27 33 54 60 However, results from two studies of moderate to high methodological study quality indicated a trend for a greater risk of burning or painful urination with FGM/C (RR=2.56, 95% CI 0.80 to 8.22; RR=1.66, 95% CI 0.96 to 2.85).33 60 Menstrual problems

were reported in five studies (n=6564).30 31 33 54 64 They showed find more information a trend towards a greater risk of menstrual problems with FGM/C: dysmenorrhoea (RR=1.44, 95% CI 1.11 to 1.86), difficulty in menstruation (RR=1.02, 95% CI 0.06 to 16.28), menstrual problems (RR=0.77, 95% CI 0.61 to 0.97), irregular menses (RR=2.56, 95% CI 1.48 to 3.45) and difficulty in passing menstrual blood (RR=1.75, 95% CI 0.78 to 3.93). Ten comparative studies (n=28 940) reported results concerning long-term genitourinary infections.21 29 30 37 43 46 54 55 64 65 Owing to few studies and the low number of events, the findings were inconclusive for the following outcomes:

chronic pelvic infections, reproductive tract infections, genital infections and vaginitis. However, in adjusted analyses, two studies of low to moderate methodological quality found a statistically higher risk of reproductive tract infections (AOR=1.54, 95% CI 1.08 to 2.21) and genital infections (AOR=1.72, 95% CI 1.02 to 2.92) with FGM/C.37 43 Meta-analyses showed a greater risk of urinary tract infections (RR=3.01, 95% CI 1.42 to 6.38; GRADE: very low; figure 3)21 29 30 64 65 and bacterial vaginosis (AOR=1.68, 95% CI 1.28 to 2.22; GRADE: very low) with FGM/C (figure 4).46 54 Painful sexual intercourse Dyspareunia (painful sexual intercourse) was reported in six studies (n=6204).31 33 54 58 60 64 The meta-analysis, presented in figure 3, showed an increased risk of dyspareunia with FGM/C (RR=1.53, 95% CI 1.20 to 1.97; GRADE: very low). Correspondingly, results from two nationally representative studies from Eritrea (n=12 540) indicated a ‘dose–response’ relationship, with a lower risk of problems during sexual relations with FGM/C types I–II relative to type III (RR=0.19, 95% CI 0.16 to 0.24; RR=0.44, 95% CI 0.27 to 0.72).34 35 HIV and sexually transmitted infections HIV and sexually transmitted infections

(STIs) were clinically examined in one case–control study and 10 cross-sectional AV-951 studies (n=12 912).26 32 39 44 46 52 54 55 62 63 71 The case–control study could not establish a difference between FGM/C and no FGM/C regarding STIs (AOR=1.13, 95% CI 0.73 to 1.77).32 Similarly, the meta-analysis of cross-sectional studies failed to establish a difference (RR=1.07, 95% CI 0.75 to 1.53; GRADE: very low; figure 3).54 55 71 As shown in figure 4, also the meta-analysis for HIV, based on four studies which presented adjusted data, failed to establish a difference relative to FGM/C (AOR=0.95, 95% CI=0.54 to 1.67; GRADE: very low).44 46 62 71 Infertility Twelve studies presented data on infertility (n=36 473).20 23 40 41 46 47 48 50 54 64 Two case–control studies of high methodological quality examined whether FGM/C was a predictor for infertility.