The efficacy and safety of a combined multipolar radiofrequency with pulsed electromagnetic field technology for the treatment of vaginal laxity: a double-blinded, randomized, sham-controlled trial

Physical therapy approach and non-invasive modalities in treatment of vaginal laxity: a literature review

INTRODUCTION

Pelvic floor physical therapy (PFPT) and noninvasive modalities can be more safe and available treatments for vaginal laxity (VL) with less risk of postsurgical complications.

OBJECTIVES

The purpose of this review is to define the concepts of PFPT and noninvasive modalities, examine the evidence supporting those modalities as a treatment for VL, and evaluate their effectiveness.

METHODS

Between 2002 and 2023, clinical studies including women diagnosed with VL were examined in the Web of Science, Cochrane Library, Scopus, and PubMed databases. Exclusion criteria included studies with no outcomes or inadequate data, procedures, suggestions, editorials, book chapters, letters to editors, reviews, meta-analyses, animal research, and articles in languages other than English.

RESULT

Only seventeen studies have been identified. Four studies have demonstrated the impact of PFPT (low- and medium-energy radiofrequency (RF), ultrasound, low-energy laser treatment, par sacral stimulation, the knack method, and pelvic floor exercises), and thirteen studies have discussed the impact of noninvasive modalities (RF, combined multipolar RF with pulsed electromagnetic, combined RF and pulsed electromagnetic field, high-intensity focused ultrasound, CO2 laser, combining multipolar RF and hybrid fractional laser, microfocused ultrasound, and the VIVEVE surface-cooled RF) on vaginal laxity.

CONCLUSION

This review indicates many knowledge areas that must be attempted in order to understand the influence of nonstrengthening physical therapy and noninvasive methods on vaginal laxity. In addition to the mechanisms behind their impacts. In addition, we strongly recommend that more clinical trials of high methodological and interventional quality are required to investigate the efficacy of various physical therapy approaches, including electrical stimulation, biofeedback exertion, acupressure, manual therapy, neuromodulation, core exercise therapy, hydrotherapy, well-designed ultrasound therapy protocols, and vaginal weight training.

Vaginal Wall Thickness Measurement by 2D-Ultrasound and Pelvic Floor Muscle Morphometry by 4D-Ultrasound in Women With Vaginal Laxity Treated With Radiofrequency or Pelvic Floor Muscle Training

AIM

To compare the vaginal wall thickness (VWT) measurement by two-dimensional ultrasound (2D-US) and pelvic floor muscle morphometry by four-dimensional translabial ultrasound (4D-TLUS) in women with vaginal laxity (VL) who underwent treatment with radiofrequency (RF) or pelvic floor muscle training (PFMT) after 30 days and 6 months.

METHODS

A secondary analysis of a randomized clinical trial that occurred between February 2020 and December 2021 was performed. Women with VL were enrolled and treated with RF or PFMT for 12 weeks. Ultrasound examiners were blinded for the groups. Transabdominal (TAUS) and transvaginal (TVUS) ultrasound were performed with 2D-US analysis. The 4D-TLUS was used for PFM morphometry assessment. We performed per-protocol and intention-to-treat analysis (5% significance).

RESULTS

Women with ballooning presented significantly worse scoring in sexual function (p = 0.037) and vaginal symptoms (p = 0.007) than women without ballooning. Analysis of variance among 2D-US, intervention groups and assessment periods has shown that measurements of the TAUS proximal vagina increased in the PFMT group after 6 months (from 9.90 ± 3.14 mm to 10.53 ± 2.71 mm; p = 0.006). TAUS/TVUS distal vagina measurements were reduced after 6 months of RF (TAUS from 11.79 ± 3.67 mm to 10.51 ± 2.51 mm; p = 0.018/TVUS from 7.94 ± 1.83 mm to 7.32 ± 2.10 mm; p = 0.037). On the other hand, 4D-TLUS measurements did not present differences according to the intervention and/or groups.

CONCLUSION

Women with ballooning on 4D-TLUS presented significantly worse scoring in sexual function and vaginal symptoms. 2D-US found that RF reduced the VWT of the distal vagina after 6 months and PFMT increased the VWT of the proximal vagina after 6 months.

CLINICAL TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos-REBEC-RBR-2zdvfp as a clinical trial.

New developments in cosmetic applications of electromagnetic fields: Client and occupational hazard assessment

Energy-based devices are used to improve features of appearance for aesthetic reasons while avoiding more invasive methods. Examples of treatment targets are the reduction of wrinkles, sagging, unwanted skin lesions, body hair and excess fatty tissue, and the enhancement of muscle tissue. One treatment modality is the use of electromagnetic fields (EMF, 0‒300 GHz). The present work aims to give an up-to-date survey of cosmetic applications of EMF for professional use with an assessment of client and worker exposure and possible adverse effects. A systematic search was conducted for peer-reviewed articles (2007-2022), patents, premarket notifications, manufacturer data, and adverse effects reports. Five categories of cosmetic EMF device with increasing frequency were identified: sinusoid low frequency magnetic fields for lipolysis; pulsed low frequency magnetic fields for skin rejuvenation; pulsed low frequency magnetic fields for muscle building; radiofrequency EMF for lipolysis or skin rejuvenation; microwaves for hair removal or hyperhidrosis. In the vicinity of the last four device categories, there is a potential for exceeding the occupational exposure limits in the European Union EMF Directive, which could lead to nerve or muscle stimulation, burns or overheating. There are also potential hazards for clients or workers wearing active or passive medical devices. The severity of reported adverse effects increases with EMF frequency.

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.

Ultrasound imaging of core muscles activity in multiparous women with vaginal laxity: a cross-sectional study

Vaginal laxity (VL) is a common condition among multiparous women, especially those who have delivered vaginally. Since pelvic floor muscles (PFMs) work synergistically with other core muscles, physical therapy protocols that aim to treat VL should train the PFMs in combination with other core muscles. To investigate the activity of core muscles in multiparous women with and without VL, and its relation to sexual function. An observational, cross-sectional study. The study included 100 multiparous women, who were divided into two groups according to their scores on the vaginal laxity questionnaire (VLQ). Women who scored between 1 and 3 on the VLQ were categorized as having VL (n = 48), while those who scored between 5 and 7 were placed in the control group (n = 52). The primary outcomes were PFM displacement, diaphragmatic excursion, transversus abdominis activation ratio, and lumbar multifidus thickness measured by ultrasound imaging. The secondary outcome was sexual functioning, evaluated using the Arabic female sexual function index (ArFSFI). The VL group had significantly lower PFM displacement (mean difference (MD) - 0.42; 95% confidence interval (CI) - 0.49 to - 0.33; p = 0.001), diaphragmatic excursion (MD - 2.75; 95% CI - 2.95 to - 2.55; p = 0.001), lumbar multifidus thickness (MD - 10.08; 95% CI - 14.32 to - 5.82; p = 0.02), and ArFSFI scores (MD - 9.2; 95% CI - 10.59 to - 7.81; p = 0.001) in comparison to the control group (p < 0.05). Nevertheless, the transversus abdominis activation ratio demonstrated no significant difference between the two groups (MD 0.06; 95% CI - 0.05 to 0.17; p = 0.33). Multiparous women with VL had significantly lower PFM displacement, diaphragmatic excursion, lumbar multifidus thickness, and sexual function index scores than women in the control group. The only exception was transversus abdominis activation, which did not differ significantly between the VL and control groups.

Efficacy and safety of a device that combines multipolar radiofrequency with pulsed electromagnetic field for the treatment of vulvovaginal atrophy: a randomized, sham-controlled trial

BACKGROUND

Vulvovaginal atrophy (VVA) negatively affects the sexual well-being and quality of life of postmenopausal women, yet it is underreported and undertreated.

AIM

The study sought to investigate the efficacy and safety of a nonablative, noncoagulative multipolar radiofrequency (RF) and pulsed electromagnetic field-based device (PEMF) in treatment of symptoms related to VVA.

METHODS

Seventy-six women ≥19 years of age with symptoms associated with VVA were enrolled into this prospective, randomized, sham-controlled, multicenter clinical study. Subjects were randomized to receive 3 RF + PEMF treatments (active group) or sham treatments (sham group) delivered to vaginal tissue at monthly intervals. The Vaginal Health Index (VHI), along with the Female Sexual Function Index (FSFI), subject sexual satisfaction and vaginal laxity (VL) score, treatment-associated pain, and adverse events were assessed at 4 follow-up (FU) visits between 1 and 12 months after treatment.

OUTCOMES

Changes from baseline VHI, pH, FSFI, VL, and sexual satisfaction scores between the active and sham groups were compared before and after treatment.

RESULTS

Mean VHI scores in the active group were significantly better compared with the sham group after treatment at all but the last FU visit (P < .001). A greater decrease in pH (active over sham) was seen at 1 and 4 months after treatment (P < .05). FSFI improvement was shown in the active group; however, it was not significantly better than sham improvement at all FU visits. Subject sexual satisfaction in the active group showed better improvement over sham at all FU visits (P < .05), while VL evaluations saw greater improvement in the active group at 4, 6, and 12 months posttreatment (P < .05). Treatment satisfaction was greater in the active group and pain was minimal in both groups. No serious adverse effects were reported.

CLINICAL IMPLICATIONS

As a noninvasive alternative to traditional surgical and topical procedures, 3 sessions of noninvasive combination RF/PEMF safely demonstrated improvement in symptoms related to VVA.

STRENGTHS AND LIMITATIONS

This study was strengthened by the randomized, sham-controlled design; large sample size; and extended FU period. The study assessments were decreased at later FU visits due to the global COVID pandemic, and this was a key limitation to the study.

CONCLUSION

Nonablative, noncoagulative multipolar RF/PEMF therapy was safe, improved symptoms associated with VVA, and improved female sexual function while yielding high subject satisfaction.

[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.

Applicability of vaginal energy-based devices in urogynecology: evidence and controversy

OBJECTIVE

This study aimed to analyze the evidence and controversies about the use of vaginal energy-based devices (laser and radiofrequency) for treatment of genitourinary syndrome of menopause, recurrent urinary tract infection, urinary incontinence, and genital prolapse through a literature review.

METHODS

A search of literature databases (PubMed, Medline) was performed for publications in December 2022. Keywords included genitourinary syndrome of menopause, vaginal laxity, vaginal/vulvovaginal atrophy, urinary tract infection, urgency incontinence, frequency, urgency, stress urinary incontinence, genital prolapses AND energy-based devices, AND vaginal laser, AND vaginal radiofrequency, AND CO2 laser, AND Er:YAG laser. Publications in English from the last 7 years were reviewed and selected by the authors.

RESULTS

The literature regarding vaginal energy-based devices in the treatment of urogynecological conditions is primarily limited to prospective case series with small numbers and short-term follow-up. Most of these studies showed favorable results, improvement of symptoms with low risk, or no mention of serious adverse events. Consensus statement documents from major medical societies suggest caution in recommending these therapies in clinical practice until more relevant data from well-designed studies become available.

CONCLUSION

The potential of the vaginal laser and radiofrequency as a therapeutic arsenal for the evaluated urogynecological conditions is great, but qualified research must be done to prove their efficacy and long-term safety, define application protocols, and recommend the use of these technologies in clinical practice.

The efficacy and safety of temperature controlled dual-mode radiofrequency in women with vaginal laxity

OBJECTIVE

Vaginal laxity could negatively influence women's sexual function. This study aimed to explore the efficacy and safety of temperature controlled dual-mode (monopolar and bipolar) radiofrequency (RF) in women with vaginal laxity.

METHODS

A total of 102 patients with vaginal laxity were treated with temperature-controlled RF. The present study implemented Vaginal Laxity Questionnaire (VLQ), Female Sexual Function Index (FSFI) questionnaire and Sexual Satisfaction Questionnaire (SSQ) on all patients at baseline and after treatment. Pelvic Organ Prolapse Quantification System (POP-Q) system was applied to physical examination, and vaginal manometer to examine the strength of voluntary contractions of the pelvic floor muscles.

RESULTS

The VLQ score was gradually increased after RF treatment at 1, 3, 6 and 12 months, accompanying by the significant improvement in total FSFI scores and the six domains (sexual desire, sexual arousal, lubrication, orgasm, satisfaction, pain). The increased sexual satisfaction based on the SSQ score was found after temperature-controlled RF. The result of POP-Q stage showed significant difference in women after treatment, with the women having Stage I of 45.10% at baseline, 36.27% at 1 month, 28.43% at 3 months, 19.61% at 6 months and 10.78% at 12 months. The mean pressure and mean duration of pelvic contractions were increased gradually at the 1-, 3-, 6- and 12- month follow-up.

CONCLUSION

Temperature controlled dual-mode (monopolar and bipolar) radiofrequency may be associated with improvement of vaginal laxity, and contribute to enhancement to female sexual function and pelvic floor muscles.

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.

A Randomized, Placebo-Controlled Trial Evaluating the Single and Combined Efficacy of Radiofrequency and Hybrid Fractional Laser for Nonsurgical Aesthetic Genital Procedures in Post-Menopausal Women

BACKGROUND

The efficacy of interventions that provide long-term relief of genitourinary symptoms of menopause has not been determined.

OBJECTIVES

The authors sought to evaluate radiofrequency and hybrid fractional laser (HFL) treatments for menopausal vulvovaginal symptoms.

METHODS

Thirty-one postmenopausal women completed all treatments and at least 1 follow-up. Outcomes included the Vulvovaginal Symptom Questionnaire (VSQ), Vaginal Laxity Questionnaire (VLQ), Urogenital Distress Short Form, Incontinence Impact Questionnaire (IIQ), Female Sexual Function Index (FSFI), laxity measurements via a vaginal biometric analyzer probe, and gene expression studies.

RESULTS

Mean VSQ score decreased 2.93 (P = 0.0162), 4.07 (P = 0.0035), and 4.78 (P = 0.0089) among placebo, dual, and HFL groups 3 months posttreatment and decreased to 3.3 (P = 0.0215) for dual patients at 6 months. FSFI scores increased in the desire domain for placebo and dual groups and in arousal, lubrication, orgasm, satisfaction, and pain domains for the HFL group 3 and 6 months posttreatment. An increase of 1.14 in VLQ score (P = 0.0294) was noted 3 months and 2.2 (P = 0.002) 6 months following dual treatment. There was also a mean decrease of 15.3 (P = 0.0069) in IIQ score for HFL patients at 3 months. Dual, HFL, and RF treatments resulted in statistically significant decreases in collagen I, elastin, and lysyl oxidase expression.

CONCLUSIONS

Several self-reported improvements were noted, particularly among HFL, dual, and placebo groups 3 and 6 months posttreatment. Objective biopsy analysis illustrated decreased gene expression, suggesting that treatments did not stimulate new extracellular matrix production.

LEVEL OF EVIDENCE: 2