data.

* •

No surgical technique shows clear superiority; carefully performed CHR does not reduce genital sensitivity.

Abstract

Objectives

To evaluate postoperative sexual function after female genital cosmetic surgery (FGCS)—predominantly labia minora reduction with or without clitoral hood reduction (CHR)—and to contextualize safety, satisfaction, and technique-related signals.

Methods

We systematically searched MEDLINE, Embase, Scopus, and Cochrane (2015–2025). Eligible designs included randomized or nonrandomized studies and case series (n ≥ 5) reporting validated sexual outcomes. Two reviewers independently screened and extracted data; risk of bias was assessed with Cochrane Risk of Bias 2, the Newcastle–Ottawa Scale, and the JBI checklist. Random-effects meta-analysis was performed, with prespecified subgroups by technique (trim/edge, wedge, composite) and follow-up.

Results

Eleven studies met inclusion; six used the Female Sexual Function Index (FSFI) and were pooled quantitatively. In primarily uncontrolled pre–post cohorts, pooled standardized mean change in sexual function corresponded to a moderate improvement (standardized mean difference 0.52; 95 % confidence interval 0.38–0.65)., although the certainty of evidence was low due to nonrandomized single-arm designs and serious risk of bias. Studies using other validated instruments (Female Genital Self-Image Scale, Sexual Function Questionnaire-28, Sexual Quality of Life–Female, BODY-Q) demonstrated convergent gains in genital self-image and sexual well-being. Reported complications were uncommon and mostly minor, with infrequent revisions during follow-up. No technique showed clear superiority. One prospective cohort with standardized sensory testing found no reduction in clitoral or labial sensitivity after labiaplasty with CHR.

Conclusions

Observational pre–post data suggest that FGCS is associated with moderate short-term improvements in sexual function and genital self-image, but these findings are based on small, uncontrolled studies that are vulnerable to regression to the mean, expectancy effects, and natural recovery. High-quality controlled trials are needed to confirm the magnitude and durability of benefit. Benefits appear consistent across commonly used techniques, but technique-specific differences remain uncertain. Counseling should integrate validated patient-reported measures and realistic timelines for recovery and sexual resumption. Further comparative studies with standardized reporting and ≥12-month follow-up are needed.

Introduction

Female genital cosmetic surgery (FGCS)—most commonly labiaplasty with or without clitoral hood reduction—has moved from a niche practice to a frequently discussed option in contemporary aesthetic and sexual medicine. International surveillance data show a sustained expansion of aesthetic procedures worldwide over the last decade, with continued growth reported in 2022–2023, placing FGCS within a broader rise in demand for appearance- and function-oriented interventions [1]. While volume trends are clear, high-quality, technique-specific evidence on sexual health outcomes remains comparatively diffuse.

Professional guidance underscores the need for accurate counseling, realistic expectation setting, and careful assessment of psychosocial context before offering FGCS. The American College of Obstetricians and Gynecologists (ACOG) advises clinicians to provide information on normal anatomic variation, avoid misleading claims, and recognize the limited strength of evidence for many cosmetic genital procedures beyond labiaplasty [2]. National and specialty guidelines similarly emphasize ethics, informed consent, screening for body-image concerns, age-appropriate care, and standardized outcome reporting [3].

Existing systematic reviews suggest high patient satisfaction with labiaplasty and generally low complication and revision rates, but methodological limitations (single-arm designs, variable follow-up, and inconsistent use of validated instruments) temper certainty and hinder between-technique comparisons [4]. The evidence base on postoperative sexual function has grown, yet it remains dominated by small samples and methodological heterogeneity, limiting precision and generalizability. A recent synthesis identified multiple investigations—several using the Female Sexual Function Index (FSFI)—but overall study quality was modest and outcome timing varied [5]. Additional single-center cohorts corroborate improvements in sexual function and mood measures in the early postoperative window, but generalizability remains constrained by sample size and design [6].

The measurement landscape itself contributes to heterogeneity. Sexual function and distress are best assessed with validated instruments such as the FSFI (domains of desire, arousal, lubrication, orgasm, satisfaction, and pain) [7], [8], [9] and the Female Sexual Distress Scale-Revised (FSDS-R), which captures the distress component central to sexual dysfunction definitions [10]. Genital self-image—an important determinant of perceived sexual well-being—can be quantified with the Female Genital Self-Image Scale (FGSIS), available in multiple languages and clinical contexts [11], [12]. Aesthetic and broader quality-of-life effects can be profiled using BODY-Q, a modular patient-reported outcome (PRO) instrument developed with modern psychometric methods and increasingly applied in cosmetic surgery outcomes research [13].

Given growing utilization, persistent questions around technique selection (trim/edge, wedge, composite, de-epithelialization, energy-assisted variants), and the centrality of sexual health outcomes, a comprehensive synthesis is warranted. The objective of this systematic review and meta-analysis is to (i) quantify changes in postoperative sexual function using validated PRO measures; (ii) estimate satisfaction, complications, and revision/reoperation rates; and (iii) examine whether results differ by technique, perioperative context, and follow-up duration. By foregrounding sexual function and patient-reported outcomes, this review aims to provide pragmatic, technique-stratified estimates to inform counseling and shared decision-making for patients considering FGCS.

Anatomy papers that speak to the same worry

* Kelishadi et al., Aesthetic Surgery Journal 2016 — “Safe Labiaplasty: A Study of Nerve Density in Labia Minora.” Four cadaver labia, six subunits, H&E + S100. Nerve density was heterogeneous, no subunit statistically denser. Their conclusion: most techniques are unlikely to wipe out sensation because there is no single “do-not-cut” nerve highway in the minora.

* ASJ

* Schober et al. 2010 (older, still the cautionary histology): labia minora are richly innervated along the entire free edge, so a trim does remove sensory tissue even if patients do not report numbness. That is the paper critics still cite against edge resection.

* ScienceDirect

Newer patient-reported sensation / sexual function (not monofilaments)

These are what filled the gap after 2015. They measure orgasm, pain, and FSFI — not pressure thresholds.

* Turini et al., Plast Reconstr Surg 2018. Controlled. Sexual-function questionnaire improved in pain and enjoyment at 3 months; self-esteem and SF-36 did not move.

* PubMed

* Nahidi et al., Aesthetic Plastic Surgery 2025. Meta-analysis of 6 FSFI studies (671 patients): about 18.8% FSFI rise. Quality rated weak-to-moderate; none strong.

* Springer

* McGrattan et al. / long-term outcomes review, Aesthet Surg J 2025. ≥1-year follow-up. Sustained appearance and sexual satisfaction; complications mostly asymmetry, scar, revision. Not QST.

* PubMed

What this means in the Clinic

Placik is still the only elective labiaplasty + CHR series with a mapped monofilament protocol. Nobody has published a wedge-versus-trim QST head-to-head, a vibration/thermal battery, or a 2-year monofilament follow-up.

FOR THE SURGEON

The BEST place to learn Cosmetic Gynecology from your home and office. Anywhere.

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos of actual surgeries.

For Cosmetic Gynecology Before and After Video Gallery go HERE. The patient’s Story from Start to Finish.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576www.alinsodinstitute.comwww.gynflix.com

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

Another Before and After Video of my patient’s STORY from start to finish. See how she goes from feeling heavy and bulky and self conscious to petite and confident in her jeans. This is a Bread and Butter surgery for me. I invented this technique.

Instead of the standard picture of a Before Surgery and a picture of an After Surgery you now have access to the patient’s history shared via videos showing the transformation through time. This story captures several months of a journey but many of my releases cover a decade. Take a peek.

No one else has this type of documented transformation available. You can watch the entire collections on www.gynflix.com also. Over 20 stories of hope. My Before and After Videos are a Labor of Love that has taken 20 years to compile and compose. Go watch them.

All I do is labial and vaginal surgery. No tummies, no butts, no breasts. I specialize only on Cosmetic Gynecology. Visit www.alinsodinstitute.com.

FOR THE SURGEON

The BEST place to learn Cosmetic Gynecology from your home and office. Anywhere.

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos of actual surgeries.

For Cosmetic Gynecology Before and After Video Gallery go HERE. The patient’s Story from Start to Finish.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, consider becoming a paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

Just released another Before and After Video of my patient’s STORY from start to finish. Instead of the standard picture of a Before Surgery and a picture of an After Surgery you now have access to the patient’s history shared via a video showing the transformation through time. Sometimes after six weeks and sometimes after ten years! This one is after four years. No one else has this type of documented transformation available. You can watch the entire collections on www.gynflix.com also. Over 20 stories of hope. My Before and After Videos are a Labor of Love that has taken 20 years to compile and compose. Go watch them.

FOR THE SURGEON

The BEST place to learn Cosmetic Gynecology from your home and office. Anywhere.

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos of actual surgeries.

For Cosmetic Gynecology Before and After Video Gallery go HERE. The patient’s Story from Start to Finish.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, consider becoming a paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

Labiaplasty has been my CORE surgery for over 20 years and is a surgical procedure that reduces and reshapes the labia minora—the inner lips of the vulva—when they cause discomfort, irritation, chafing during activity or intercourse, or when a woman simply prefers a different appearance. I have found that many women also notice excess tissue on the clitoral hood that can create imbalance once the labia are reduced. It looks “Top Heavy.” That’s why a clitoral hood reduction is frequently performed at the same time for symmetry and a balanced result. It keeps the visual appearance pleasing and without sudden and abrupt changes and improves the flow from top to bottom. This video is a summary of steps to get to a Barbie Look Labiaplasty. The full length version is on www.gynflix.com..

I developed two specific approaches in 2005 while practicing in Laguna Beach, California: the Barbie Look and the Hybrid Look. The Barbie Look removes nearly all, or all, of the labia minora so they no longer protrude beyond the labia majora. The goal is a smooth, streamlined “clamshell” appearance that many active women and athletes find especially comfortable—no more adjusting, tugging, or outlining under tight clothing, swimsuits, or workout gear. The Hybrid Look is a close relative: most of the tissue is removed, but a small, natural remnant remains, still tucked below the level of the outer lips. The most conservative appearance is the Rim Look where only the edges are excised. All use the same foundational curvilinear (curved linear) excision technique that I refined over years of practice. This approach allows precise control over the final shape and edge color while avoiding some of the healing issues more common with traditional wedge methods.

BARBIE LOOK EXAMPLE

HYBRID LOOK EXAMPLE

RIM LOOK EXAMPLE

Medial clitoral hood reduction is often paired with these procedures. Excess folds of skin over and beside the clitoris are carefully reduced from the medial side (and sometimes laterally) so the overall appearance remains proportional. Leaving a prominent hood after aggressive labial reduction can create an unbalanced look; addressing both areas together produces a more harmonious result. These are superficial skin procedures performed with great care around sensitive structures. Risk to the clitoral nerves is exceptionally low when done with by an expert who performs these surgeries in volume and has had specialized training outside their internships/residencies/fellowships. These procedures are not taught in the vast majority of formal academia. Buyer beware.

I do these surgeries mostly in the office under local anesthesia while the patient is awake—no intravenous line required in most cases. A topical numbing cream is applied first, followed by carefully placed local injections. Optional oral medication can help with relaxation. Precision radiofrequency instruments allow fine control with minimal lateral heat, which supports clean edges and good healing. The same basic technique is tailored to each woman’s anatomy and goals—whether she wants the more conservative Rim Look (just the darkened edges), the middle-ground Hybrid, or the full Barbie appearance.

Who benefits most? Women who experience daily or occasional irritation, pulling, or discomfort with clothing, exercise, or intimacy, as well as those who simply prefer a neater, less prominent appearance. Those who are afraid to wear their bikinis, Lululemon’s, tights. Athletes and very active women often choose the Barbie Look for maximum comfort. Examples are volleyball players, competitive swimmers, gymnasts, equestrian competitors. Good candidates have realistic expectations, adequate labia majora volume to provide natural coverage after reduction, and a clear understanding that the Barbie Look cannot be reversed. Proper screening and a thorough consultation—ideally with a mirror so the patient can see and discuss her own anatomy—are essential.

Benefits typically include reduced irritation and chafing, improved comfort in clothing and during activity, and greater confidence. You just feel better and less self conscious. Risks of any labiaplasty include temporary swelling, bruising, asymmetry during healing, delayed wound healing, infection, or the need for minor revision. Over-resection can happen with more aggressive techniques, which is why experience and precise marking on relaxed tissue matter. The vast majority of patients recover well with careful aftercare. Wound breakdowns are quite few when compared to Wedge Labiaplasties that have a 10-22% dehiscence rate of complications.

What to expect afterward: Swelling and mild-to-moderate discomfort are normal in the first days and peak early. Most will only use Ibuprofen or a mild narcotic for pain. Rest, ice help. Most women return to desk work in a few days. Many go to work the next day. You can drive the next day if you don’t use narcotics. Sexual activity and more vigorous exercise are usually deferred for about six weeks. Final contour and resolution of residual swelling continue over several months. Absorbable sutures start melting away in about two weeks and are gone by six weeks.

If you are considering labiaplasty and want to understand the full range of options—including the techniques I developed and have taught internationally—I invite you to schedule a consultation. Live, Zoom, FaceTime are all available. The Alinsod Institute is in Arlington, Texas, convenient to DFW Airport. You can learn more at alinsodinstitute.com and gynflix.com, where educational resources and case examples are available. A thoughtful consultation helps ensure the plan matches both your anatomy and your personal goals.

Here is a link to the Before and After Photos I perform:

BEFORE AND AFTER PHOTO GALLERY

Here is a link to the Before and After Videos of CORE surgeries I perform:

BEFORE AND AFTER VIDEOS

Curvilinear Excision Labiaplasty Overview

Curvilinear (curved linear / elliptical) excision is the preferred labiaplasty technique I described (with co-author David Ghozland) in the 2022 Clinics in Plastic Surgery chapter on Curvilinear Labiaplasty and Clitoral Hood Reduction Surgery. After years of experience with multiple methods, it is presented as the most effective approach with the fewest risks for achieving a wide range of desired outcomes (Rim, Hybrid, or Barbie Looks). Here is a PDF of that chapter:

Core Advantages

* The incision follows the natural length of the labia minora, allowing precise removal of darker, pigmented, or wrinkled edge tissue while accurately sculpting the new contour according to the patient’s goals.

* It supports greater reduction in both length and thickness compared with central or modified V-wedge techniques.

* Tissue tension is lower, reducing risks of edge separation, holes, or “pizza-slice” gaps that can occur with wedge methods when blood supply or tension is suboptimal.

* One foundational technique with adjustable markings produces the full spectrum of results: conservative Rim (edge-only), middle-ground Hybrid (small remnant still below the majora), or aggressive Barbie (near-total or total removal for a smooth clamshell appearance).

* It pairs naturally with concurrent clitoral hood reduction for overall balance and symmetry. Leaving a relatively prominent hood after substantial labial reduction can create an unbalanced or “heavy” appearance.

The technique is only as good as the surgeon’s judgment, markings, and experience. Conservative resection is advised early in the learning curve because of the labia’s significant natural retraction, especially in the upper third.

Preoperative Markings (Critical Step)

Markings are performed on completely relaxed, untugged labia before any local anesthetic injection that could distort anatomy. A sterile surgical marker is used.

* Begin laterally and just below the frenular crease (a practical landmark ~1–2 cm below and lateral to the clitoris).

* Extend the line inferiorly to the desired final length and contour.

* Mark the medial side as well.

* “Kiss” the medial edges together to check bilateral symmetry.

* Taper the upper third carefully and stay above Hart’s line (approximately 1.5 cm from the base in the upper third) because of substantial tissue retraction in this region.

* Avoid traction while marking—right-handed surgeons must be especially careful not to over-mark the right side by pulling.

For concurrent clitoral hood reduction (frequently recommended):

* Spare a 6–8 mm vertical midline strip of skin over the central axis of the hood (“bridge”).

* Preserve a 5–6 mm medial attachment to the labia minora.

* Connect markings to the lateral edge of the interlabial sulcus while keeping the bridge at least 1 cm wide.

Anesthesia and Setting

Nearly all cases are performed in the office, awake, without an IV. Topical compounded anesthetic cream (often driven deeper with predictive permeation/dermoelectroporation) is applied first. Minimal volumes of buffered local anesthetic (typically 4–6 cc total of lidocaine/bupivacaine mixtures) are then injected medial to the planned dissection planes and in the minora–majora crease using a fine 30-gauge needle. Optional oral anxiolytic and light narcotic can be given. Keeping injectate volume low preserves accuracy. I also recommend long acting Exparel (Bupivacaine coated in a fat globule) that can give many days of numbness.

Excision Technique

Radiofrequency (RF) pinpoint needle tips are preferred (Ellman Surgitron/Pelleve or Soniquence systems). Typical settings: cutting mode 10–15 W; blend or coagulation mode 20–25 W. Advantages include exceptional precision, minimal lateral thermal spread, adjustable tip angle, and some intrinsic hemostasis. Scalpel, scissors, or laser are alternatives used by some surgeons.

* Start on the more challenging side.

* A recommended refinement is the “canal incision”: cut at a ~45-degree angle into the mid-substance of the labia minora. This creates a small internal canal that produces a natural debulking effect when the edges are later reapproximated, reducing bulk and thickness. I have many video examples on www.gynflix.com.

* Achieve meticulous pinpoint hemostasis (avoid broad spray cautery). Note that cautery itself causes additional tissue shrinkage and retraction—this must be anticipated in the original markings.

* After the main excision, use the same RF tip in a “feathering” technique (multiple light passes) to smooth irregular or rough edges.

* One advantage of the awake setting is the option to hand the patient a mirror (if she is comfortable) so she can confirm the amount of tissue removed before closure begins.

Closure

Layered closure that eliminates dead space is essential to minimize hematoma risk.

* Deepest layer: 4-0 or 5-0 monofilament (Monocryl) on a non-cutting tapered needle, typically run as an inverted mattress starting from the most cephalad point below the frenulum. Close the deep layer on both sides first so minor adjustments remain possible.

* Superficial layer(s): 5-0 Vicryl, loosely tied interrupted sutures spaced ~5 mm apart. Sutures are tied loosely to accommodate expected swelling and to avoid scalloping or stair-step appearance.

* Clitoral hood closures follow the same multilayer principles (deep running non-interlocking Monocryl, then Vicryl).

Postoperative Course and Risk Mitigation

Recovery timelines for labiaplasty and hood reduction are essentially identical, making the combination efficient. Early swelling and bruising can be dramatic (“Frankenstein period”). Standard measures include frequent icing (15 minutes every hour when possible for the first 48–72 hours), limited walking, “Velcro knees” (keeping the knees together), no heavy lifting or exercise for about 4 weeks, and no soaking baths or sitz baths for 4 weeks. Gentle showering is fine. Suture dissolution can produce temporary odor or itching (antihistamines like Benadryl Cream can help). Most patients resume full activity including intercourse around 6 weeks; residual firmness softens by roughly 4 months. Follow-up is typically at 1–2 weeks.

Complication rates in the literature cited are low (roughly 2.65–6%). The most concerning risk with any aggressive reduction is over-resection. With a Barbie Look that is not an issue since the goal is maximum tissue removal. Other potential issues include hematoma, infection, asymmetry during healing, wound-edge problems, or excessive retraction. These are minimized by conservative marking on relaxed tissue (for Hybrid or Rim Labiaplasties), layered dead-space closure, meticulous hemostasis, loose superficial sutures, and strict adherence to activity restrictions.

Summary of Key Principles

The curvilinear approach offers the broadest range of aesthetic and functional outcomes with a relatively straightforward learning curve when markings, tissue handling, and hemostasis are precise. Most labia minora reductions benefit from simultaneous hood reduction for proportional results. Patient involvement in viewing markings and (when appropriate) the intermediate result enhances shared decision-making. Exceptional hemostasis and complete dead-space closure optimize healing.

This technique, refined and popularized by Alinsod for in-office use with RF precision instruments, underpins the Barbie Look, Hybrid Look, and more conservative variations such as Rim Look. It prioritizes adjustability, pigment removal, and reduced tension-related complications compared with pure wedge methods.

If you would like a version tailored specifically for surgeon education, a simplified lay-public explanation, step-by-step operative checklist, comparison tables versus wedge techniques, or focus on the medial clitoral hood component, let me know.

PAST NEWSLETTERS ON LABIAPLASTY SURGERY

FOR THE SURGEON

The BEST place to learn Cosmetic Gynecology from your home and office. Anywhere.

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos of actual surgeries.

For Cosmetic Gynecology Before and After Video Gallery go HERE. The patient’s Story from Start to Finish.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, become a paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

Lumisque offers CO2Lift Carboxytherapy gel mask for beauty and facial use. Their feminine version for genital use is called “The V” (CO2Lift V). Listen and Learn of the amazing results it provides without the use of hormones.

This Newsletter covers two main points:

* Carboxytherapy using Lumisque’s CO2Lift V for Pre-Treatment and Post Surgical enhancement of blood flow for Optimized Surgical Outcomes

* How I use this to improve skin and tissues before surgery and how I use it after surgery to make sure there is plenty of oxygen in the tissues for best outcomes.

* How doctors can add this to their practices.

Patients can ask their doctors for CO2Lift V to help improve the dry vagina, painful sex, and reduced sensitivity. This treatment works very well and very fast.

Enjoy the presentation.

Lumisque is at https: //lumisque.com

POWERPOINT SLIDES

Past Newsletters and Carboxytherapy Presentations

* CO2Lift Pro & Surgery, June 30, 2026

* Carboxytherapy for Post Op Care for Gynecologic Cancer Surgery, April 28, 2026

* CO2LiftV with Jennifer Owen, MD, October 27, 2025

* CO2LiftV’s New Role for Post Op Healing, April 15, 2025

* How CO2LiftV is Helping Patients, From a Panel of Urogynecologists, Marach 19, 2025

* CO2LiftV for Vaginal Restoration, March 14, 2023

* How Vaginal Restoration with Carboxytherapy is Changing in 2023, January 25, 2023

* Carboxytherapy for Gynecologic Conditions, May 2, 2022

FOR THE SURGEON

The BEST place to learn Cosmetic Gynecology from your home and office. Anywhere.

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos of actual surgeries.

For Cosmetic Gynecology Before and After Video Gallery go HERE. The patient’s Story from Start to Finish.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, become a paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

Upcoming Zoom Webinar on July 29, 2026, 6 PM CST

I will be giving an update on CO2LiftV Carboxytherapy for both Surgical and Non-Surgical use and improving outcomes. I will share my secrets on how to use CO2LiftV to both help improve tissues for healing, help local anesthesia go deeper under the skin, and help improve surgical outcomes. Just block off 6 PM CST for July 29, 2026. Created for Medical Providers but open to ALL.

REGISTRATION LINK: Click HERE

Description: Patient care doesn’t end when the procedure is over. In this educational session, Dr. Alinsod will share how supporting tissue health beyond the office can help enhance the patient experience, encourage adherence to treatment plans, and extend the continuum of care through thoughtful at-home support.Attendees will also receive an exclusive introduction to the new CO2Lift® V Provider Direct Program—a new way to seamlessly integrate professional homecare into your practice while creating new opportunities to support patients long after they leave the office.You’ll leave with practical clinical insights, new ideas for strengthening patient engagement, and a clear understanding of how CO2Lift® is making it easier than ever to bring at-home intimate wellness support into your practice—with the resources needed to get started.Whether you currently offer intimate wellness procedures or are looking to expand your treatment offerings, this webinar will provide actionable strategies you can begin implementing right away.

Zoom Registration: Click on Link or Photo Below

REGISTRATION LINK: Click HERE

Past Newsletters and Carboxytherapy Presentations

* CO2Lift Pro & Surgery, June 30, 2026

* Carboxytherapy for Post Op Care for Gynecologic Cancer Surgery, April 28, 2026

* CO2LiftV with Jennifer Owen, MD, October 27, 2025

* CO2LiftV’s New Role for Post Op Healing, April 15, 2025

* How CO2LiftV is Helping Patients, From a Panel of Urogynecologists, Marach 19, 2025

* CO2LiftV for Vaginal Restoration, March 14, 2023

* How Vaginal Restoration with Carboxytherapy is Changing in 2023, January 25, 2023

* Carboxytherapy for Gynecologic Conditions, May 2, 2022

FOR THE SURGEON

The BEST place to learn Cosmetic Gynecology from your home and office. Anywhere.

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos of actual surgeries.

For Cosmetic Gynecology Before and After Video Gallery go HERE. The patient’s Story from Start to Finish.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

What is this video for?

This video is Example 1 of the New Section I am about to add to my two websites called “Before and After Videos” as well as a teaser for you to take advantage of my Summer pricing for a “Vampire Wing Lift” with FemXHA. My teaching website is called Gynflix and my practice website is called Alinsod Institute. Both will house the collection.

My Vampire Wing Lift with FemXHA is only $1776 for the month of July to honor America’s 250th Birthday. It is more than 50% off!

Why it is important to have Before and Afters in Video?

Just about all Cosmetic Gynecology websites have a section on Before and After Photos. Some better than others. You can rightly assume that a surgeon with few Before and After photo sets probably does not do many of those type of cases. Makes sense. I just happen to have the Largest and Best collection found anywhere. Check it out here: Before and After Gallery. This is a good place to start.

These pictures are quite helpful to patients. In fact, when a patient is asked why they pick me as their surgeon it is most often the case that I had the better collection and variety of pictures that show off my surgical skills as well as surgical volume for this singularly specialized surgery. It is so helpful for patients. I was not satisfied with static pictures of my results and wanted a more 3D or mutiple angled view so I started putting my videos together. I have about a decade’s worth of videos to work with. I started piecing them together to tell a story.

So now I can level up and showcase my surgical thinking method and my eventual results through my videos. In these Before and Afters Videos that I will post later this week, I will show the patient’s Before appearance and then fully discuss what the patient wants to achieve and how I intend to achieve it. Many months will pass as the patient heals and eventually follows up with me. I will take more pictures and then I can blend my content together and create a story that's 1 to 3 minutes long. You get to see how things turned out. How it all heals and comes together. This is what I will start with. In the coming weeks I will also add my Barbie Look Labiaplasty and numerous Clitoral Hood Reduction stories as well as my Non-Surgical stories together. It will forever change how you want to see Before and After results.

Inaugural List of Video Before and Afters

* Before and After FemXHA Injections

* #262 Before and After Hybrid LP with CHR

* #241 Before and After Hybrid Labiaplasty with Lateral CHR 4K

* Before and After Majoraplasty for Camel Toes

* Before and After Labia Majoraplasty with Fat Pad Excision

* Before and After Luksenburg, VP, Peri, Hybrid, CHR, Majora Thread, O-Shot

* #197 Before and After Anal Skin Tag Excision

* Before and After Feathering and Grooving for Labial Creation

This is just the start of a new way to evaluate surgical results. It is like going from Black and White TV to Full Color Panavision! Remember when Dorothy went from the Black and White/Sepia world to enter the Land of Oz in all its glorious color?! Pure Wow. That is what I will do for you.

More Videos on Vulvar Aging, Majora looseness, Vampire Wing Lifts, and the use of FemXHA

If you do not know what Vulvar Plumping is then watch any of these to get a full detailed discussion on how I use PRP plus Hyaluronic Acid to add volume to a saggy Labia Majora.

* Dr. Michael Reed Demonstrates FemXHA Vulvar Plumping

* Large Volume Vampire Wing Lift with FemXHA

* What is a Vampire Wing Lift? Ask for FemXHA!

* FemXHA Vampire Wing Lift Treatments for the Sagging Labia Majora

* What’s Alinsod Up To in 2025?

* Feminine Restoration 2024: Putting It All Together

* Management of Camel Toes: Combination Labia Minoraplasty and Majoraplasty with Fat Pad Removal

* What is a Vampire Wing Lift?

* Management of the Saggy Labia Majora without Surgery

* The Aging Vagina and GSM

Reminder: Purchase your Vampire Wing Lift with FemXHA in the month of July for $1776, save over 50%, and get it done before the year ends. First Come First Served. Limited supplies of FemXHA kits.

Call Dian today at 945-900-7576

Amy Haddad, RNP, and I are ready to help you get that youthful look and feeling back. Call Revique Medical and Aesthetics at ‭(817) 533-0988‬ for Non-Surgical Feminine Wellness treatments, Bioidentical Hormones, Peptides, Weight Management, Hair Restoration, and much much more.

FOR THE SURGEON

I built an online community of expert Cosmetic Gynecologists from around the world who you will be able to communicate with and pick their brains. Click on the logo picture for the link:

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

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For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix.This is made for the Lay Public. Dozens of high def, high quality videos.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576 (Dian White)www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

A sneak peak at my Medical School past and the fun years training to become a doc. I loved photography then. I love videography now. I got to blend the two skills during my career and created Gynflix to host my educational platform for both patients and the medical community. Follow more of my Alinsod Adventures.

FOR THE PATIENT

For those of you who do not know me or my background this is a good start. I was born in the Philippines, emigrated in ‘69 to LA. Grew up in Glendale, CA, went to Glendale Academy for elementary and High School, then went to Pacific Union College in the Napa Valley. Then medical school and residency at Loma Linda University. All my education was in California. I spent 8 years as Air Force Reserve and 4 years Active Duty and left as a Major in 1994. For ten years I was a Urogynecologist/gynecologic surgeon in Los Angeles then spent two decades in solo Cosmetic Gynecology practice in Laguna Beach, California. For three decades I taught pelvic surgery and reconstructive pelvic surgery and Cosmetic Gynecology. I moved to Texas to be closer to my kids in 2022 and now run the Alinsod Institute in Arlington, Texas. The Center of the Universe for Cosmetic Gynecology! For labiaplasty, vaginoplasty, pelvic reconstruction and cosmetic gynecologic procedures we are the one to choose.

Dian is my Point Person for more information: 945-900-7576

LLUSM Class of 1986

Alinsod Adventure Update: I will be joining about 20 of my Med 86 Classmates for a Mediterranean Cruise in August to catch the Total Eclipse of the sun on a boat, off the coast of Spain, in what we hope are perfect conditions to witness God’s handiwork.

FOR THE SURGEON

I built an online community of expert Cosmetic Gynecologists from around the world who you will be able to communicate with and pick their brains. Click on the logo picture for the link:

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix.This is made for the Lay Public. Dozens of high def, high quality videos.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on InstagramasVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

Thanks for reading Feminine Wellness Newsletter! This post is public so feel free to share it.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

Dryness, tightness, menopause, endometriosis, prolapse, childbirth injury, hysterectomy pain, mesh problems, skin disease, size mismatch, and treatment options explained in plain English

By Red M. Alinsod, MDAlinsod Institute | Revique Medical & AestheticsArlington, Texas

Painful sex is common. But it is not something a woman should be expected to silently endure. Too many just live with it.

The medical term is dyspareunia, which means pain before, during, or after intercourse. Some women feel burning at the opening. Some feel tearing. Some describe “sandpaper.” Others feel deep stabbing pain, pelvic pressure, a “wall,” a tight band, or soreness that lasts for hours or days afterward. The American College of OBGYN notes that nearly 3 out of 4 women have pain with intercourse at some time in their lives.

Common does not mean normal. Pain is not normal.

Painful sex can come from the vulva, the vaginal opening, the vaginal canal, the pelvic floor muscles, the uterus, the bladder, the rectum, prior childbirth injuries, prior surgeries, mesh exposure, endometriosis, menopause, cancer therapy, or skin disease. Often, there is more than one cause. Detective work has to be done.

My goal with this article is simple: to help you understand what may be happening, give you language for your symptoms, and show you that there are thoughtful medical, hormonal, regenerative, pelvic floor, and surgical options when the cause is properly identified. It is a pretty intensive Newsletter this month. Pick and choose what interests you and click on the links that lead to detailed explanations.

Start here: Where does it hurt?

The first question is not “What treatment do you want?”The first question is where is the pain?

Pain at the opening

Pain at the vaginal opening often feels like burning, tearing, stretching, paper cuts, or “too tight.” This can happen with menopausal dryness, Genitourinary Syndrome of Menopause, lichen sclerosus, vestibulodynia, scar tissue, childbirth injury, prior labiaplasty, prior vaginoplasty, pelvic floor spasm, or a small/tight introitus. Take a look at these pictures for the many causes of Painful Sex at the opening:

Pain inside the vaginal canal

Vaginal canal pain may feel like friction, dryness, narrowing, rubbing, rawness, or inability to stretch. This can happen after menopause, breastfeeding, hysterectomy, chemotherapy, pelvic radiation, hormone-blocking cancer therapy, scarring, or vaginal stenosis. Here are some causes of Painful Sex that is beyond that you can see on your own:

Deep pain

Deep pain often feels like a collision. Patients say, “It feels like he is hitting something,” or “It only hurts in certain positions.” Deep pain can be related to endometriosis (lining of the uterus found outside the lining of the uterus), adenomyosis (endometriosis in the body of the uterus), fibroids (firm mass of muscle tissue found in the walls of the uterus), ovarian cysts, uterine prolapse, pelvic floor dysfunction, bladder pain, bowel pain, hysterectomy scarring, vaginal cuff tenderness, or cancer-treatment changes. Mayo Clinic lists deep thrusting pain as a dyspareunia pattern and includes endometriosis, uterine prolapse, adenomyosis, pelvic floor conditions, ovarian cysts, hysterectomy scarring, radiation, and chemotherapy among possible causes. Here are examples of pictures of the most common cause of Pelvic Pain: Endometriosis.

.

Pressure, bulging, or “uncontrollable” sex

A bulge, pressure, heaviness, looseness, blocked feeling, bowel trapping, or bladder urgency during sex may point toward pelvic organ prolapse: cystocele, rectocele, uterine prolapse, vaginal vault prolapse, or enterocele.

* Transvaginal Uterine Suspension with Dermal Allograft Surgery

Partner pain

Sometimes the partner feels hard “rocks” constipation stools. He can also feel poking, scratching, or sharpness. This can happen when mesh or permanent suture is exposed in the vagina. The FDA specifically advises patients with mesh to notify their provider if they have persistent vaginal bleeding or discharge, pelvic or groin pain, or pain with sex.

Let’s systematically go over the main causes of Painful Sex once more in a bit more detail. This is not an exhaustive list but it does cover all the main culprits. I will organize and number them and also give you some of the therapies I use in my office to manage the problems:

1. Menopausal dryness, tightness, and Genitourinary Syndrome of Menopause

One of the most common and most under-treated causes of painful sex is Genitourinary Syndrome of Menopause, or GSM.

GSM is the modern term for what used to be called vaginal atrophy or atrophic vaginitis. It is broader and more accurate because the problem affects more than the vagina. GSM can involve the vulva, labia, clitoris, vaginal opening, vaginal canal, urethra, bladder, and pelvic tissues.

GSM can happen with:

natural menopausesurgical menopause after ovary removalhysterectomy with hormonal changeschemotherapypelvic radiationbreast cancer endocrine therapyanti-estrogen medicationsbreastfeedingperimenopausemedications that reduce arousal or lubrication

ACOG explains that low estrogen can thin, dry, and inflame the vaginal walls, reducing lubrication, elasticity, and tissue comfort. Vaginal dryness can also happen after childbirth, breastfeeding, cancer treatment, or anti-estrogen medications.

* The Aging Vagina and GSM

What low estrogen does to the tissue

Estrogen helps maintain vaginal and vulvar tissue thickness, moisture, blood flow, elasticity, pH balance, lubrication, and resistance to tearing. When estrogen stimulation drops, the tissue can become thin, dry, pale, tight, fragile, and inflamed.

Women often describe:

“sandpaper” sexburning at the openingtearing at the bottom of the vaginableeding after sexdryness that lubricant does not fixtightness that feels newpain with pelvic examsurinary urgency or recurrent UTIsloss of confidence and desire because sex now hurts

This is not simply a lubrication problem. It is a tissue-health problem.

2. “I use lubricant and it still hurts”

Lubricant is helpful, but lubricant does not rebuild estrogen-deprived tissue.

Lubricants reduce friction during sex. Moisturizers improve day-to-day tissue hydration. Both can be valuable. The 2025 AUA/SUFU/AUGS GSM guideline recommends vaginal moisturizers and lubricants to improve dryness and painful sex.

But if the underlying issue is GSM, many patients need more than lubricant. Pull out the vaginal estrogens and Carboxytherapy and think about radiofrequency treatments such as ThermiVa or even the vaginal lasers. They both work well.

The same guideline recommends offering local low-dose vaginal estrogen for GSM-related vulvovaginal dryness, discomfort, irritation, and dyspareunia. It also recommends offering vaginal DHEA as an option for GSM-related dryness and painful sex.

Vaginal Estrogen Options

Vaginal estrogen can come as a cream, tablet, insert, or ring. ACOG explains that low-dose vaginal estrogen releases a small dose directly into the vaginal tissue to help restore thickness and elasticity and relieve dryness and irritation.

Common forms include:

Creams: flexible dosing and useful for vulvar and opening symptomsTablets or inserts: less messy and easy to useRings: steady release over time for patients who prefer less frequent dosing

ACOG states that topical estrogen for vaginal or vulvar dryness and pain with intercourse usually improves symptoms within a few weeks and acts locally on tissues.

For cancer survivors, treatment should be individualized with the oncology team. The American Cancer Society notes that cancer therapy can cause vaginal dryness, thinning, narrowing, shortening, and painful sex, and that vaginal estrogen is sometimes used for dryness, narrowing, and atrophy after discussion with the cancer care team.

Carboxytherapy Options

There is now a Carboxytherapy Gel treatment that gets results even faster than vaginal estrogens. It is made by Lumisque and called CO2LiftV or “The V.” In Latin America, Europe, Asia, carbon dioxide is injected under the skin to cause local tissue trauma and start the healing cascade to form new vessels, stimulate new collagen and elastin formation, and increase local moisture production. It hurts and is is not FDA approved in the USA. The Japanese came up with the same carbon dioxide treatment without the need for needles and with a mixture that created localized carbon dioxide that helped heal the skin. It was first used in the face as a mask then modified to work in feminine genital tissues. And it worked like Rocket Fuel in the speed of results obtained to create vaginal moisture and comfort. Not just for dry and thin skin but also for Lichen Sclerosus.

The stuff works so well it is a CORE product for my Center of Excellence in Arlington, Texas. Go to www.lumisque.comfor info.

Watch this Doctor Discussion on CO2LiftV:

Doctor Discussion on The V

How CO2LiftV is Helping Patients, From a Panel of Urogynecologists

3. Tightness is not always vaginismus

Many women say, “I think I’m too tight.” That may be true, but the reason matters.

Vaginismus is a type of sexual dysfunction. It happens when vaginal muscles cramp up or spasm involuntarily. We call them Levator Muscle Spasms. dYou can get aroused, get wet, but penetration is a No No and hurts too much. Even the touch of a QTip swab may incapacitate a patient!

A woman may feel tight because of GSM dryness. She may have scar tissue from birth, episiotomy, perineal tearing, surgery, radiation, mesh, or a prior vaginal repair. She may have lichen sclerosus causing narrowing of the opening. She may have pelvic floor muscle guarding because sex has hurt for months or years. She may have vaginal stenosis after cancer therapy or surgery. An exam will help identify the problem. See a gynecologist and not a plastic surgeon or cosmetic surgeon or dermatologist. Family Practice specialists can be very helpful on the other hand.

Cleveland Clinic describes vaginal stenosis as narrowing and shortening of the vagina from scar tissue, often after childbirth, surgery, or pelvic radiation, and notes that treatment may include vaginal dilators, estrogen medication, or vaginal moisturizers.

The treatment for tightness depends on the cause. Dry tissue needs tissue restoration. Scar bands may need release. Pelvic floor spasm may need pelvic floor therapy. Lichen sclerosus needs skin-directed treatment. A shortened vaginal cuff after hysterectomy requires a different evaluation. Dilator work may be needed.

Summary of what you can do for yourself: Vaginal estrogens, progressive dilator use, pelvic floor physical therapy, Carboxytherapy, Radiofrequency treatments such as ThermiVa.

4. Endometriosis, adenomyosis, and collision-type deep pain

Deep pain during sex often has a pelvic source.

Endometriosis

Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus. Look back at the pictures I showed earlier. Notice it can involve the ovaries, fallopian tubes, pelvic lining, bowel, bladder, uterosacral ligaments, and tissue behind the vagina. Mayo Clinic lists pain during or after sex as a common symptom of endometriosis.

Endometriosis can cause adhesions, scarring, and inflammation. During deep penetration, those tender or fixed areas may be hit or stretched, creating sharp “collision” pain that may last long after sex. The treatments for this are can be medication such as birth control pills, progesterone, and even medical menopause inducing shots to stop or reduce estrogen production that cause endometriosis to act up. Often times those medications fail and surgery to get rid of adhesions, chocolate spots, or remove organs such as the uterus, tube, and ovaries, may be needed.

ACOG’s 2026 endometriosis diagnostic guideline focuses on improving evaluation and diagnosis for reproductive-aged adults and adolescents with symptoms suggestive of endometriosis. Your gynecologist can help with the diagnosis.

Adenomyosis

Adenomyosis happens when endometrial tissue grows into the muscle wall of the uterus. It can make the uterus enlarged, tender, heavy, crampy, and painful. Mayo Clinic lists heavy or long-lasting periods, severe cramping, chronic pelvic pain, painful sex, and lower abdominal pressure among adenomyosis symptoms.

Patients may describe deep aching, cramping after sex, pelvic heaviness, or a bruised feeling when the uterus is contacted.

The definitive treatment is to remove the uterus. A hysterectomy. It does not always work because those spots of endometrial tissue can implant in other places such as the bladder, the top of the vagina, the lining of the bowel and just about anywhere else. I have found them in the belly button, the inside of an ankle, on the outside of the labia, the inside of the labia, in the lungs, in the bones. Just about anywhere.

5. Pain after hysterectomy: vaginal cuff tenderness, scarring, and shortened vagina

After a total hysterectomy, the cervix is removed and the top of the vagina is closed. This closed top is called the vaginal cuff.

Many women do well after hysterectomy.

But some develop new pain with sex because of:

vaginal cuff tenderness from unknown cause or short vaginal lengthgranulation tissue from the healing processscar tissue from the suturing can even entrap nervesnarrowing of the vaginal canalpelvic floor spasm triggered by traumatic surgery, vaginal delivery, examinationslack of estrogen stimulationovary removal and surgical menopause results in loss of estrogen producedendometriosis persistence in other locationsmesh or suture exposure when advanced reconstruction is donevaginal vault prolapse (fallen vagina) if the top is not properly anchored

Mayo Clinic includes scarring from pelvic surgery, including hysterectomy, among causes of painful intercourse.

A post-hysterectomy exam should look carefully at the cuff, the vaginal length, tissue mobility, estrogen status, pelvic floor muscles, and whether deep contact reproduces the patient’s pain.

Things you can do by yourself to help: Vaginal Estrogens, Carboxytherapy, Radiofrequency treatments, Dilator work.

6. Lichen sclerosus, lichen planus, and inflammatory vulvar disease

Not all painful sex comes from inside the vagina. Sometimes the problem is the vulvar skin. This is a whole new other level of complex.

Lichen sclerosus

Lichen sclerosus is an autoimmune chronic inflammatory skin condition that often affects the genital and anal areas. Mayo Clinic notes that lichen sclerosus can cause fragile skin, itching, burning, bleeding, open sores, painful sex, and scarring, and that postmenopausal women are at higher risk.

Patients may notice:

white patchesthin or shiny skinitchingburningpaper-cut tearsbleeding after sexpain at the openingclitoral hood scarringnarrowing of the introitus

Lichen sclerosus needs proper diagnosis and long-term follow-up. Treatment often includes high-potency topical steroids, vulvar skin care, estrogen support when GSM is present, and sometimes regenerative or surgical approaches for scarring and narrowing.

* Lichen Sclerosus Part 1: The Silent Itch

* Lichen Sclerosus Part 2: The Silent Itch

Lichen planus and lichenoid disease

Lichen planus can involve the vulva and vagina. Genital lichen planus looks like lacy white patches, sometimes with painful sores, and can cause scarring, severe pain, and painful sex.

Other inflammatory causes include eczema, contact dermatitis, psoriasis, lichen simplex chronicus, recurrent yeast, bacterial vaginosis, allergic reactions, and vestibulodynia.

The same treatments for Lichen Sclerosus often work with Lichen Planus. Go see your dermatologist first. If they cannot help you then we may be able to help with non-standard therapy such as radiofrequency, PRP, Exosomes, Hyaluronic Acid, and lasers.

7. Size mismatch: large penis, small vagina, short vagina, or painful depth

Size mismatch is real, and patients deserve plain language.

Pain may occur when a partner is long, wide, or both — especially if the patient has GSM, scarring, a short vaginal canal, a tender cuff, lichen sclerosus, pelvic floor spasm, vaginal stenosis, prolapse, or prior surgery

Possible solutions may include:

restoring tissue moisture and elasticityusing high-quality lubricanttreating GSM with vaginal estrogen or DHEA when appropriatepelvic floor physical therapydilator therapyposition changes that limit depthpatient-controlled positionsdepth-limiting rings or devicestreating cuff tenderness, endometriosis, or prolapsesurgical correction when scar tissue or distorted anatomy is the cause

A larger partner may simply reveal an underlying medical problem that a smaller partner did not trigger.

Dilator Work

Surgical Band Release

This is usually done in the surgery center but can be done in the office that is well equipped. This same method of band release can be applied to #8 below. Links to surgical Band Release in these two Newsletter Videos:

* Perineal Band Release with Radiofrequency for Dyspareunia

* Sutureless Band Release and the Management of the Tight Introitus

8. Birth trauma, episiotomy scars, and perineal damage

Childbirth can permanently change the perineum, vaginal opening, pelvic floor, and rectovaginal wall.

The Royal College of Obstetricians and Gynaecologists states that up to 9 in 10 first-time mothers who have a vaginal birth experience some type of tear, graze, or episiotomy. Cleveland Clinic explains that vaginal tears range from first-degree tears to fourth-degree tears involving the anal sphincter and rectum, and notes that complications can include painful intercourse, fecal incontinence, ongoing pain, and soreness.

Most tears heal well. Some do not.

Post-birth causes of painful sex can include:

painful episiotomy scarrigid perineal scarover-tight repairunder-repaired perineal bodygaping or loss of supportrectocelepainful scar bandsgranulation tissuefecal urgency or leakageloss of sensationpelvic floor spasm

Treatments may include pelvic floor therapy, scar massage, topical estrogen, injections, perineoplasty, rectocele repair, revision of episiotomy scar, or reconstruction of the perineal body.

The goal is not simply to make the vagina “tight.” The goal is to restore comfort, anatomy, support, and function.

This is all done in the office under local anesthesia without IVs or intubation or spinals.

9. Pelvic organ prolapse: pressure, bulging, looseness, and painful sex

Take a look at all the prolapse pictures I showed earlier. Pelvic organ prolapse happens when pelvic floor muscles and tissues no longer support the pelvic organs well. The FDA explains that prolapse can involve the vagina, cervix, uterus, bladder, urethra, and rectum, with the bladder being the most commonly involved organ.

Common types include:

Cystocele: bladder bulging into the front vaginal wallRectocele: rectum bulging into the back vaginal wallUterine prolapse: uterus dropping into the vaginaVaginal vault prolapse: top of the vagina dropping after hysterectomyEnterocele: small bowel bulging into the vaginal space

Mayo Clinic describes cystocele symptoms such as pelvic or vaginal pressure, a vaginal bulge, increased pressure with straining, urinary difficulty, incomplete bladder emptying, frequency, and leakage. Rectocele symptoms may include a vaginal bulge, trouble with bowel movements, rectal pressure, incomplete emptying, and sexual concerns such as looseness or embarrassment. Uterine prolapse can cause heaviness, tissue bulging, bladder emptying problems, bowel movement difficulty, pelvic pressure, and sexual concerns.

During sex, prolapse may cause pressure, bulging, air trapping, bowel urgency, bladder urgency, pain, looseness, or a sense that sex is blocked or out of control.

Treatment may include pelvic floor physical therapy, pessary fitting, vaginal estrogen, bowel management, bladder treatment, and surgery when symptoms are significant

* What is the Bulge?

10. Mesh, sutures, and prior surgery complications

Prior surgery can help many women. But prior surgery can also cause pain when scarring, permanent sutures, vaginal shortening, adhesions, or mesh exposure develop.

In 2019, the FDA ordered manufacturers to stop selling surgical mesh intended for transvaginal repair of pelvic organ prolapse because manufacturers had not demonstrated reasonable assurance of safety and effectiveness. The FDA also notes there are currently no FDA-approved surgical mesh products for transvaginal prolapse repair marketed in the United States.

Mesh-related pain may involve:

vaginal mesh exposurebleeding or dischargepartner discomfortscratchy or poking sensationpelvic paingroin paindyspareuniascar contractionnerve irritationrecurrent prolapseurinary or bowel symptoms

Some patients need estrogen and observation. Some need trimming of a small exposure. Others need complex revision or removal. These are individualized, anatomy-driven decisions.

These simple trims sometimes are inadequate to relive Painful Sex or Pelvic Pain. The entire mesh had to be removed by the finest pelvic surgeons in the land. It is a very tough dissection and excision and not for the faint of heart.

11. When prior labiaplasty or vaginoplasty causes pain

This is a sensitive topic, but it needs to be discussed.

Some patients develop painful sex after prior labiaplasty, clitoral hood reduction, vaginoplasty, perineoplasty, or “tightening” surgery. ACOG cautions that female genital cosmetic procedures can have complications including pain, bleeding, infection, scarring, adhesions, altered sensation, dyspareunia, and need for reoperation. Cleveland Clinic also lists labiaplasty complications such as wound breakdown, scarring, ongoing pain, pain with sex, or loss of sensitivity.

Patients may search online for “botched labiaplasty” or “botched vaginoplasty.” In the office, I prefer to describe what actually happened anatomically:

wound breakdownnotchingpainful scarover-resectionassymetrykeloid or hypertrophic scartethered tissuepainful clitoral hood scarringover-tightened introitusinternal vaginal scar bandsshortened vaginal canaldistorted openingloss of tissue mobility

Revision surgery is highly specialized. It may involve scar release, layered closure, flap advancement, RF Feathering, mucosal advancement, perineoplasty, grafting, fat grafting, or careful reconstruction of the opening and canal. You have to find the highest volume revision specialist to avoid being botched.

The goal is comfort, function, appearance, sensation, and mobility — not simply “making it look better.”

Dr. Alinsod’s professional materials describe his long-standing work in aesthetic vulvovaginal surgery, pelvic reconstructive surgery, physician training, and development of surgical techniques, with more than 28 years of teaching and presentations worldwide.

Examples of Labiaplasty Surgery resulting in Pain:

* Feathering for Botched Labiaplasty Repair

12. Vaginismus and pelvic floor guarding

Vaginismus is involuntary tightening or spasm of the pelvic floor muscles around the vagina. It can make penetration painful or impossible.

Sometimes vaginismus is the main condition. Other times it develops secondarily because the body has learned that penetration hurts. A woman with GSM, endometriosis, lichen sclerosus, birth trauma, mesh pain, or vaginal scarring may begin to guard. The pelvic floor tightens in anticipation of pain, which creates more pain.

Mayo Clinic lists vaginismus as a cause of painful penetration and notes that stress can tighten pelvic floor muscles, contributing to pain during intercourse.

This is why telling a patient to “relax” is not enough. The muscles may be reacting automatically to a real pain generator.

13. Pelvic floor physical therapy and dilator therapy

Pelvic floor physical therapy is often one of the most important parts of treating painful sex, especially when muscle guarding, vaginismus, pelvic floor dysfunction, postpartum injury, scar pain, or chronic pain cycles are present.

Therapy may include:

external and internal muscle assessmenttrigger point releasemyofascial releasescar mobilizationbreathing and nervous system down-trainingbiofeedbackpelvic floor coordinationhome exercisesgraded dilator therapyreturn-to-intercourse planning

Dilators: what they do and what they do not do

Dilators are not used to “force the vagina open.” They are used to gradually teach the tissues and pelvic floor muscles that gentle insertion can be safe.

Memorial Sloan Kettering explains that vaginal dilators can help when the vagina becomes drier, less elastic, narrower, or shorter after menopause, cancer treatment, or surgery, and that patients usually start with the smallest dilator and increase size gradually. Cleveland Clinic describes dilators as a treatment option for pain with penetration and pelvic floor dysfunction, helping gradually improve flexibility and comfort.

A safe dilator plan should be gentle, guided, and never forced. Pain is information. If dilators worsen symptoms, the plan needs to be adjusted. Here is a video example link on Vaginal Softening Exercises to show it is done in my office:

Vaginal Softening Exercise

14. Treatment options: matching the treatment to the cause

Painful sex does not have one universal treatment. The best treatment depends on the diagnosis.

Foundational treatments

Problem: Common treatments:

GSM dryness/tightnessVaginal estrogen, vaginal DHEA, moisturizers, lubricants, vulvar carePelvic floor spasm/vaginismusPelvic floor PT, dilators, breathing, manual therapy, sometimes medications/injectionsLichen sclerosus/lichen planus diagnosis, topical steroids or immune therapy, vulvar care, estrogen if GSM overlaps.

Endometriosis/adenomyosis: Imaging, medical management, surgical evaluation when appropriate.

Birth trauma/scarringScar therapy, estrogen, pelvic floor PT, perineoplasty or revision if neededProlapsePelvic floor PT, pessary, estrogen, bowel/bladder management, prolapse repairMesh exposure/pain, Estrogen, observation, trimming, revision, removal, pelvic floor therapy.

Prior labiaplasty/vaginoplasty pain: Scar release, reconstruction, revision surgery, pelvic floor therapySize/depth mismatch, tissue restoration, position changes, depth control, PT, treatment of anatomy/pain source.

15. Hormonal and prescription options for GSM-related painful sex

Vaginal estrogen

As mentioned earlier, vaginal estrogen is often foundational. It can improve tissue thickness, elasticity, moisture, pH, and comfort. ACOG lists vaginal estrogen creams, rings, and tablets as options that deliver lower estrogen than systemic hormone therapy and have fewer risks.

Vaginal DHEA

Vaginal DHEA, also called prasterone, is a prescription intravaginal option for GSM-related dyspareunia. The 2025 AUA/SUFU/AUGS guideline recommends offering vaginal DHEA for GSM-related dryness and painful sex.

It should not be called “hormone-free,” because it works through local hormone conversion inside tissues. A better phrase is a non-estrogen intravaginal prescription option.

Ospemifene

Ospemifene is an oral selective estrogen receptor modulator that may be used in selected patients for GSM-related dryness or dyspareunia. The 2025 AUA/SUFU/AUGS guideline says clinicians may offer ospemifene for these symptoms.

Vaginal testosterone

Vaginal testosterone is sometimes discussed for low arousal, low sensitivity, vestibular pain, or GSM-related symptoms, but it is generally off-label and evidence is still developing. The 2025 AUA/SUFU/AUGS guideline notes insufficient evidence to support clinical recommendations for vaginal or systemic testosterone for GSM symptoms.

In a Substack article, I would present testosterone as individualized and investigational/off-label, not as a proven standard GSM therapy.

And don’t forget about Carboxytherapy! It is non-hormonal, non-prescription and available at our office.

16. Energy-based treatments, biologics, and regenerative adjuncts

This section is important, and it must be written with balance.

Patients hear about “vaginal rejuvenation,” radiofrequency, lasers, plasma, PRP, and carboxytherapy online. Some patients have had good experiences. Others have been disappointed or harmed. The best approach is honest counseling.

ACOG states that the FDA has not approved laser or other energy-based treatments for vaginal cosmetic surgery, menopausal symptoms, urinary incontinence, or sexual problems, and warns that serious problems can include burns, scarring, pain with sex, and long-lasting pain. With that being said, ACOG is a decade behind the times and closes its eyes to progress made. The energy based devices such as radiofreuquency and lasers are exceptionally safe in the well trained hands. And they work. Go watch the video on this dedicated Newsletter for more details:

The 2025 AUA/SUFU/AUGS GSM guideline states that evidence does not support CO₂ laser, Er:YAG laser, or radiofrequency for GSM-related dryness, discomfort, dysuria, quality of life, satisfaction, or dyspareunia outcomes; it also says CO₂ laser may be considered only in shared decision-making when patients are not candidates for or prefer alternatives to FDA-approved treatments, with disclosure that therapy is experimental outside clinical trials.

That does not mean these tools have no role in any patient. It means they should be framed as adjuncts, not replacements for diagnosis, tissue evaluation, GSM treatment, pelvic floor therapy, or surgery when anatomy is the problem.

* The Synergy of Energy Plus Biologics

ThermiVa radiofrequency

ThermiVa is a radiofrequency technology associated with vulvovaginal tissue heating and tightening. The Alinsod Institute states that ThermiVa was invented by Red Alinsod, MD, and developed in collaboration with ThermiAesthetics. Link for info:

* Feminine Restoration 2024: State-Of-The-Art Introduction to FemXHA

* ThermiVa from Start to Finish

* What is ThermiVa Radiofrequency Treatment?

Jett Plasma / plasmaporation

The Alinsod Institute describes Jett Plasma as a direct-current technology used in vulvovaginal therapy, with proposed mechanisms involving heat, membrane depolarization, and reversible electroporation. Link for info:

* Plasmaporation for Gynecology ISCG 2025

Fractional CO₂ and Erbium lasers

Examples include MonaLisa Touch-type CO₂ platforms and Erbium systems such as Sciton diVa. These should be discussed with clear consent about evidence, FDA status, risks, alternatives, and expected outcomes.

PRP and biologics

Platelet-rich plasma and related biologic approaches are used by some clinicians for tissue quality, sensitivity, lubrication, and healing support. These should also be presented as adjunctive and individualized. Link for info:

* Feminine Restoration 2024: State-Of-The-Art Introduction to FemXHA

* Clitoxin for Improved Female Sexual Response

17. Surgical treatment: when anatomy is the problem

Surgery is not the answer for every patient. But when anatomy is the pain generator, surgery may be the most direct solution.

Surgical options may include:

perineoplastyrevision of episiotomy scarvaginal scar band releasevaginal cuff revisionrectocele repaircystocele repairuterine prolapse repairvaginal vault prolapse repairmesh exposure revision or removallabiaplasty revisionvaginoplasty revisionvulvar scar releaselysis of adhesionsendometriosis surgerybirth trauma reconstruction

A successful surgical plan must respect function, sensation, tissue health, estrogen status, pelvic support, and the patient’s goals.

* It’s Too Tight!

18. Why integrated care matters

Painful sex rarely belongs to only one specialty.

A menopausal patient may also have lichen sclerosus.A prolapse patient may also have GSM.A hysterectomy patient may have cuff pain and pelvic floor spasm.A cancer survivor may have stenosis, dryness, and fear of penetration.A postpartum patient may have scar pain, rectocele, and muscle guarding.A mesh patient may have exposure, estrogen-deprived tissue, and nerve pain.A prior labiaplasty patient may have scar tethering plus vestibular pain.

This is why an integrated approach matters.

At the Alinsod Institute and Revique Medical & Aesthetics in Arlington, Texas, Dr. Red Alinsod, Amy Haddad, RNP, and Dian White, MA, provide a model that brings surgical and non-surgical options together. The Alinsod Institute describes Dr. Alinsod’s work in urogynecology, pelvic reconstructive surgery, aesthetic vulvovaginal surgery, physician education, Gynflix, and innovation in vulvovaginal techniques. Gynflix is as an online training platform for physicians and surgeons in reconstructive pelvic surgery and aesthetic vulvovaginal surgery. The 1st and only one of its kind in the world. 20 years in the making.

Revique Medical & Aesthetics lists services including hormone replacement, peptide therapy, advanced lab testing, women’s intimate health, ThermiVa, Emsella, O-Shot, Clitoxin, and related wellness services.

The goal is not to sell one procedure. The goal is to identify the real cause and match the treatment to the tissue, anatomy, muscles, hormones, and patient goals. The goal is teamwork, excellence, and Platinum Service.

Pelvic Pain Review written by my friend John Paulson:

19: Interstitial Cystitis / Bladder Pain Syndrome: The Great Imitator of Pelvic Pain

Another major cause of painful sex that is often missed is Interstitial Cystitis, also called Bladder Pain Syndrome, or IC/BPS. I am going go spend a bit more time on this because it is so frequently missed and overlooked. The average patient sees about 7 doctors before this diagnosis is even brought up.

IC is a chronic pain condition involving the bladder and surrounding pelvic tissues. It can cause bladder pressure, bladder pain, pelvic pain, urinary urgency, urinary frequency, and pain with sex. Mayo Clinic describes IC as a chronic condition that causes bladder pressure, bladder pain, and sometimes pelvic pain, with pain ranging from mild discomfort to severe pain. It also notes that symptoms can flare with menstruation, stress, sitting for a long time, exercise, and sexual activity.

I often call IC “The Great Imitator” because it can look and feel like so many other pelvic pain conditions.

It can feel like endometriosis.It can feel like adenomyosis.It can feel like a recurrent urinary tract infection.It can feel like pelvic floor spasm.It can feel like vaginal cuff pain after hysterectomy.It can feel like deep dyspareunia or collision pain.It can even trigger burning, urgency, and pelvic pressure that patients may assume is coming from the vagina, uterus, ovaries, or bowel.

This is why IC must be part of a thorough painful-sex evaluation, especially when a patient has chronic pelvic pain, urinary urgency, bladder pressure, pain that worsens with bladder filling, or pain that persists despite treatment for endometriosis.

IC and endometriosis: the “evil twins”

Interstitial cystitis and endometriosis frequently overlap. Some studies in chronic pelvic pain populations have reported very high coexistence rates. One review reported that among patients with endometriosis, 86% were also diagnosed with IC, and among patients with IC, 72% were also diagnosed with endometriosis.

I would word this carefully for patients: “In some chronic pelvic pain studies, IC has been found in nearly 90% of women with endometriosis.” That is powerful and accurate, but it avoids implying that 90% applies to every endometriosis patient in every setting. Broader reviews show wide variation in coexistence rates, with one 2024 meta-analysis reporting coexistence of endometriosis and IC/BPS in chronic pelvic pain populations ranging from 15.5% to 78.3%.

The practical point is this: if a woman has endometriosis and painful sex, bladder pain syndrome should be on the checklist. Treating endometriosis alone may not resolve pain if IC is also present.

What IC feels like

Patients with IC may describe:

bladder pressurepelvic pressureburning pelvic painpain with bladder fillingrelief after urinationurinary urgencyurinary frequencywaking at night to urinatepain during or after sexpain with pelvic examspain that flares before or during the periodpain after certain foods or drinkssymptoms that feel like a UTI but urine cultures are negative

NIDDK explains that IC pain often worsens as the bladder fills and improves after urination. Patients may also feel pain in the groin and pelvic floor muscles, and symptoms may include pelvic pressure, tenderness, urinary urgency, and urinary frequency. Mayo Clinic similarly notes that IC symptoms can resemble a chronic urinary tract infection, but there is usually no infection.

This “UTI feeling without infection” is one of the biggest clues.

Why IC causes painful sex

Sex can irritate the bladder, urethra, pelvic floor muscles, and anterior vaginal wall. For some women, penetration places direct pressure on the bladder base. For others, the pelvic floor muscles tighten in response to bladder pain, creating a secondary vaginismus-like guarding pattern.

This can produce:

burning during penetrationdeep anterior vaginal painbladder pressure during sexurgency during or after sexpain after orgasmpelvic cramping after sexa flare that lasts hours or days

NIDDK notes that chronic pelvic pain and vulvodynia can be associated with pain during sex, and that sex may increase bladder pain flares in some patients with IC. This is one reason IC can be confused with endometriosis, pelvic floor dysfunction, GSM, vulvodynia, hysterectomy cuff pain, or prolapse-related pressure.

What causes IC?

The exact cause is not fully known. It is likely not one single disease in every patient, but a syndrome with multiple pathways.

Possible contributors include:

a damaged or “leaky” protective bladder liningbladder wall inflammationoveractive pain nervespelvic floor muscle dysfunctionimmune or allergic factorsmast-cell activationprior infections that trigger lingering pain sensitivitycentral sensitization, where the nervous system becomes more reactiveoverlap with other chronic pain conditions such as IBS, fibromyalgia, vulvodynia, migraine, and chronic fatigue

Mayo Clinic states that the exact cause is unknown, but possible contributors include a defect in the protective bladder lining that may allow irritating substances in urine to affect the bladder wall, as well as possible autoimmune, hereditary, infection-related, or allergy-related factors. NIDDK also notes that IC is more likely to occur with other chronic pain conditions, gastrointestinal disorders, allergies, autoimmune diseases, depression, and anxiety.

How IC is diagnosed

There is no single simple test that proves every case of IC. The diagnosis is usually made by listening carefully to the symptoms, examining the pelvis and pelvic floor, ruling out infection, and looking for other conditions that can mimic or coexist with IC.

Evaluation may include:

urinalysis and urine culturepelvic examassessment of pelvic floor tenderness and spasmscreening for endometriosis, adenomyosis, vulvodynia, GSM, and prolapsebladder symptom questionnairescystoscopy in selected patientsevaluation for Hunner lesions in more severe or classic bladder-centered cases

The important point is that repeated antibiotics for “UTIs” without positive cultures may delay the real diagnosis. If the cultures are negative and the symptoms keep returning, IC/BPS deserves consideration.

Treatment for IC/BPS

Treatment is individualized. There is no one-size-fits-all cure, but many patients improve when the correct pain generators are addressed.

Lifestyle and trigger management

Many patients learn that certain foods or drinks flare their bladder. Common triggers include caffeine, carbonated drinks, citrus, tomatoes, alcohol, spicy foods, artificial sweeteners, and high-acid foods. Mayo Clinic lists the “four Cs” as common bladder irritants: carbonated beverages, caffeine, citrus products, and high-vitamin-C foods.

A bladder diary or food diary can help identify patterns without making the patient feel afraid of food.

Bladder training

Bladder training can help reduce urgency and frequency by gradually increasing the time between voids. NIDDK notes that bladder training may help the bladder hold more urine, reduce pain and urgency, and decrease bathroom trips.

Pelvic floor physical therapy

Pelvic floor physical therapy is often essential. Many IC patients have tight, reactive, painful pelvic floor muscles. These muscles may need relaxation, lengthening, trigger-point release, myofascial work, breathing techniques, and down-training.

This is not the same as Kegels. In fact, NIDDK specifically advises that patients with IC symptoms should avoid pelvic floor strengthening exercises such as Kegels unless working with a physical therapist.

Oral medications

Depending on the patient, medications may include:

anti-inflammatory pain relieversbladder pain medicationstricyclic antidepressants such as amitriptyline to help calm pain signaling and relax the bladderantihistamines in selected patients with allergic or mast-cell featurespentosan polysulfate sodium, also known as Elmiron, in selected cases

Mayo Clinic lists tricyclic antidepressants, antihistamines, and pentosan polysulfate sodium among medication options for IC. It also notes that pentosan polysulfate may take months to help and has been associated with macular eye disease in some patients, requiring eye monitoring.

Bladder instillations

Some patients benefit from bladder instillations, where medication is placed directly into the bladder through a small catheter. Mayo Clinic describes DMSO bladder instillation and other instillation mixtures that may include lidocaine, sodium bicarbonate, heparin, or pentosan.

Neuromodulation and procedures

For persistent symptoms, options may include TENS, sacral nerve stimulation, bladder hydrodistention, Botox injections into the bladder wall, and treatment of Hunner lesions when present. NIDDK lists neuromodulators, bladder instillation, bladder stretching or hydrodistention, Botox, and electrocauterization of Hunner lesions among treatment approaches.

Surgery is rarely needed for IC and is generally reserved for severe, refractory cases because major bladder surgery does not always cure the pain.

Why IC belongs in a painful-sex article

IC is one of the most important missed diagnoses in women with painful sex and chronic pelvic pain.

A woman may come in thinking she has recurrent UTIs.Another may think her endometriosis has returned.Another may believe her hysterectomy cuff is the only problem.Another may have GSM dryness and bladder pain at the same time.Another may have pelvic floor spasm that started because the bladder was painful.

The key is to look for all contributors, not just the most obvious one.

When IC is present, treating the bladder, pelvic floor, hormones, vulvar tissue, endometriosis, prolapse, or scar pain together can make the difference between partial relief and meaningful recovery.

20. When should you schedule an evaluation?

Consider evaluation if you have:

pain with sex that keeps returningburning, tearing, or bleeding after sexdryness that lubricant does not fixnew tightness after menopause, hysterectomy, childbirth, or cancer therapydeep pelvic pain with penetrationpain after hysterectomypain after labiaplasty or vaginoplastyvulvar itching, white patches, fissures, or scarringa vaginal bulge, pressure, or heavinessdifficulty emptying bladder or bowelpain or partner discomfort after mesh surgerysex that has become impossible or frightening because of pain

You do not need to know the diagnosis before you call. That is what the evaluation is for.

A personal note

Painful sex is not just about sex.

It affects relationships, confidence, mood, sleep, identity, and how a woman feels in her own body. Many women apologize when they finally bring it up.

Please do not apologize. It surely is more common than you think.

Your pain is real. Your story matters. And in many cases, there are answers.

At the Alinsod Institute and Revique Medical & Aesthetics in Arlington, Texas, our goal is to listen carefully, examine respectfully, explain clearly, and build a plan that fits your body and your life.

I hope this Newsletter helps your understanding of Painful Sex. Do something about it. Don’t live with it. Don’t ignore it. It does not get better with time.

Watch how these procedures are done

For Patients and Physicians who want to understand the surgical artistry and technical details, I encourage you to visit www.gynflix.com.

Gynflix includes a section called Video Shorts, which is designed for both patients and doctors and features educational videos about procedures, outcomes, and post-operative care. (Gynflix)

The Shorts section includes many videos related to vaginoplasty, perineoplasty, posterior compartment repair, combined procedures, and radiofrequency treatments. (Gynflix)

Here is an example of the videos found on Video Shorts section of Gynlix.com:

FOR THE SURGEON

I built an online community of expert Cosmetic Gynecologists from around the world who you will be able to communicate with and pick their brains. Click on the logo picture for the link:

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos.

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on Instagram asVageniusMD.I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

Follow me on my Adventures Worldwide

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576🌐 www.alinsodinstitute.comwww.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe

I have had the largest collection of Before and After pictures of any Cosmetic Gynecology Practice in the world and I'm quite proud of it. Dozens of Labiaplasty and Vaginoplasty photo sets for you to see what is possible. My staff and I have exerted a great deal of effort to provide accurate and useful photographs of my work. Many you have seen my surgical photographs on Alinsodinstitute.com. Now I begin the buildout on Gynflix.com to host my surgical video library of Before and Afters.

The Summer of 26 begins the next logical evolution of Gynflix.com with the creation of my video version of Before and After surgery transitions. This video is the first of many to come that shows how I take a patient though the process of her youthful feminine transformation . Take a peek and see what is ahead for my two websites: www.alinsodinstitute.com and www.gynflix.com.

The Alinsod Institute Procedure Gallery

Follow me on my Adventures Worldwide

Watch how these procedures are done

For patients and physicians who want to understand the surgical artistry and technical details, I encourage you to visit www.gynflix.com.

Gynflix includes a section called Video Shorts, which is designed for both patients and doctors and features educational videos about procedures, outcomes, and post-operative care. (Gynflix)

The Shorts section includes many videos related to vaginoplasty, perineoplasty, posterior compartment repair, combined procedures, and radiofrequency treatments. (Gynflix)

Here is an example of the videos found on Video Shorts section of Gynlix.com:

About Dr. Red Alinsod and the Alinsod Institute

I am Red M. Alinsod, MD, FACOG, FACS, ACGE, a cosmetic gynecologist and pelvic reconstructive surgeon based in Arlington, Texas.

My medical training was completed at Loma Linda University Medical Center in 1990. I served a 12-year Air Force career, practiced in Southern California, Nevada, and Texas, and now base my practice in Arlington. I am the Director and founder of South Coast Urogynecology and the Alinsod Institute for Aesthetic Vulvovaginal Surgery, and I founded Gynflix as an online e-learning platform for physicians. (alinsodinstitute.com)

My international teaching program combines pelvic reconstructive and aesthetic principles, and I have trained many leading doctors and instructors in cosmetic gynecology while presenting my techniques worldwide for more than 28 years. (alinsodinstitute.com)

I have also developed or invented multiple techniques, instruments, and devices related to cosmetic gynecology, pelvic reconstruction, labiaplasty, perineoplasty, vaginoplasty, and ThermiVa. (alinsodinstitute.com)

Verified patient ratings list Dr. Red Alinsod with a 4.8 rating and 321 reviews, with patients commonly describing his care as thorough, warm, attentive, and confidence-building. (Real Patient Ratings)

A few short Patient Testimonial excerpts say it best:

“My results are amazing.” (alinsodinstitute.com)

“True artist and true professional.” (alinsodinstitute.com)

“My results are impeccable.” (alinsodinstitute.com)

Testimonials are not a guarantee of individual outcome, but they do reflect the kind of trust, detail, and artistry patients look for when choosing a surgeon for such personal work.

FOR THE SURGEON

I built an online community of expert Cosmetic Gynecologists from around the world who you will be able to communicate with and pick their brains. Click on the logo picture for the link:

GYNFLIX Cosmetic Gynecology e-Learning

For Detailed Videos Click on the Index Photo Below:

For more Cosmetic Gynecology Training join Gynflix.com

Gynflix is an online e-Learning platform dedicated to Feminine Wellness. Videos of topics such as labiaplasty, vaginoplasty, cliteroplasty, clitoral hood reduction, anal skin tag excision.

Click here for Silver Bullet Subscription at $98 a month: Gynflix Subscription

Contact Suzette Peterson at ‭(909) 374-1000‬ or email her at [email protected] if you are interested in Fellows Gold Subscription at $198 a month.

GOLD FELLOWS MEMBERSHIP: This unique and valuable service provides access to all future surgical and non-surgical videos on www.gynflix.com.There will be 1-2 complete and unique videos per month. Dr. Alinsod will be available to discuss the intricacies and details of topics covered in the videos and answer specific questions that may arise . This is the first and only true Master’s Course for continuing education focused on cosmetic gynecology.

I love hearing from my Fellows, Grads, subscribers. Text or email me. I answer questions from all around the world!

NOW AVAILABLE IN SPANISH: CLICK HERE FOR GYNFLIX ESPANOL!

I have spent two years finding and curating my best videos to translate into Spanish. Now I have over 100 videos, both in short form and long form, to introduce into the Latin professional societies. These are the exquisite core videos that will be used in universities in Barcelona and Argentina in the near future. Latin America is the fastest growing part of the world in Cosmetic Gynecology and I am here to 100% to support its growth and ascendancy.

For Cosmetic Gynecology Short Videos (free for all) go to Video Shorts on Gynflix. This is made for the Lay Public. Dozens of high def, high quality videos.

More videos are also available on my YouTube Channel:

Red Alinsod, MD (@vageniusmd)

Let’s Stay Connected

I’m so grateful for the opportunity to serve you, whether you’re a patient, a colleague, or someone curious about what we do. Our new Arlington location is ready to welcome you with the same compassionate, personalized care you’ve come to expect. Explore our services, my background, and our mission at:

* alinsodinstitute.com

* About Dr. Red Alinsod

* About Alinsod Institute

I’d love to hear from you—reach out with questions, feedback, or just to say hello. Together, we’re shaping a brighter, healthier future for women everywhere.

Social Media:

Follow my Social Media adventures below as I educate and entertain every week. Join me on Instagram asVageniusMD. I have around 190,000 subscribers to my Cosmetic Gynecology Newsletter and 90,000 subscribers to this Labiaplasty Newsletter. Follow me on Instagram for fun and knowledge.

Instagram: VageniusMD

FB: Vagenius - Red Alinsod, MD

TicTok: VageniusMD

Websites:

Alinsod Institute

Gynflix

My Three Newsletters:

For the Lay Public and Medical Professionals: Feminine Wellness Newsletter

For Medical Professionals: Cosmetic Gynecology Newsletter

For Surgeons: Subscribe to the Labiaplasty and Vaginoplasty Newsletter:

MY PRACTICE WEBSITE

MY LOCATION

Alinsod Institute — Red M. Alinsod, MD📞 945-900-7576🌐 www.alinsodinstitute.com🌐 www.gynflix.com

Feminine Wellness Newsletter is a reader-supported publication. To receive new posts and support my work, subscribe and be a paid subscriber.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit femininewellness.substack.com/subscribe