Genital Filler

What is genital filler?

Genital filler is the injection of a hyaluronic acid-based filler under the skin of the female external genitalia. The most studied area is the labia majora: the structures running along both sides of the external genitalia, commonly known as the outer labia or outer lips. The mons pubis, the pad of fatty tissue over the pubic bone, is also included.

These two structures are the parts of the vulva (the external genital organs) made up of fatty tissue. According to the authors of a measurement study in 214 women, the anatomy of these areas has not been studied in much detail. Volume loss in the labia majora is linked to ageing, hormonal changes and some medical conditions; the external genitalia are reported to lose elasticity and volume with age.

The American College of Obstetricians and Gynecologists (ACOG) lists labia majora augmentation under the general heading of ‘female genital cosmetic surgery’. This heading also covers very different procedures, such as labiaplasty (labia reduction surgery) and ‘G-spot’ procedures. This page covers only hyaluronic acid filler in the external genitalia; injections into the vagina are a separate medical topic.

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What does ‘genital filler’ mean?

‘Genital filler’ is not a medical term but a name that has become established in everyday language. On its own, it does not say which structure is treated, with which substance or for what purpose. The medical literature mostly refers to these treatments with terms that name the structure treated, such as ‘labia majora augmentation’ or ‘labia majora volume restoration’.

The naming problem also exists in scientific publications. In a systematic review of cosmetic gynaecology (a publication that searches for the studies on a topic using a set method and assesses them together), 42 of the 1,837 publications screened were included. The terms and outcome measures varied widely from study to study, and the authors stressed the need for shared terms and measures. According to ACOG, the lack of standard terminology also means that data on the risks and benefits of these procedures remain limited.

The guideline of the Society of Obstetricians and Gynaecologists of Canada (SOGC) goes a step further: it describes expressions such as ‘vaginal rejuvenation’, ‘clitoral resurfacing’ and ‘G-spot amplification’ as marketing terms with no medical basis, and states that for this reason they cannot be assessed scientifically.

In short, ‘genital filler’ here means only hyaluronic acid treatment of the labia majora and mons pubis.

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Volume loss in the labia majora

Genital filler has been studied most for volume loss in the labia majora (outer labia). In the medical literature this is called hypotrophy (reduced volume) or atrophy (thinning of the tissue), and it is described as a result of ageing, hormonal changes and some medical conditions. Two series that reviewed past patient records also note that the external genitalia lose elasticity and volume with age.

According to a multicentre prospective study, atrophy of the labia majora and the inner labia (labia minora) extending beyond the outer labia can bother some women because of how it looks, and sometimes for functional reasons.

Volume loss and laxity (sagging) are separate problems. A randomised trial (a trial in which participants are randomly assigned to groups) of ten people with sagging or volume loss in the labia majora compared hyaluronic acid with calcium hydroxylapatite (CaHA, a different filler). The researchers could not show that either one was better, and recommended assessing sagging and volume loss separately.

This is why the following questions are considered separately at the consultation: Is your concern mainly volume loss, laxity or both? Does filler have anything to offer for this concern? Is another assessment needed first?

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Mons pubis

The mons pubis is the pad of fatty tissue over the pubic bone; together with the labia majora, it makes up the fatty part of the vulva. There is even less evidence on hyaluronic acid filler in this area than for the labia majora.

According to a measurement study in 214 women, the anatomy of the mons pubis and labia majora has not been studied in much detail. In the same study, the volumes of the two structures differed between two groups divided by body mass index (a value calculated from height and weight). The researchers recommend taking body mass index and the proportions of the area into account in any aesthetic treatment here.

The mons pubis is also considered in terms of sagging (ptosis). A review on this topic describes in detail how the area should be assessed and the surgical options proposed, such as a mons pubis lift or monsplasty. The systematic review of cosmetic gynaecology also lists mons pubis reduction or lift procedures among the procedures described in this field.

In the sources searched, no study was found that described hyaluronic acid treatment of the mons pubis in a way that could be assessed. This does not mean that such treatment has never been reported, but it does show that the evidence is even more limited than for the labia majora. Whether filler has a role in this area is assessed at the consultation, with sagging considered separately.

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How strong is the evidence?

There is little evidence on hyaluronic acid treatment of the labia majora. Most of it comes from retrospective case series (publications that review past patient records), a small number of prospective studies (studies that recruit participants at the start and follow them over time) and small randomised trials. Long-term data are limited.

One of the first publications in this field reviews the records of 54 patients treated between November 2010 and December 2014; according to the authors, at that time there was no study describing hyaluronic acid treatment of the labia majora. A second retrospective series covers 37 patients. In both studies, results were assessed using appearance-focused scales completed by the patient and the doctor.

A multicentre prospective study enrolled 73 women, of whom 72 were treated and followed up for 52 weeks. This study had no control group, and participants knew what they were receiving (an open-label design). In a single-centre randomised trial, 76 women were divided into two groups: filler (40) and no treatment (36). They were followed up for six months, and the researchers ask that the results be seen as preliminary findings and confirmed by long-term research. The other publications are a randomised comparison of ten people, a pilot study of ten people and case reports.

When reading this evidence, it helps to know a few things. What is measured is mostly appearance ratings. Most studies have no control group; where there is one, the comparison is with no treatment, not with a sham treatment (a procedure that only imitates the real treatment). A case report of two patients draws attention to reports of fillers being used off-label (outside the uses covered by the product’s licence or approval) in this area. In small series, a statement that ‘no complications were recorded’ does not prove that complications are rare; it only shows that none occurred in that series.

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What do professional bodies say?

Professional bodies in obstetrics and gynaecology take a cautious approach to genital cosmetic procedures done without a medical reason. ACOG asks that women be told there are no high-quality data supporting the effectiveness of these procedures, and that they be given information about possible complications.

According to the current version of the Canadian guideline, most women who request these procedures have normal genital anatomy, and up to 87% are reassured by counselling. The same guideline states that procedures done for non-medical reasons cannot be supported, because there is no rigorous evidence on their effectiveness and safety in the short or long term. The previous version of the guideline stresses that these procedures should not be recommended to adolescents before they reach full maturity, including genital development.

ACOG recommends, where appropriate, assessment for body dysmorphic disorder (BDD; a psychiatric disorder that affects how a person perceives their own appearance). If a psychological concern is suspected, it recommends referral for this kind of assessment before a procedure is considered. According to a review of the topic, this disorder often goes unrecognised in plastic surgery.

These recommendations were written mainly for surgical procedures; however, ACOG lists labia majora augmentation and ‘G-spot’ procedures under the same heading. ACOG’s 2007 opinion also recommends discussing with the patient why she is requesting these procedures, and assessing her for findings that could indicate a need for surgery.

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Sexual function claims and ‘G-spot’ injections

Professional bodies do not support the claim that filler improves sexual function. The effectiveness and safety of injections into the ‘G-spot’ area, promoted as a way to enhance sexual function, have not been documented either.

According to ACOG, unless there is a medical reason, such as a clinically diagnosed problem, procedures intended to change sexual appearance or function are not medically indicated (not medically necessary). They carry significant risks, and their safety and effectiveness have not been proven. The SOGC guideline also states that there is little evidence that these procedures improve sexual satisfaction or self-image, and that they should not be promoted as a way to enhance sexual function.

The ‘G-spot’ itself is disputed. A systematic review of 31 studies concludes that the existence of such a structure has not been proven, and that even in studies that assume it exists, there is no agreement on its location, size or nature. A detailed dissection (anatomical examination) study of 13 cadavers also found no structure matching this description in the front wall of the vagina, other than the urethra (the tube that carries urine) and the vaginal wall itself. ACOG’s 2007 opinion also states that ‘G-spot amplification’ procedures are not medically indicated.

A publication bringing together cases of pulmonary embolism (a blockage in a blood vessel in the lungs) linked to filler injections into the genital area reviewed 14 cases. Silicone was used in most of them; in the female patients, the injection site was the ‘G-spot’ in one case and the vaginal wall in the others. Seven of the 14 patients died. The authors describe aesthetic filler injections into the genital area as experimental procedures that have not been rigorously studied.

Some small studies of labia majora filler report changes in sexual function scores. However, according to a systematic review that mainly covers labiaplasty (labia reduction surgery), the improvements in sexual function reported after genital cosmetic procedures are based on small, uncontrolled studies (studies with no comparison group), are open to the expectation effect, and the certainty of the evidence is low; this review does not include filler studies. Another systematic review gathering the views of healthcare professionals also found little agreement that these procedures have a positive effect on sexual function. For this reason, no expectations are raised about filler’s effect on sexual function.

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Symptoms that need a gynaecological assessment first

If you have symptoms such as pain, vaginal dryness, pain during sex (dyspareunia), urinary incontinence or a feeling of sagging, you need a gynaecological assessment before filler is considered. Diagnosing and treating these symptoms is a separate medical field.

According to the North American Menopause Society’s 2020 position statement, genitourinary syndrome of menopause (GSM; a condition that includes vulval and vaginal atrophy) is very likely underdiagnosed and undertreated, even though in most cases the symptoms can be managed effectively. The statement lists lubricants and moisturisers, vaginal hormone treatments and other medicine options. Which of these is suitable depends on a doctor’s assessment.

The European Board and College of Obstetrics and Gynaecology (EBCOG) points out that the first-line treatment for pelvic organ prolapse and stress incontinence (leaking urine when you cough, sneeze or exercise) is conservative, meaning non-surgical, and that vaginal oestrogen is often prescribed for vaginal atrophy that causes symptoms. ACOG also keeps clinical indications such as pain during sex, vaginal prolapse and urinary incontinence separate from cosmetic procedures. SOGC recommends taking a full medical, sexual and gynaecological history (health background) from women who request genital cosmetic procedures.

There are also small studies in which hyaluronic acid injections into the vulva and vagina have been tried for vaginal atrophy; for example, a randomised trial in 20 women comparing hyaluronic acid with platelet-rich plasma (PRP). However, this is a separate medical topic that belongs to menopause treatment; it is not the same as filler in the external genitalia. Injections into the vagina are covered separately on the Genital Rejuvenation page.

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Limits of this treatment

Genital filler is a treatment for volume loss; it is not a substitute for surgical procedures and does not solve problems with sexual function. The limits set by the scientific data are as follows:

Reducing the inner labia (labiaplasty) is a surgical procedure; filler does not replace it.

In the medical literature, sagging of the mons pubis is treated with surgical methods.

Volume loss and sagging are separate problems; the authors of a randomised trial recommend assessing them separately.

Hyaluronic acid fillers are considered a reversible type of filler and are distinct from fillers that give a permanent correction. Long-term data for the genital area are limited; the authors of the randomised trial also state that long-term research is needed.

The safety and effectiveness of procedures intended to change sexual appearance or function have not been proven.

Symptoms such as pain, vaginal dryness, urinary incontinence and sagging are not a cosmetic matter; they need a gynaecological assessment.

This information is not given to steer you in one direction, but so that you can compare the options. Which path makes sense for you — filler, a gynaecological assessment, a surgical option or none of these — is decided by the assessment at your consultation and by your own decision.

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Known risks

The side effects reported in labia majora filler studies are mostly temporary, mild local reactions. However, serious events such as tissue damage from vascular occlusion (a blocked blood vessel) and severe infection have been reported in case reports.

In the randomised trial, there were no serious adverse events; only temporary, mild local reactions were reported. In the retrospective series of 37 patients, only mild adverse events were recorded. The most detailed data on which local reactions can be expected come from facial fillers: a systematic review of hyaluronic acid fillers in the face reported swelling, pain, redness, bruising, and lumps and firmness you can feel. According to another review of facial fillers, most adverse effects are mild and temporary; vascular occlusions, which are rare, need to be recognised and treated quickly. However, these data come from the face and cannot be applied directly to the genital area.

A publication describing vascular occlusion after hyaluronic acid injection into the vulva and vagina adds a fourth case to three previously reported cases of vascular complications. This patient was treated in the labia majora, labia minora and vagina, and developed severe pain and a skin wound caused by tissue death. She was given treatment directed at the internal pudendal artery, one of the arteries that supply the genital area. The authors state that this complication is rare but serious, and that severe cases can be life-threatening.

Infection is also among the reported risks. In a patient who had received a filler of unknown type in the external genitalia a year earlier, an inflammatory nodule (a small lump under the skin) was followed by a severe soft-tissue infection (necrotising fasciitis) and sepsis (a severe reaction to infection that affects the whole body).

Case reports do not show how often these risks occur, but they do not mean the risk can be ignored either. ACOG asks that, before genital cosmetic procedures, patients are told about possible complications such as pain, bleeding, infection, scarring and altered sensation.

RELATEDWhat should you ask before a treatment?

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Can filler be reversed?

Hyaluronic acid fillers are considered a reversible type of filler; their complications can be reversed with an enzyme called hyaluronidase. The authors of the labia majora series also state that the treatment is reversible.

A review of facial fillers describes reversibility as a feature of hyaluronic acid fillers and distinguishes this type from fillers that give a permanent correction. According to a review of hyaluronidase, the enzyme can reverse complications of these fillers. However, controlled data on this are limited, and in emergencies such as vascular occlusion, treatment must be given without delay. Most of these data come from the face.

Hyaluronidase is kept at the clinic. If you have had filler elsewhere, you will first be asked what type of filler it was, when it was done and which area was treated. Dissolving is not carried out directly on filler of unknown type, or on filler that cannot be confirmed to be hyaluronic acid.

So if you have had a treatment in this area before, you need to say at your consultation what was done, when, and by whom. If you do not know, saying so is also useful information.

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