The efficacy of erbium-doped yttrium aluminum garnet (Er:YAG) laser in the treatment of decreased sexual sensation: a randomized, placebo-controlled trial

Pelvic floor muscle training vs radiofrequency for women with vaginal laxity: randomized clinical trial

BACKGROUND

Vaginal laxity (VL) is a complaint of excessive vaginal looseness with a prevalence ranging from 24% to 38% across studies.

AIM

The study sought to compare the effect of radiofrequency (RF) and pelvic floor muscle training (PFMT) on the treatment of women with VL.

METHODS

From February 2020 to December 2021, a prospective, parallel, noninferiority, randomized clinical trial was carried out in women ≥18 years of age and complaining of VL in a tertiary hospital. Two groups (RF and PFMT) were evaluated at the beginning of the study and 30 days and 6 months postintervention. A total of 42 participants per arm was sufficient to demonstrate a difference in sexual function on the Female Sexual Function Index at 90% power, 1-sided type 1 error of 0.025 with a noninferiority margin of 4 on the FSFI total score. Analysis was intention-to-treat and per-protocol based.

OUTCOMES

The primary endpoint was the change of FSFI score after treatment, and the secondary outcomes were improvement in symptoms of VL and changes in questionnaire scores of sexual distress, vaginal symptoms, and urinary incontinence, in the quantification of pelvic organ prolapse, and pelvic floor muscle (PFM) contraction.

RESULTS

Of 167 participants recruited, 87 were included (RF: n = 42; PFMT: n = 45). All questionnaires improved (P < .05) their total scores and subscales in both groups and during the follow-ups. After 30 days of treatment, RF was noninferior to PFMT to improving FSFI total score (mean difference -0.08 [95% confidence interval, -2.58 to 2.42]) in the per-protocol analysis (mean difference -0.46 [95% confidence interval, -2.92 to 1.99]) and in the intention-to-treat analysis; however, this result was not maintained after 6 months of treatment. PFM contraction improved significantly in both groups (RF: P = .006, 30 days; P = .049, 6 months; PFMT: P < .001, 30 days and 6 months), with better results in the PFMT group.

CLINICAL IMPLICATIONS

Sexual, vaginal, and urinary symptoms were improved after 30 days and 6 months of treatment with RF and PFMT; however, better results were observed in the PFMT group after 6 months.

STRENGTHS & LIMITATIONS

The present randomized clinical trial used several validated questionnaires evaluating quality of life, sexual function and urinary symptoms, in addition to assessing PFM contraction and classifying the quantification of pelvic organ prolapse aiming at anatomical changes in two follow-up periods. The limitations were the lack of a sham-controlled group (third arm) and the difficulty of blinding researchers to assess treatments due to the COVID-19 pandemic.

CONCLUSION

After 30 days and 6 months of treatment, sexual, vaginal, and urinary symptoms improved with RF and PFMT; however, better results were observed in the PFMT group after 6 months. RF was noninferior to PFMT in improving FSFI total score after 30 days; however, this result was not maintained after 6 months of treatment.

A novel objective evaluation method, shear wave elastography, in the treatment of atrophic vaginitis by nonablative intravaginal Er:YAG laser, a randomized-sham controlled pilot study

OBJECTIVE

The aim of the study was to investigate the effectiveness of intravaginal Er:YAG laser for treating atrophic vaginitis in postmenopausal women utilizing shear wave elastography.

METHODS

In this prospective randomized sham-controlled double-blind pilot study, 20 participants were included (laser group [n = 12] / sham-control group [n = 8]). A nonablative (Smooth mode) Er:YAG laser with a wavelength of 2,940 nm was used. Objective evaluation of laser treatment efficacy was conducted using a special ultrasonic technique: shear wave elastography. Ultrasonic velocity measurements were taken from the anterior and posterior vaginal walls. Mean elasticity (E mean ) was expressed in kilopascals (kPa). Additional outcome parameters were vaginal pH, Vaginal Health Index (VHI), Female Sexual Function Index (FSFI), and visual analog scale (VAS) scores for dyspareunia.

RESULTS

Baseline clinical characteristics, vaginal pH, VHI, VAS and FSFI scores, and E mean values were comparable between the laser and sham-control groups. Statistically significant differences were observed in the final E mean values of the anterior vaginal wall (13.1 ± 6.3 vs 20.0 ± 3.3 kPA, P = 0.01) and posterior vaginal wall (12.7 ± 10.3 vs 19.4 ± 6.9 kPA, P = 0.04) between the laser and sham-control group. Despite comparable baseline E mean values, significant differences in vaginal wall stiffness posttreatment indicated a notable increase in tissue elasticity following laser treatment. Statistically significant differences were also observed in final vaginal pH values, VHI, VAS scores, and FSFI score improvement in favor of laser treatment.

CONCLUSIONS

Shear wave elastography may be considered as a reliable and objective technique for evaluating the efficacy of Er:YAG laser treatment in women with atrophic vaginitis. However, additional studies with larger sample sizes are necessary to establish conclusive evidence.

Treatment of women with vaginal laxity: systematic review with meta-analysis

BACKGROUND

Despite several treatments that have been used for women reporting vaginal laxity (VL), to our knowledge no systematic review is available on the topic so far.

AIM

In this study, we sought to summarize the best available evidence about the efficacy and safety of interventions for treating VL, whether conservative or surgical.

METHODS

A comprehensive search strategy was performed in Medline, Embase, Scopus, Web of Science, and Cochrane Library for reports of clinical trials published from database inception to September 2022. Studies selected for inclusion were in the English language and were performed to investigate any type of treatment for VL, with or without a comparator, whether nonrandomized studies or randomized controlled trials (RCTs). Case reports and studies without a clear definition of VL were excluded.

OUTCOMES

The outcomes were interventions (laser, radiofrequency, surgery, and topical treatment), adverse effects, sexual function, pelvic floor muscle (PFM) strength, and improvement of VL by the VL questionnaire (VLQ).

RESULTS

From 816 records, 38 studies remained in the final analysis. Laser and radiofrequency (RF) were the energy-based treatment devices most frequently studied. Pooled data from eight observational studies have shown improved sexual function assessed by a Female Sexual Function Index score mean difference (MD) of 6.51 (95% CI, 5.61-7.42; i2 = 85%, P < .01) before and after intervention, whether by RF (MD, 6.00; 95% CI, 4.26-7.73; i2 = 80%; P < .001) or laser (MD, 6.83; 95% CI, 5.01-8.65; i2 = 92%; P < .01). However, this finding was not shown when only 3 RCTs were included, even when separated by type of intervention (RF or laser). When RF treatment was compared to sham controls, VLQ scores did not improve (MD, 1.01; 95% CI, -0.38 to 2.40; i2 = 94%; P < .001). Patient PFM strength improved after interventions were performed (MD, 4.22; 95% CI, 1.02-7.42; i2 = 77%; P < .001). The ROBINS-I (Risk Of Bias In Nonrandomized Studies of Interventions) tool classified all non-RCTs at serious risk of bias, except for 1 study, and the risk of bias-1 analysis found a low and unclear risk of bias for all RCTs. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) certainty of the evidence was moderate for sexual function and the VLQ questionnaire and low for PFM strength.

CLINICAL IMPLICATIONS

Sexual function in women with VL who underwent RF and laser treatment improved in observational studies but not in RCTs. Improvement in PFM strength was observed in women with VL after the intervention.

STRENGTHS AND LIMITATIONS

Crucial issues were raised for the understanding of VL, such as lack of standardization of the definition and for the development of future prospective studies. A limitation of the study was that the heterogeneity of the interventions and different follow-up periods did not make it possible to pool all available data.

CONCLUSIONS

Vaginal tightening did not improve sensation in women with VL after intervention, whereas RF and laser improved sexual function in women with VL according to data from observational studies, but not from RCTs. PFM strength was improved after intervention in women with VL.

[Vaginal laxity: Semiology, diagnosis and treatments]

OBJECTIVES

Vaginal laxity concerns 24 to 38% of women but it's still poorly understood and studied. The objective of this study is to do an inventory of current scientific knowledge about its definition, its diagnostic criteria, and treatments.

METHODS

We conducted a non systematic review of literature including original articles in French and English about the definition, diagnostic criteria and treatments of vaginal laxity using data bases such as Cochrane, Embase, Medline, PubMed et Science Direct.

RESULTS

It is a feeling of excessive looseness that can alter the quality of sexual intercourses. The main risk factor is vaginal delivery. The feeling of vaginal laxity appears to be linked to an excessive distensibility of the levator ani muscle that can be evaluated during physical examination by the measure of the genital hiatus and the perineal body (GH and PB measures from the POP-Q classification) during vasalva or by the measure of genital hiatus area by translabial sonography during valsalva. Although pelvic muscle training is currently prescribed as a first line treatment, data are limited to confirm its effectiveness in this affection. Colpoperineorraphy with levator ani myorraphy which was mostly evaluated in case of genital prolapse is associated with a high success rate but is at risk of dyspareunia. New nonsurgical treatments such as radiofrequency and vaginal laser seems to lead to lower success rate than surgical treatments but they are less invasive. Their effectiveness and long-term effects are still unknown which restrict their application in this condition.

CONCLUSION

Vaginal laxity is a frequent condition that impacts on the quality of life and sexual function. Further studies should be conducted to better understand its physiopathology and the optimal treatment.

Current Perspectives in Vaginal Laxity Measurement: A Scoping Review

This scoping review aimed to identify and categorize the available measurement options for vaginal laxity (VL), their indications of use, and whether these measurements can sufficiently provide objective clinical judgment for cases indicated for vaginal rejuvenation with many treatment options nowadays. Systematic searches were conducted on five electronic databases, manually searching articles' bibliographies and predetermined key journals with no date or study design limitations. We included all studies involving VL in their inclusion criteria, treatment indications, and outcome parameters. We used the Arksey and O'Malley frameworks as the guideline in writing this scoping review. Of the 9,464 articles identified, 66 articles and 11,258 subjects were included in the final analysis. The majority of studies were conducted in obstetrics and gynecology (73%), followed by plastic surgery (10%), medical rehabilitation (4.5%), dermatology (4.5%), and others (8%). Most studies originated from the North American region (30%). The following measurement tools were used: (1) interviews, (2) questionnaires, (3) physical/digital examinations, (4) perineometers, and (5) others. Our results suggested that subjective perception of laxity confirmed by directed interview or questionnaire is sufficient to confirm VL. Additional evaluation of pelvic floor muscle through digital examination or perineometer or other preferred tools and evaluation of sexual function through validated questionnaire (Female Sexual Function Index, Female Sexual Distress Scale-Revised, etc.) should follow to ensure holistic care to patients. Future research on the psychometric properties (reliability and validity) of commonly used measurements and the correlation in between subjective and objective measurements should be initiated before their clinical applications.

Effect of Fractional Carbon Dioxide vs Sham Laser on Sexual Function in Survivors of Breast Cancer Receiving Aromatase Inhibitors for Genitourinary Syndrome of Menopause: The LIGHT Randomized Clinical Trial

IMPORTANCE

Survivors of breast cancer present more severe symptoms of genitourinary syndrome of menopause (GSM) than patients without history of breast cancer. Recently, new treatments, such as vaginal laser therapy, have appeared, but evidence of their efficacy remains scarce.

OBJECTIVE

To assess the safety and efficacy of carbon dioxide (CO2) vs sham vaginal laser therapy after 6 months of follow-up in survivors of breast cancer with GSM receiving aromatase inhibitors.

DESIGN, SETTING, AND PARTICIPANTS

This prospective double-blind sham-controlled randomized clinical trial with two parallel study groups was performed during October 2020 to March 2022 in a tertiary referral hospital. Survivors of breast cancer using aromatase inhibitors were assessed for eligibility, and eligible patients were randomized into the 2 treatment groups. Follow-up was conducted at 6 months. Data were analyzed in July 2022.

INTERVENTIONS

All patients from both groups were instructed to use the first-line treatment (FLT) based on nonhormonal moisturizers and vaginal vibrator stimulation. Patients for each group were allocated to 5 monthly sessions of fractional CO2 laser therapy (CLT) or sham laser therapy (SLT).

MAIN OUTCOMES AND MEASURES

The primary outcome was sexual function, evaluated through Female Sexual Function Index (FSFI) score. Other subjective measures of efficacy included a visual analog scale of dyspareunia, vaginal pH, a Vaginal Health Index, quality of life (assessed via Short-Form 12), and body image (assessed with the Spanish Body Image Scale). Objective measures of efficacy included vaginal maturation index, vaginal epithelial elasticity (measured in Pascals) and vaginal epithelial thickness (measured in millimeters). Measures were assessed before and after the intervention. Tolerance (measured on a Likert scale), adverse effects, and estradiol levels were recorded.

RESULTS

Among 211 survivors of breast cancer assessed, 84 women were deemed eligible and 72 women (mean [SD] age, 52.6 [8.3] years) were randomized to CLT (35 participants) or SLT (37 participants) and analyzed. There were no statistically significant differences between groups at baseline. At 6 months, both groups showed improvement in FSFI (mean [SD] score at baseline vs 6 months: CLT, 14.8 [8.8] points vs 20.0 [9.5] points; SLT, 15.6 [7.0] points vs 23.5 [6.5] points), but there was no significant difference between CLT and SLT groups in the improvement of sexual function evaluated through the FSFI test overall (mean [SD] difference, 5.2 [1.5] points vs 7.9 [1.2] points; P = .15) or after excluding women who were not sexually active (mean [SD] difference, 2.9 [1.4] points vs 5.5 [1.1] points; P = .15). There were also no differences between improvement of the 2 groups at 6 months of follow-up in the other assessed subjective outcomes, including dyspareunia (mean [SD] difference, -4.3 [3.4] vs -4.5 [2.3]; P = .73), Vaginal Health Index (mean [SD] difference, 3.3 [4.1] vs 5.0 [4.5]; P = .17), body image (mean [SD] difference, -3.7 [4.5] vs -2.7 [4.8]; P = .35), and quality of life (mean [SD] difference, -0.3 [3.6] vs -0.7 [3.2]; P = .39). Similarly, there were no differences in improvements in objective outcomes, including vaginal pH (mean [SD] difference, -0.6 [0.9] vs -0.8 [1.2]; P = .29), vaginal maturation index (mean [SD] difference, 10.2 [17.4] vs 14.4 [17.1]; P = .15), vaginal epithelial thickness (mean [SD] difference, 0.021 [0.014] mm vs 0.013 [0.012] mm; P = .30), vaginal epithelial elasticity (mean [SD] difference, -1373 [3197] Pascals vs -2103 [3771] Pascals; P = .64). There were significant improvements in the overall analysis regardless of group in many outcomes. The 2 interventions were well tolerated, but tolerance was significantly lower in the CLT group than the SLT group (mean [SD] Likert scale score, 3.3 [1.3] vs 4.1 [1.0]; P = .007). No differences were observed in complications or serum estradiol levels.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, vaginal laser treatment was found to be safe after 6 months of follow-up, but no statistically significant differences in efficacy were observed between CLT and SLT.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04619485.

Vaginal laser therapy for gynecologic conditions: re-examining the controversy and where do we go from here

Despite significant controversy, vaginal laser therapy continues to be used for treatment of many gynecologic and pelvic conditions including vaginal atrophy, vaginal dryness, dyspareunia, urinary incontinence and pelvic pain. This commentary reviews the controversy surrounding vaginal laser therapy and summarizes the important distinction between ablative and non-ablative vaginal lasers. While much research is still needed, the article describes what is important for healthcare professionals to know before making the decision to integrate this technology into their clinical practice.