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Perelmuter S, Burns R, Shearer K, Grant R, Soogoor A, Jun S, Meurer JA, Krapf J, Rubin R. Genitourinary syndrome of lactation: a new perspective on postpartum and lactation-related genitourinary symptoms. Sex Med Rev 2024; 12:279-287. [PMID: 38757214 DOI: 10.1093/sxmrev/qeae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/16/2024] [Accepted: 04/25/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND The genitourinary syndrome of menopause (GSM) is a well-documented condition characterized by a range of genitourinary symptoms in peri- and postmenopausal women. As with GSM, postpartum lactating women experience reduced estrogen and androgen levels. However, there is limited research on the impact of symptoms during the postpartum breastfeeding period. OBJECTIVES The aim was to review the literature for genitourinary health in the postpartum breastfeeding population and summarize key findings and potential treatments. METHODS We performed a comprehensive literature review in PubMed, Google Scholar, and Scopus from inception of database to November 2023 using the following keywords individually and in combination: "physiology of postpartum" or "physiology of lactogenesis" or "vulvovaginal health" or "vaginal atrophy" or "vaginal dryness" or "dyspareunia" or "urinary incontinence" or "lactation" or "breastfeeding" or "vaginal estrogen." All identified articles published in English were considered. Relevant studies were extracted, evaluated, and analyzed. The work presented in this article represents a summative review of the identified literature. RESULTS During lactation, high levels of prolactin inhibit estrogen and androgen secretion via negative feedback, which leads to an increased prevalence of vulvovaginal atrophy, vaginal dryness, dyspareunia, and urinary incontinence in lactating postpartum women. Despite these highly prevalent and potentially devastating symptoms, there is a lack of consistent screening at postpartum visits and no treatment guidelines available to health care providers. CONCLUSION Postpartum breastfeeding women experience similar physiology and symptoms to the postmenopausal phase, as seen in GSM. We propose the introduction of a novel term to describe the genitourinary changes seen in postpartum breastfeeding individuals: genitourinary syndrome of lactation. The diagnostic use of genitourinary syndrome of lactation will equip health care providers with an all-encompassing term to bring awareness to the symptoms experienced by postpartum breastfeeding individuals and lead to improved screening and treatment for the high numbers of individuals experiencing these genitourinary changes.
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Affiliation(s)
- Sara Perelmuter
- Weill Cornell Medical College, New York, NY 10021, United States
| | - Ramzy Burns
- Department of Urology, Indiana University, Indianapolis, IN 47405, United States
| | - Katie Shearer
- University of Tennessee Health Science Center, Memphis, TN 38163, United States
| | - Raeven Grant
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States
| | - Anantha Soogoor
- College of Osteopathic Medicine, William Carey University, Hattiesburg, MS 39401, United States
| | - Soyoun Jun
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX 76107, United States
| | - Janine Alexis Meurer
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY 14203, United States
| | - Jill Krapf
- Obstetrics and Gynecology, Center for Vulvovaginal Disorders, Washington, DC 20037, United States
| | - Rachel Rubin
- Department of Urology, Georgetown University, Washington, DC 20007, United States
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Jin Z, Tian C, Kang M, Hu S, Zhao L, Zhang W. The 100 top-cited articles in menopausal syndrome: a bibliometric analysis. Reprod Health 2024; 21:47. [PMID: 38589898 PMCID: PMC11003046 DOI: 10.1186/s12978-024-01770-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 03/10/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Significant scientific research has been conducted concerning menopausal syndrome(MPS), yet few bibliometric analyses have been performed. Our aim was to recognise the 100 most highly cited published articles on MPS and to analytically evaluate their key features. METHODS To identify the 100 most frequently cited articles, a search was conducted on Web of Science using the term 'menopausal syndrome'. Articles that matched the predetermined criteria were scrutinised to obtain the following data: citation ranking, year of publication, publishing journal, journal impact factor, country of origin, academic institution, authors, study type, and keywords. RESULTS The publication period is from January 1, 2000, to August 31, 2022. The maximum number of citations was 406 and in 2012. The median citations per year was 39.70. Most of the articles focused on treatment and complications. These articles were published in 36 different journals, with the Journal of MENOPAUSE having published the greatest number (14%). Forty-eight articles (48%) were from the United States, with the University of Pittsburgh being the leading institute (9%). Joann E. Manson was the most frequent first author (n = 6). Observational studies were the most frequently conducted research type (n = 53), followed by experimental studies (n = 33). Keyword analysis identified classic research topics, including genitourinary syndrome of menopause, bone mineral density (BMD), and anti-mullerian hormone (AMH) loci. CONCLUSION Using bibliometrics, we conducted an analysis to identify the inadequacies, traditional focal points, and potential prospects in the study of MPS across current scientific areas. Treatment and complications are at the core of MPS research, whereas prediction and biomarkers have less literature of high quality. There is a necessity for innovative analytical metrics to measure the real effect of these papers with a high level of citation on clinical application.
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Affiliation(s)
- Zishan Jin
- Beijing University of Chinese Medicine, Beijing, 100029, China
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Chuanxi Tian
- Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Mengjiao Kang
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Shiwan Hu
- Beijing University of Chinese Medicine, Beijing, 100029, China
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Linhua Zhao
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Wei Zhang
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
- Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China.
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Ni Y, Lian J. Carbon dioxide laser therapy for the management of genitourinary syndrome of menopause: A meta‑analysis of randomized controlled trials. Exp Ther Med 2024; 27:10. [PMID: 38223331 PMCID: PMC10785041 DOI: 10.3892/etm.2023.12297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/21/2023] [Indexed: 01/16/2024] Open
Abstract
Genitourinary symptoms of menopause (GSM) affect ~50% of women after menopause. Recently, CO2 laser therapy has been used for managing GSM but without high quality evidence. The present review assessed the effectiveness of CO2 laser therapy in the management of GSM. PubMed, Embase, Web of Science, CENTRAL and Scopus databases were searched for randomized controlled trials (RCTs), published up to June 30, 2023, comparing CO2 laser and sham laser treatments for GSM management. The outcomes of interest included Female Sexual Function Index (FSFI), Vaginal Health Index (VHI) and visual analog scale (VAS) for dyspareunia, dryness, burning, itching and dysuria. A total of seven RCTs were included in the review and meta-analysis, with 6/7 studies using three sessions of laser therapy, 4-8 weeks apart. Meta-analysis demonstrated no statistically significant difference in FSFI [mean difference (MD), -1.48; 95% CI, -5.85, 2.89; I2=45%] and VHI scores (MD, -0.18; 95% CI, -1.66, 1.31; I2 =72%) between laser and control groups. Meta-analysis also demonstrated no statistically significant difference in VAS scores for dyspareunia (MD, -1.63; 95% CI; -4.06, 0.80; I2=91%), dryness (MD, -1.30; 95% CI, -3.14, 0.53; I2=75%), burning (MD, -0.76; 95% CI, -2.03; 0.51 I2=56%), itching (MD, -0.28; 95% CI, -0.95, 0.38; I2=0%) and dysuria (MD, 0.15; 95% CI, -0.37, 0.67; I2=23%) between the groups. The included RCTs had low risk of bias. In conclusion, meta-analyses of high-quality sham-controlled RCTs indicated that CO2 may not have any beneficial effect on GSM. Limited data and high heterogeneity in meta-analyses in this area of research are important limitations that need to be addressed by future RCTs.
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Affiliation(s)
- Yihua Ni
- Department of Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Junyu Lian
- Department of Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
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de Oliveira CD, de Mello Bianchi AMH, Campos MLP, Nogueira MCC, Sartori MGF, de Góis Speck NM. Women with Genitourinary Syndrome of Menopause Treated with Vaginal Estriol, Microablative Fractional CO 2 Laser and Microablative Fractional Radiofrequency: A Randomized Pilot Study. Photobiomodul Photomed Laser Surg 2023; 41:718-724. [PMID: 38085184 DOI: 10.1089/photob.2023.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Objective: This pilot study intended to assess the feasibility of a large-scale randomized clinical trial designed to analyze the effectiveness of microablative fractional CO2 laser (CO2L) and microablative fractional radiofrequency (RF) compared with vaginal estriol (VE) as treatments for women with moderate-to-severe Genitourinary Syndrome of Menopause (GSM). Methods: Participants were randomized into VE, CO2L, or RF groups. In the VE group, women were required to use vaginal estriol cream for 14 days and then twice a week for 4 months. In the CO2L and RF groups, three energy therapies were administered at monthly intervals. Visual Analog Scale (VAS) for GSM symptoms, Female Sexual Function Index (FSF-I), Vaginal Health Index (VHI), and Nugent Score (NS) were analyzed before and 120 days after the beginning of the treatments. Pain scores were verified after each CO2L and RF session. Results: Thirty-four participants completed the study: 11 in the VE group, 11 in the CO2L group, and 12 in the RF group. No unexpected or serious adverse events were observed. We also verified that GSM symptoms, sexual function, and VHI significantly improved (p < 0.05) with no difference among the groups. NS did not show statistically significant difference before and after the treatments. Pain during RF application was associated with higher scores. Conclusions: The study is feasible and does not seem to have safety implications. Preliminary results suggest that CO2L and RF are good alternatives to VE for ameliorating clinical symptoms, FSF-I, and VHI in patients with GSM. Clinical Trial Registration number: NCT04045379.
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Affiliation(s)
- Carla Dias de Oliveira
- Department of Ginecology from Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
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Serquiz N, Sarmento ACA, Almeida NR, Nobre ML, Medeiros KS, Oliveira RD, Costa APF, Gonçalves AK. Laser and radiofrequency for treating genitourinary syndrome of menopause in breast cancer survivors: a systematic review and meta-analysis protocol. BMJ Open 2023; 13:e075841. [PMID: 37949628 PMCID: PMC10649472 DOI: 10.1136/bmjopen-2023-075841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/20/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Breast cancer survivors (BCSs) experience more severe symptoms of genitourinary syndrome of menopause (GSM) than healthy postmenopausal women. As hormonal therapy with oestrogen should be avoided in BCSs, finding an effective and safe therapy to address vaginal symptoms and sexual dysfunction is urgently needed. Physical methods may be promising alternatives for the specificities of this group of women. This review aims to evaluate the efficacy and safety of physical methods (laser and radiofrequency) for treating GSM in BCSs. METHODS AND ANALYSIS The PubMed, Embase, Web of Science, SciELO, LILACS, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases will be searched. A search strategy was developed to retrieve clinical trials that evaluate the efficacy and safety of any physical method (laser or radiofrequency) used for GSM in BCSs. No date or language restrictions will be imposed. Two authors will independently select studies by title, abstract and full text to meet the inclusion criteria. Data will be extracted, and the risk of bias will be evaluated using the Cochrane risk-of-bias tool (RoB 2). Review Manager 5.4.1 will be used for data synthesis. The Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the strength of the evidence. ETHICS AND DISSEMINATION This study reviews the published data; thus, obtaining ethical approval is unnecessary. The findings of this systematic review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023387680.
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Affiliation(s)
- Nicoli Serquiz
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Department of Obstetrics and Gynecology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Ayane Cristine Alves Sarmento
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Department of Clinical Analysis and Toxicology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Natalie Rios Almeida
- Postgraduate Program student in Obstetrics and Gynecology, UNICAMP, Campinas, Brazil
| | - Maria Luisa Nobre
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Department of Surgery, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | - Ronnier de Oliveira
- Graduate medical student, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Ana Paula Ferreira Costa
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Institute of Teaching, Research and Innovation, League Against Cancer, Natal, Brazil
| | - Ana Katherine Gonçalves
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Department of Obstetrics and Gynecology, Federal University of Rio Grande do Norte, Natal, Brazil
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Casiano Evans EA, Hobson DTG, Aschkenazi SO, Alas AN, Balgobin S, Balk EM, Dieter AA, Kanter G, Orejuela FJ, Sanses TVD, Rahn DD. Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review. Obstet Gynecol 2023; 142:555-570. [PMID: 37543737 DOI: 10.1097/aog.0000000000005288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/25/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM). DATA SOURCES MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators. METHODS OF STUDY SELECTION We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group. TABULATION, INTEGRATION, AND RESULTS Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function. CONCLUSION Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.
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Affiliation(s)
- Elizabeth A Casiano Evans
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Texas at San Antonio, San Antonio, the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, Michigan; the Division of Urogynecology, ProHealth Women's Services, Waukesha Memorial Hospital, Waukesha, Wisconsin; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Departments of Obstetrics and Gynecology and Urology, MedStar Washington Hospital Center, Georgetown University School of Medicine, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Howard University College of Medicine, Washington, DC; and the Salinas Valley Memorial Healthcare System, Salinas, California
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7
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Cucinella L, Tiranini L, Cassani C, Martella S, Nappi RE. Genitourinary Syndrome of Menopause in Breast Cancer Survivors: Current Perspectives on the Role of Laser Therapy. Int J Womens Health 2023; 15:1261-1282. [PMID: 37576184 PMCID: PMC10422970 DOI: 10.2147/ijwh.s414509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023] Open
Abstract
Genitourinary syndrome of menopause (GSM) is a frequent consequence of iatrogenic menopause or anti-estrogenic adjuvant therapies in breast cancer survivors (BCSs). GSM may profoundly affect sexual health and quality of life, and a multidimensional unique model of care is needed to address the burden of this chronic heterogeneous condition. Severe symptoms may be insufficiently managed with non-hormonal traditional treatments, such as moisturizers and lubricants, recommended as the first-line approach by current guidelines, because concerns exist around the use of vaginal estrogens, particularly in women on aromatase inhibitors (AIs). Vaginal laser therapy has emerged as a promising alternative in women with GSM who are not suitable or do not respond to hormonal management, or are not willing to use pharmacological strategies. We aim to systematically review current evidence about vaginal laser efficacy and safety in BCSs and to highlight gaps in the literature. We analyzed results from 20 studies, including over 700 BCSs treated with either CO2 or erbium laser, with quite heterogeneous primary outcomes and duration of follow up (4 weeks-24 months). Although evidence for laser efficacy in BCSs comes mostly from single-arm prospective studies, with only one randomized double-blind sham-controlled trial for CO2 laser and one randomized comparative trial of erbium laser and hyaluronic acid, available data are reassuring in the short term and indicate effectiveness of both CO2 and erbium lasers on the most common GSM symptoms. However, further studies are mandatory to establish long-term efficacy and safety in menopausal women, including BCSs.
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Affiliation(s)
- Laura Cucinella
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Centre for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
| | - Lara Tiranini
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Centre for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
| | - Chiara Cassani
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Unit of Obstetrics and Gynecology, IRCCS San Matteo Foundation, Pavia, Italy
| | - Silvia Martella
- Unit of Preventive Gynecology, IRCCS European Institute of Oncology, Milan, Italy
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Centre for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
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8
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Salvatore S, Ruffolo AF, Phillips C, Athanasiou S, Cardozo L, Serati M. Vaginal laser therapy for GSM/VVA: where we stand now - a review by the EUGA Working Group on Laser. Climacteric 2023; 26:336-352. [PMID: 37395104 DOI: 10.1080/13697137.2023.2225766] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/09/2023] [Accepted: 07/12/2023] [Indexed: 07/04/2023]
Abstract
Vulvovaginal atrophy (VVA) is a chronic progressive condition that involves the genital and lower urinary tracts, related to the decrease of serum estrogenic levels when menopause occurs. The definition of genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing and publicly acceptable term than VVA. Due to the chronic progressive trend of GSM, symptoms tend to reappear after the cessation of therapy, and frequently long-term treatment is required. First-line therapies include vulvar and vaginal lubricant or moisturizers, and, in the case of failure, low-dose vaginal estrogens are the preferred pharmacological therapy. Populations of patients, such as breast cancer (BC) survivors, are affected by iatrogenic GSM symptoms with concerns about the use of hormonal therapies. The non-ablative erbium:YAG laser and the fractional microablative CO2 vaginal laser are the two main lasers evaluated for GSM treatment. The aim of this comprehensive review is to report the efficacy and safety of Er:YAG and CO2 vaginal lasers for GSM treatment. Vaginal laser therapy has been demonstrated to be effective in restoring vaginal health, improving VVA symptoms and sexual function. The data suggest that both Er:YAG and CO2 vaginal lasers are safe energy-based therapeutic options for management of VVA and/or GSM symptoms in postmenopausal women and BC survivors.
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Affiliation(s)
- S Salvatore
- Obstetrics and Gynaecology Department, IRRCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - A F Ruffolo
- Obstetrics and Gynaecology Department, IRRCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - C Phillips
- Department of Obstetrics and Gynecology, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - S Athanasiou
- First Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, 'Alexandra' General Hospital, Athens, Greece
| | - L Cardozo
- Department of Urogynaecology, King's College Hospital, London, UK
| | - M Serati
- Department of Obstetrics and Gynecology, Del Ponte Hospital, University of Insubria, Varese, Italy
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Yan Y, Guo T, Zhang M, Cui G. Vaginal metastasis from breast cancer: A case report. Open Life Sci 2023; 18:20220623. [PMID: 37360785 PMCID: PMC10290277 DOI: 10.1515/biol-2022-0623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Breast cancer is one of the most common malignancies in women. However, cases of vaginal metastases of breast cancer are rarely reported in China and abroad. The main clinical symptom of vaginal metastases of breast cancer is vaginal bleeding. This article aims to provide a reference for the diagnosis and clinical management of vaginal metastases from breast cancer. This article describes in detail the management of a 50-year-old woman with vaginal metastases from breast cancer, who was admitted to the hospital with persistent vaginal bleeding without apparent causes. Persistent vaginal bleeding was found after two and a half years when her breast cancer surgery was performed. After comprehensive evaluation, vaginal mass resection was performed. Postoperative histopathology confirmed that the vaginal mass was breast cancer metastasis. The patient was treated with local radiotherapy and three cycles of eribulin and bevacizumab after the vaginal mass was removed. A reexamination of computed tomography showed that the chest wall metastases were less extensive than before. Orbital metastases were also reduced in size, which was revealed by the physical examination. The patient had since failed to return to hospital on time for a regular treatment due to personal reasons. After 9 months of follow-up, the patient died of multiple metastases. The diagnosis of vaginal masses is based on pathological examination, and systemic treatment should be the mainstay when extensive metastases are presented.
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Affiliation(s)
- Yunbo Yan
- Hebei Medical University, Shijiazhuang, China
- Second Department of Thyroid and Breast Surgery, Cangzhou Central Hospital, No. 16 of Xinhua West Road, Yunhe District, Cangzhou, Hebei Province, 061000, China
| | - Tianjiao Guo
- Hebei Medical University, Shijiazhuang, China
- Department of Diagnostic Computed Tomography, Cangzhou Central Hospital, Cangzhou, China
| | - Minmei Zhang
- Vascular Surgery Department, TCM Hospital of Shijiazhuang City, Shijiiazhuang, China
| | - Guozhong Cui
- Second Department of Thyroid and Breast Surgery, Cangzhou Central Hospital, No. 16 of Xinhua West Road, Yunhe District, Cangzhou, Hebei Province, 061000, China
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10
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Woźniak A, Woźniak S, Poleszak E, Kluz T, Zapała Ł, Woźniak A, Rechberger T, Wróbel A. Efficacy of Fractional CO 2 Laser Treatment for Genitourinary Syndrome of Menopause in Short-Term Evaluation-Preliminary Study. Biomedicines 2023; 11:biomedicines11051304. [PMID: 37238975 DOI: 10.3390/biomedicines11051304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/29/2023] [Accepted: 04/19/2023] [Indexed: 05/28/2023] Open
Abstract
The postmenopausal state covers 40% of modern women's lives and 50-70% of postmenopausal women report GSM symptoms such as vaginal dryness, itching, frequent inflammations, lack of elasticity, or dyspareunia. Consequently, a safe and effective method of treatment is crucial. In a group of 125 patients, a prospective observational study was performed. The aim was to evaluate the clinical effectiveness of fractional CO2 laser in the treatment of GSM symptoms using a protocol of three procedures in 6-week intervals. The vaginal pH, VHIS, VMI, FSFI, and treatment satisfaction questionnaire were used. The fractional CO2 laser treatment was effective in improving all the objective forms of evaluation: vaginal pH (from 5.61 ± 0.50 at the baseline up to 4.69 ± 0.21 in the 6-week follow-up after the third procedure); VHIS (12.02 ± 1.89 at the baseline vs. 21.50 ± 1.76); VMI (21.5 ± 5.66 vs. 48.4 ± 4.46). Similar results were obtained for FSFI: 12.79 ± 5.351 vs. 24.39 ± 2.733, where 79.77% of patients were highly satisfied. Fractional CO2 laser therapy increases the quality of life by having a beneficial effect on the sexual function of women with GSM symptoms. This effect is obtained by restoring the correct structure and proportions of the cellular composition of the vaginal epithelium. This positive effect was confirmed by both objective and subjective forms of evaluating GSM symptom severity.
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Affiliation(s)
- Andrzej Woźniak
- Independent Public Clinical Hospital No. 4, 8 Jaczewskiego, 20-954 Lublin, Poland
| | - Sławomir Woźniak
- Third Department of Gynecology, Medical University of Lublin, 8 Jaczewskiego, 20-090 Lublin, Poland
| | - Ewa Poleszak
- Laboratory of Preclinical Testing, Chair and Department of Applied and Social Pharmacy, Medical University of Lublin, 1 Chodźki Street, 20-093 Lublin, Poland
| | - Tomasz Kluz
- Department of Gynecology, Gynecology Oncology and Obstetrics, Institute of Medical Sciences, Medical College of Rzeszow University, 16c Rejtana, 35-959 Rzeszow, Poland
| | - Łukasz Zapała
- Clinic of General, Oncological and Functional Urology, Medical University of Warsaw, 4 Lindleya, 02-005 Warsaw, Poland
| | - Aleksander Woźniak
- University Clinical Center of the Medical University of Warsaw, 1A Banacha, 02-097 Warsaw, Poland
| | - Tomasz Rechberger
- Second Department of Gynecology, Medical University of Lublin, 8 Jaczewskiego, 20-090 Lublin, Poland
| | - Andrzej Wróbel
- Second Department of Gynecology, Medical University of Lublin, 8 Jaczewskiego, 20-090 Lublin, Poland
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11
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Chin C, Damast S. Brachytherapy impacts on sexual function: An integrative review of the literature focusing on cervical cancer. Brachytherapy 2023; 22:30-46. [PMID: 36567175 DOI: 10.1016/j.brachy.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
There is growing awareness of the importance of sexual health in the quality of life of cancer patients and survivors. Brachytherapy, a vital component for the curative treatment of cervical cancer, leads to both direct and indirect sequelae that result in vaginal and sexual morbidity. The emergence of 3D image-guided adaptive brachytherapy has led to a better understanding of dose-and-effect relationships for critical organs-at-risk and there are new recommendations for vaginal dose reporting in the ongoing EMBRACE II study. An understanding of the vagina as an organ-at-risk and its dose-and-effect relationships can help brachytherapists limit dose to the vagina and improve sexual morbidity. Brachytherapists play a critical role in the primary and secondary prevention of vaginal and sexual sequelae resulting from treatment. Through close surveillance and recognition of common symptoms, brachytherapists can intervene with effective strategies to prevent and treat vaginal and sexual symptoms. This review summarizes the current literature on dosimetric factors that may predict for vaginal morbidity. It will focus on quantitative and qualitative reports of brachytherapy-related vaginal toxicity and sexual dysfunction. Lastly, it will review the available evidence supporting clinical interventions to mitigate the development and progression of vaginal and sexual sequelae to improve functional quality post-treatment.
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Affiliation(s)
- Christine Chin
- Radiation Oncology, Columbia University Irving Medical Center New York, New York, NY.
| | - Shari Damast
- Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
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12
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Mejia-Gomez J, Petrovic I, Doherty M, Kennedy E, Wolfman W, Jacobson M, Brezden C, Philippopoulos E, Lukovic J. Sexual dysfunction in female patients with anal cancer treated with curative intent: A systematic review of the literature. Radiother Oncol 2023; 178:109437. [PMID: 36481383 DOI: 10.1016/j.radonc.2022.109437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Patients with anal squamous cell carcinoma (SCC) are treated with sphincter-preserving radiation therapy and concurrent chemotherapy, achieving excellent oncologic outcomes. Patients, however, may experience treatment-related morbidity including sexual dysfunction. The objective of this systematic review was to review the literature on sexual dysfunction in female patients treated for anal cancer and to identify knowledge gaps. MATERIALS AND METHODS This systematic review was registered in PROSPERO prior to initiation. Databases searched included MEDLINE, Embase, PubMed, Cochrane, and Google Scholar. There were no restrictions on the study time period. Studies were limited to English. All study designs were included except review articles, letters to the editor, and case reports with less than ten patients. RESULTS In total, 1801 studies were retrieved and 19 met the inclusion criteria, including: 13 cross-sectional surveys, 3 prospective studies, 1 longitudinal intervention study, 1 retrospective chart review, 1 case control study. Sexual function was assessed using the female sexual functioning index (FSFI), EORTC-QLQ-CR30 and -CR38; response rates were low (<50 % in most studies). Sexual dysfunction was reported by up to 85 % of women; the most common symptoms being dyspareunia (17-65 %), vaginal dryness (22-88 %), and loss of libido (38-95 %). Gastrointestinal issues, such as bowel problems, and body image concerns additionally affected sexual function and quality of life. CONCLUSION Sexual dysfunction is a common issue affecting most female patients treated for anal cancer and there is a paucity of evidence on the management of this important survivorship issue. There is additionally a lack of ethnic, economic, and educational diversity and there are no studies addressing the unique needs of LGBTQ individuals - future studies should make a concerted effort to include a diverse patient population.
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Affiliation(s)
| | - Irina Petrovic
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Mary Doherty
- Department of Radiation Oncology, University of Toronto and Odette Cancer Centre, Toronto, ON, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Wendy Wolfman
- Department of Obstetrics and Gynecology, Division of Menopause and Premature Ovarian Failure, Mt. Sinai Hospital, University of Toronto, Canada
| | - Michelle Jacobson
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Christine Brezden
- Department of Medical Oncology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Jelena Lukovic
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
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13
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Wamsley C, Kislevitz M, Vingan NR, Oesch S, Lu K, Barillas J, Hoopman J, Akgul Y, Basci D, Kho K, Zimmern PE, Kenkel JM. 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. Aesthet Surg J 2022; 42:1445-1459. [PMID: 35882474 DOI: 10.1093/asj/sjac202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 12/30/2022] Open
Abstract
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
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Affiliation(s)
- Christine Wamsley
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mikaela Kislevitz
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nicole R Vingan
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sydney Oesch
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karen Lu
- Department of Plastic Surgery, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Jennifer Barillas
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Hoopman
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yucel Akgul
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Deniz Basci
- plastic surgeon in private practice in Dallas, TX, USA
| | - Kimberly Kho
- Department of Obstetrics and Gynecology, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Phillipe E Zimmern
- Department of Urology, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeffrey M Kenkel
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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14
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Miao Y, Sudol NT, Li Y, Chen JJ, Arthur RA, Qiu S, Jiang Y, Tadir Y, Lane F, Chen Z. Optical coherence tomography evaluation of vaginal epithelial thickness during CO 2 laser treatment: A pilot study. JOURNAL OF BIOPHOTONICS 2022; 15:e202200052. [PMID: 35860856 PMCID: PMC9633389 DOI: 10.1002/jbio.202200052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/18/2022] [Accepted: 07/19/2022] [Indexed: 05/20/2023]
Abstract
Genitourinary syndrome of menopause (GSM) negatively affects more than half of postmenopausal women. Energy-based therapy has been explored as a minimally invasive treatment for GSM; however, its mechanism of action and efficacy is controversial. Here, we report on a pilot imaging study conducted on a small group of menopause patients undergoing laser treatment. Intravaginal optical coherence tomography (OCT) endoscope was used to quantitatively monitor the changes in the vaginal epithelial thickness (VET) during fractional-pixel CO2 laser treatment. Eleven patients with natural menopause and one surgically induced menopause patient were recruited in this clinical study. Following the laser treatment, 6 out of 11 natural menopause patient showed increase in both proximal and distal VET, while two natural menopause patient showed increase in VET in only one side of vaginal tract. Furthermore, the patient group that showed increased VET had thinner baseline VET compared to the patients that showed decrease in VET after laser treatment. These results demonstrate the potential utility of intravaginal OCT endoscope in evaluating the vaginal tissue integrity and tailoring vaginal laser treatment on a per-person basis, with the potential to monitor other treatment procedures.
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Affiliation(s)
- Yusi Miao
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Neha T Sudol
- Department of Obstetrics & Gynecology, University of California, Irvine, Medical Center, Irvine, CA, USA
| | - Yan Li
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Jason J Chen
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Rebecca A. Arthur
- Department of Obstetrics & Gynecology, University of California, Irvine, Medical Center, Irvine, CA, USA
| | - Saijun Qiu
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Yuchen Jiang
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Yona Tadir
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, Irvine, CA, USA
| | - Felicia Lane
- Department of Obstetrics & Gynecology, University of California, Irvine, Medical Center, Irvine, CA, USA
| | - Zhongping Chen
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
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15
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Fractional Co2 laser for vulvo-vaginal atrophy in gynecologic cancer patients: A valid therapeutic choice? A systematic review. Eur J Obstet Gynecol Reprod Biol 2022; 277:84-89. [PMID: 36037664 DOI: 10.1016/j.ejogrb.2022.08.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION One of the most common adverse events reported by gynecological cancer survivors with spontaneous or iatrogenic menopause is vulvo-vaginal atrophy (VVA). An increasing number of women have this kind of discomfort related to the menopause induced by different cancer therapies. In this regard, fractional CO2 laser may be a valid therapeutic choice for these patients. METHODS We performed a literature search of PubMed, EMBASE, SCOPUS and Web of Science databases with search terms of laser CO2 treatment of vulvovaginal atrophy and gynecologic cancer survivors and reviewed major US Society Guidelines to create this narrative review of this topic. Breast, ovarian endometrial and cervical cancers were included. RESULTS Nine studies were included. Fractional CO2 laser improves clinical symptoms and sexual function, in terms of VHI (vaginal health index) and FSFI (female sexual function index). Non severe adverse event occurred. CONCLUSION According to the best evidence available, fractional CO2 laser treatment for VVA is an effective and safe therapeutic option for gynecological cancer survivors, improving sexual life and quality of life (QoL).
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16
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Zipper R, Lamvu G. Vaginal laser therapy for gynecologic conditions: re-examining the controversy and where do we go from here. J Comp Eff Res 2022; 11:843-851. [PMID: 35726603 DOI: 10.2217/cer-2021-0281] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Ralph Zipper
- Zipper Urogynecology & Associates, Melbourne, FL, 32935 USA
| | - Georgine Lamvu
- University of Central Florida College of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology, Orlando, FL, 32827 USA
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17
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Phillips C, Hillard T, Salvatore S, Cardozo L, Toozs-Hobson P. Laser treatment for genitourinary syndrome of menopause: Scientific Impact Paper No. 72 (July 2022): Scientific Impact Paper No. 72 (July 2022). BJOG 2022; 129:e89-e94. [PMID: 35892242 DOI: 10.1111/1471-0528.17195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Genitourinary syndrome of menopause (GSM) is the term used to describe the group of symptoms including vaginal pain, vaginal dryness, itching, pain during sexual intercourse and fragile vaginal tissues as well as urinary symptoms including urinary frequency, urgency, incontinence, blood in the urine (haematuria) and recurrent urinary tract infections that occur due to a lack of the hormone estrogen. These symptoms can have a significant negative impact on psychosexual issues, sexual function and quality of life in postmenopausal women. Traditionally women have been treated with vaginal lubricants, vaginal moisturisers or low-dose vaginal estrogens. Lasers have been used in the cosmetic industry for collagen remodelling and repair of the skin. Therefore, it has been suggested that laser therapy may be used on the vagina as an alternative treatment for GSM. A review of all the published studies assessing the safety and efficacy of laser therapy for GSM have shown promising beneficial results. The majority of studies to date have been small, short-term, observational studies. However, there are randomised controlled trials underway. Laser treatment may be beneficial for the symptoms of GSM but until more robust evidence is available it should not be adopted into widespread practice, and should be used as part of a research study only.
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18
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New Innovations for the Treatment of Vulvovaginal Atrophy: An Up-to-Date Review. Medicina (B Aires) 2022; 58:medicina58060770. [PMID: 35744033 PMCID: PMC9230595 DOI: 10.3390/medicina58060770] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 12/03/2022] Open
Abstract
Vulvovaginal atrophy (VVA) is a chronic progressive disease involving the female genital apparatus and lower urinary tract. This condition is related to hypoestrogenism consequent to menopause onset but is also due to the hormonal decrease after adjuvant therapy for patients affected by breast cancer. Considering the high prevalence of VVA and the expected growth of this condition due to the increase in the average age of the female population, it is easy to understand its significant social impact. VVA causes uncomfortable disorders, such as vaginal dryness, itching, burning, and dyspareunia, and requires constant treatment, on cessation of which symptoms tend to reappear. The currently available therapies include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hormone therapy, and Ospemifene. Considering, however, that such therapies have some problems that include contraindications, ineffectiveness, and low compliance, finding an innovative, effective, and safe treatment is crucial. The present data suggest great efficacy and safety of a vaginal laser in the treatment of genital symptoms and improvement in sexual function in patients affected by VVA. The beneficial effect tends to be sustained over the long-term, and no serious adverse events have been identified. The aim of this review is to report up-to-date efficacy and safety data of laser energy devices, in particular the microablative fractional carbon dioxide laser and the non-ablative photothermal Erbium-YAG laser.
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19
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Mortensen OE, Christensen SE, Løkkegaard E. The evidence behind the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus: A state-of-the-art review. Acta Obstet Gynecol Scand 2022; 101:657-692. [PMID: 35484706 DOI: 10.1111/aogs.14353] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/30/2022]
Abstract
In recent years, LASER has been introduced as a minimally invasive treatment for a broad range of vaginal and vulvar symptoms and diseases. However, the efficacy and safety of vaginal and vulvar LASER has continuously been questioned. The aim of this study is to create an overview of the current literature and discuss the controversies within the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus. A search string was built in PubMed. The search was commenced on August 25, 2021 and closed on October 27, 2021. Two authors screened the studies in Covidence for inclusion according to the eligibility criteria in the protocol. The data were extracted from the studies and are reported in both text and tables. This review included 114 papers, of which 15 were randomized controlled trials (RCTs). The effect of LASER as a vaginal treatment was investigated for genitourinary syndrome of menopause in 36 studies (six RCTs), vulvovaginal atrophy in 34 studies (four RCTs) and urinary incontinence in 30 studies (two RCTs). Ten studies (three RCTs) investigated the effect of vulvar treatment for lichen sclerosus. Half of the included RCTs, irrespective of indication, did not find a significant difference in improvement in women treated with vaginal CO2 or Er:YAG LASER compared with their respective controls. However, most non-comparative studies reported significant improvement after exposure to vaginal or vulvar LASER across all indications. Included studies generally had a short follow-up period and only a single RCT followed their participants for more than 6 months post treatment. Adverse events were reported as mild and transient and 99 studies including 51 094 patients provided information of no serious adverse events. In conclusion, this review found that the effect of vaginal and vulvar LASER decreases with higher study quality where potential biases have been eliminated. We therefore stress that all patients who are treated with vaginal or vulvar LASER should be carefully monitored and that LASER for those indications as a treatment should be kept on a research level until further high-quality evidence is available.
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Affiliation(s)
- Olivia Engholt Mortensen
- Department of Obstetrics and Gynecology, Nordsjaellands Hospital, Institute of Clinical Medicine, University of Copenhagen, Hillerød, Denmark
| | - Sarah Emilie Christensen
- Department of Obstetrics and Gynecology, Nordsjaellands Hospital, Institute of Clinical Medicine, University of Copenhagen, Hillerød, Denmark
| | - Ellen Løkkegaard
- Department of Obstetrics and Gynecology, Nordsjaellands Hospital, Institute of Clinical Medicine, University of Copenhagen, Hillerød, Denmark
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20
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Mantovani M, Gennai A, Russo PR. A new approach to regenerative medicine in gynecology. Int J Gynaecol Obstet 2022; 157:536-543. [PMID: 34463351 DOI: 10.1002/ijgo.13906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/05/1901] [Accepted: 08/26/1901] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the efficacy of the injection of microfragmented adipose tissue in the treatment of women with genitourinary syndrome of menopause (GSM). METHODS This observational cohort study included 12 women who received one session of multiple injections of microfragmented adipose tissue using the SEFFIGYN™ medical device. Symptoms such as burning, itching, dryness, pain on penetration, pain during deep intercourse, and pain on urination were assessed before the patient's treatment (T0), after 15 days (T15), and after 5 months (5Mo) using the Numerical Rating Scale (NRS). RESULTS An improvement of vulvar trophism was clinically evident already 2 weeks after treatment; all symptoms were notably attenuated compared with the initial visit, as demonstrated by statistically significant reductions of the NRS scores (P = 0.003 for itching, P = 0.008 for pain on urination, and P < 0.001 for the other symptoms, Sign test). Moreover, all symptoms continued to improve over time. All patients reported a positive change in their quality of life and a resumption of sexual life. CONCLUSION The use of microfragmented adipose tissue in GSM is promising. Nevertheless, more studies will be fundamental to exclude a potential placebo effect and better understand the underlying molecular mechanism of action.
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Affiliation(s)
| | - Alessandro Gennai
- Plastic Reconstructive and Aesthetic Surgeon Medical Director STUDIO GENNAI, Bologna, Italy
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21
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Filippini M, Porcari I, Ruffolo AF, Casiraghi A, Farinelli M, Uccella S, Franchi M, Candiani M, Salvatore S. CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis. J Sex Med 2022; 19:452-470. [PMID: 35101378 DOI: 10.1016/j.jsxm.2021.12.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 11/28/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Genitourinary syndrome of menopause (GSM) is a widespread condition with a great impact on quality of life and self-image. AIM We aimed to systematically review the current literature on CO2-Laser therapy efficacy for the treatment of GSM. METHODS MEDLINE and Embase databases were systematically queried in December 2020 Studies included women with a diagnosis of Vulvo-Vaginal Atrophy (VVA) or GSM without an history of gynaecological and/or breast cancer, pelvic organ prolapse staged higher than 2, pelvic radiotherapy or Sjogren's Syndrome. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021238121. OUTCOMES Effects of CO2-Laser therapy on GSM symptoms assessed through subjective or objective efficacy measurement methods. RESULTS A total of 803 articles were identified. Of these, 25 studies were included in this review for a total of 1,152 patients. All studies showed a significant reduction in VVA and/or GSM symptoms (dryness, dyspareunia, itching, burning, dysuria). The pooled mean differences for the symptoms were: dryness -5.15 (95% CI:-5.72,-4.58; P < .001; I2:62%; n = 296), dyspareunia -5.27 (95% CI:-5.93,-4.62; P < .001; I2:68%; n = 296), itching -2.75 (95% CI:-4.0,-1.51; P < .001; I2:93%; n = 281), burning -2.66 (95% CI:-3.75, -1.57; P < .001; I2:86%; n = 296) and dysuria -2.14 (95% CI:-3.41,-0.87; P < .001; I2:95%; n = 281). FSFI, WHIS and VMV scores also improved significantly. The pooled mean differences for these scores were: FSFI 10.8 (95% CI:8.41,13.37; P < .001; I2:84%; n = 273), WHIS 8.29 (95% CI:6.16,10.42; P < .001; I2:95%; n = 262) and VMV 30.4 (95% CI:22.38,38.55; P < .001; I2:24%; n = 68). CO2-Laser application showed a beneficial safety profile and no major adverse events were reported. CLINICAL IMPLICATIONS Vaginal laser treatment resulted in both a statistically and clinically significant improvement in GSM symptoms. FSFI improved significantly in all 8 included studies but it reached a clinically relevant level only in 2 of them. STRENGTHS & LIMITATIONS The strength of the current meta-analysis is the comprehensive literature search. We reported data from a high number of patients (1,152) and high number of laser applications (more than 3,800). The main limitations are related to the high heterogeneity of the included studies investigating laser effects. Moreover, most of them are single center and nonrandomized studies. CONCLUSION The data suggest that CO2-Laser is a safe energy-based therapeutic option for the management of VVA and/or GSM symptoms in postmenopausal women; however, the quality of the body of evidence is "very low" or "low". Filippini M, Porcari I, Ruffolo AF, et al., CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis. J Sex Med 2022;19:452-470.
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Affiliation(s)
- Maurizio Filippini
- Department of Obstetrics and Gynecology, Hospital State of Republic of San Marino, San Marino, Republic of San Marino
| | - Irene Porcari
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy.
| | - Alessandro F Ruffolo
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, University Vita and Salute, Milan, Italy
| | - Arianna Casiraghi
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, University Vita and Salute, Milan, Italy
| | - Miriam Farinelli
- Department of Obstetrics and Gynecology, Hospital State of Republic of San Marino, San Marino, Republic of San Marino
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, University Vita and Salute, Milan, Italy
| | - Stefano Salvatore
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, University Vita and Salute, Milan, Italy
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Gabrieli D, Suissa-Cohen Y, Jaber S, Lev-Sagie A. "Modified Schirmer Test" as an Objective Measurement for Vaginal Dryness: A Prospective Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12030574. [PMID: 35328126 PMCID: PMC8946893 DOI: 10.3390/diagnostics12030574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/13/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023] Open
Abstract
None of the currently available parameters allow for a direct and objective measurement of vaginal moisture. We used a calibrated filter paper strip as a measurement tool for the quantification of vaginal fluid, in a similar manner as the ophthalmic “Schirmer test” (used for eye moisture measurement). The study aimed to evaluate the validity of this new, objective tool, to measure vaginal moisture. We compared vaginal moisture measurements using the “modified Schirmer test” in symptomatic women with genitourinary syndrome of menopause to those of women without vaginal dryness. The mean “modified Schirmer test” measurement in the control group was 21.7 mm compared to 3.3 mm in the study group, yielding a statistically significant difference (p < 0.001). Strong correlations were found between “modified Schirmer test” measurements and pH (correlation coefficient −0.714), Vaginal Health Index [VHI (0.775)], and Visual Analogue Score (VAS) of dryness during intercourse (−0.821). Our findings suggest that the “modified Schirmer test” can be used as an objective measurement for the assessment of vaginal fluid level. This test may also prove useful for evaluation of non-hormonal treatments aimed to treat vaginal dryness.
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Affiliation(s)
- Dana Gabrieli
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9780214, Israel;
- Correspondence:
| | - Yael Suissa-Cohen
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem 9765422, Israel; (Y.S.-C.); (S.J.)
| | - Sireen Jaber
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem 9765422, Israel; (Y.S.-C.); (S.J.)
| | - Ahinoam Lev-Sagie
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9780214, Israel;
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem 9765422, Israel; (Y.S.-C.); (S.J.)
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Quick AM, Hundley A, Evans C, Stephens JA, Ramaswamy B, Reinbolt RE, Noonan AM, Van Deusen JB, Wesolowski R, Stover DG, Williams NO, Sardesai SD, Faubion SS, Loprinzi CL, Lustberg MB. Long-Term Follow-Up of Fractional CO 2 Laser Therapy for Genitourinary Syndrome of Menopause in Breast Cancer Survivors. J Clin Med 2022; 11:jcm11030774. [PMID: 35160226 PMCID: PMC8836519 DOI: 10.3390/jcm11030774] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 02/06/2023] Open
Abstract
(1) Background: The objective of this study was to determine the long-term efficacy of fractional CO2 laser therapy in breast cancer survivors. (2) Methods: This was a single-arm study of breast cancer survivors. Participants received three treatments of fractional CO2 laser therapy and returned for a 4 week follow-up. Participants were contacted for follow-up at annual intervals. The Vaginal Assessment Scale (VAS), the Female Sexual Function Index (FSFI), the Female Sexual Distress Scare Revised (FSDS-R), the Urinary Distress Inventory (UDI), and adverse events were collected and reported for the two-year follow-up. The changes in scores were compared between the four-week and two-year and the one-year and two-year follow-ups using paired t-tests. (3) Results: In total, 67 BC survivors were enrolled, 59 completed treatments and the four week follow-up, 39 participated in the one-year follow-up, and 33 participated in the two-year follow-up. After initial improvement in the VAS from baseline to the four week follow-up, there was no statistically significant difference in the VAS score (mean Δ 0.23; 95% CI [−0.05, 0.51], p = 0.150) between the four week follow-up and the two-year follow-up. At the two-year follow-up, the FSFI and FSDS-R scores remained improved from baseline and there was no statistically significant change in the FSFI score (mean Δ −0.83; 95% CI [−3.07, 2.38] p = 0.794) or the FSDS-R score (mean Δ −2.85; 95% CI [−1.88, 7.59] p = 0.227) from the one to two-year follow-up. The UDI scores approached baseline at the two-year follow-up; however, the change between the one- and two-year follow-ups was not statistically significant (mean Δ 4.76; 95% CI [−1.89, 11.41], p = 0.15). (4) Conclusions: Breast cancer survivors treated with fractional CO2 laser therapy have sustained improvement in sexual function two years after treatment completion, suggesting potential long-term benefit.
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Affiliation(s)
- Allison M. Quick
- Department of Radiation Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA
- Correspondence:
| | - Andrew Hundley
- Department of Obstetrics and Gynecology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (A.H.); (C.E.)
| | - Cynthia Evans
- Department of Obstetrics and Gynecology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (A.H.); (C.E.)
| | - Julie A. Stephens
- The Ohio State University Center for Biostatistics, Columbus, OH 43210, USA;
| | - Bhuvaneswari Ramaswamy
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | - Raquel E. Reinbolt
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | - Anne M. Noonan
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | - Jeffrey Bryan Van Deusen
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | - Robert Wesolowski
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | - Daniel G. Stover
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | - Nicole Olivia Williams
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | - Sagar D. Sardesai
- Division of Medical Oncology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (B.R.); (R.E.R.); (A.M.N.); (J.B.V.D.); (R.W.); (D.G.S.); (N.O.W.); (S.D.S.)
| | | | | | - Maryam B. Lustberg
- Division of Medical Oncology Yale Cancer Center, New Haven, CT 06520, USA;
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Filippini M, Sozzi J, Farinelli M, Verdelli A. Effects of Fractional CO 2 Laser Treatment on Patients Affected by Vulvar Lichen Sclerosus: A Prospective Study. Photobiomodul Photomed Laser Surg 2021; 39:782-788. [PMID: 34878932 DOI: 10.1089/photob.2021.0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Fractional carbon dioxide (CO2) lasers are today considered the most effective and efficient treatment for many vulvovaginal disorders, providing mini-invasive procedures without side effects. Previous studies demonstrated the efficacy of fractional CO2 lasers in vulvar lichen sclerosus (VLS), a chronic skin disorder characterized by itching and painful lesions. Complications include pain, sexual and/or urinary dysfunction, with a negative quality of life, and an increased risk of squamous cell carcinoma. A definitive VLS treatment is still lacking. Objectives: This is a prospective, single-center study aimed at evaluating the effect of fractional microablative CO2 laser treatment on women affected by VLS. Materials and methods: Patients with histologically confirmed VLS underwent three fractional microablative CO2 laser treatments, 4 weeks apart, on the genital affected areas. Clinical and VLS-related symptoms, side effects, and patient satisfaction index were assessed and recorded for all the patients using the visual analog scale (VAS). Results: Data from a total of 70 patients were included, paired at different time points and analyzed. VLS-related symptoms and other relevant parameters (pH, vaginal introitus discomfort, dyspareunia, vaginal dryness, itching, and burning) showed a statistically significant improvement (p < 0.001) after the first laser treatment and kept improving after second and third sessions. According to VAS, the two most common symptoms, vaginal introitus discomfort and dyspareunia, went from (mean ± standard deviation) 8.2 ± 2.3 and 8.3 ± 2.2, respectively, at baseline, to 3.6 ± 2.6 and 3.8 ± 2.6, respectively, 1 month after the last treatment. Vaginal dryness, itching, and burning were significantly improved as well. Most patients declared to be very satisfied with the results of the treatment. A total of 62.8% of the women expressed a satisfaction score ≥8 on a scale from 0 to 10. Conclusions: Fractional microablative CO2 laser treatment seems to be safe and effective to treat VLS and improve VLS-related symptoms.
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Affiliation(s)
- Maurizio Filippini
- Department of Obstetrics and Gynecology, State Hospital of Republic of San Marino, San Marino, Republic of San Marino
| | - Jessica Sozzi
- Department of Obstetrics and Gynecology, State Hospital of Republic of San Marino, San Marino, Republic of San Marino
| | - Miriam Farinelli
- Department of Obstetrics and Gynecology, State Hospital of Republic of San Marino, San Marino, Republic of San Marino
| | - Alice Verdelli
- Laser Cutaneous Cosmetic and Plastic Surgery Unit, Villa Donatello Clinic, Florence, Italy
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25
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Kiesel M, Wöckel A, Zeller C, Meden H. Treatment of Vulvovaginal Atrophy with Fractional CO 2 Laser: Evaluating Real-World Data. Photobiomodul Photomed Laser Surg 2021; 39:716-724. [PMID: 34705527 DOI: 10.1089/photob.2021.0058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective: We aimed to evaluate real-world data for the use of fractional CO2 laser therapy for treating symptoms of vulvovaginal atrophy (VVA). Background: VVA is widespread and can reduce the patients' quality of life. There is a lack of data regarding its therapy with laser, especially for daily practice (i.e., real-world data). Methods: Thirty-six patients were treated in a single medical center. They consisted of pre- and postmenopausal women and received three fractional CO2 laser therapy treatments with 3-6 weeks between each treatment. Each patient financed the treatment privately. The symptoms pain, pruritus, dyspareunia, burning, dryness, and dysuria were recorded with a visual analog scale (1-10) before the first, second, and third laser treatment. The data were examined retrospectively. Results: Pain was reduced from a mean of 2.5 points (minimum 0, maximum 9 points) to 1.1 (minimum 0, maximum 8 points) before the third laser treatment. Pruritus showed a mean score of 3.8 (minimum 0, maximum 10 points). This decreased to 1.4 (minimum 0, maximum 8 points). Dyspareunia scored a mean of 6.8 (minimum 0, maximum 10 points). After two laser therapies, the score was 3.3 (minimum 0, maximum 8 points). Burning showed 4.2 points (minimum 0, maximum 10 points). Having experienced two laser therapy sessions, the patients scored 1.5 (minimum 0, maximum 9 points) points. The severity of dryness dropped from 6.5 (minimum 0, maximum 10 points) to 3.3 (minimum 0, maximum 9 points). Dysuria was stated with 1.8 points (minimum 0, maximum 10 points) before the first and 0.5 points (minimum 0, maximum 6 points) before the third laser therapy. All changes showed statistical significance (p < 0.002). Conclusions: This real-world data propose fractional CO2 laser to reduce VVA-associated genital discomfort, thus being a valuable therapy option for pre- and postmenopausal women.
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Affiliation(s)
- Matthias Kiesel
- Department of Gynecology, University Hospital Würzburg, Würzburg, Germany
| | - Achim Wöckel
- Department of Gynecology, University Hospital Würzburg, Würzburg, Germany
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26
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Mejia-Gomez J, Bouteaud J, Philippopoulos E, Wolfman W, Brezden-Masley C. Use of a vaginal CO 2 laser for the management of genitourinary syndrome of menopause in gynecological cancer survivors: a systematic review. Climacteric 2021; 25:228-234. [PMID: 34694948 DOI: 10.1080/13697137.2021.1990258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Genitourinary syndrome of menopause (GSM) may arise from the hypoestrogenism caused by ovarian function destruction following gynecological cancer treatments. GSM may also be present in menopausal women and its symptoms might be exacerbated by cancer treatments. Historically, patients with hormone-dependent gynecological cancer and physicians have been less comfortable using vaginal estrogen due to fear of recurrence. CO2 vaginal laser therapies have demonstrated efficacy as a non-hormonal alternative for GSM treatment in healthy menopausal patients. The objective of this study was to evaluate the data on the effect of a CO2 vaginal laser for the management of GSM in gynecological cancer patients. Databases searched included MEDLINE, Embase, PubMed, Cochrane and Google Scholar. Selected studies assessed use of a CO2 vaginal laser in gynecological cancer patients with GSM. A total of 269 studies were retrieved. Four studies met the inclusion criteria. Each study followed a different type of CO2 vaginal laser protocol for the management of GSM in gynecological cancer patients. There are no randomized controlled trials that assess the use of a CO2 vaginal laser in gynecologic cancer patients. The number of published gynecological cancer patients treated with a CO2 laser for the management of GSM is extremely limited (N < 100). There is a lack of literature on the impact and safety of vaginal CO2 laser use to manage GSM in gynecologic cancer patients.
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Affiliation(s)
- J Mejia-Gomez
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - J Bouteaud
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - E Philippopoulos
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - W Wolfman
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - C Brezden-Masley
- Department of Medical Oncology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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27
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Liu M, Li F, Zhou Y, Cao Y, Li S, Li Q. Efficacy of CO 2 laser treatment in postmenopausal women with vulvovaginal atrophy: A meta-analysis. Int J Gynaecol Obstet 2021; 158:241-251. [PMID: 34625949 DOI: 10.1002/ijgo.13973] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/23/2021] [Accepted: 10/07/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To explore the efficacy of CO2 laser treatment in postmenopausal women with vulvovaginal atrophy. METHOD PubMed, Embase, Cochrane Library and Web of Science were searched to June 9, 2020. Prospective studies on the efficacy of CO2 laser treatment were included. Two researchers independently reviewed articles and extracted data. Heterogeneity test was conducted for each outcome indicator. Sensitivity analysis was performed in all models. RESULTS Twelve articles including 459 participants were enrolled. Compared with baseline, vaginal health indeices (VHIs) were significantly higher at the 1-, 3-, 6-, and 12-month follow ups (P < 0.001). For VVA severity, the visual analog scale scores for vaginal dryness at 1-, 3-, 6-, and 12-month follow-ups (P < 0.050), vaginal burning, itching, and dysuria at 1-month follow up (P < 0.001), and dyspareunia at 1-, 3-, 6-, and 12-month follow-ups (P < 0.001) were all significantly lower. For FSFI, total scores at 1-, 3-, 6-, and 12-month follow ups (P < 0.001), and the scores in desire, arousal, lubrication, orgasm, satisfaction, and pain at 1-month follow up (P < 0.050) were all significantly higher. For quality of life, the PCS12 and MCS12 scores were all significantly higher (P < 0.050) at the 1-month follow up. CONCLUSION CO2 laser treatment may be effective for postmenopausal women with VVA symptoms in improving quality of life and sexual function.
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Affiliation(s)
- Meichen Liu
- Tenth Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengyong Li
- Tenth Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhou
- Tenth Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yujiao Cao
- Tenth Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Senkai Li
- Tenth Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Li
- Tenth Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Non-oestrogenic modalities to reverse urogenital aging. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2021; 20:140-147. [PMID: 34703415 PMCID: PMC8525256 DOI: 10.5114/pm.2021.109772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023]
Abstract
Urogenital aging is a common process affecting all women in the post-menopausal period of their life, and it is substantially due to oestrogen deprivation after ovarian function cessation. These changes can lead to a progressive, chronic, and complex association of symptoms identified as the genitourinary syndrome of menopause, which has a significant impact on quality of life. Genitourinary syndrome and urogenital aging do not resolve spontaneously and usually recur when treatment is stopped. Therefore, appropriate long-term management is of paramount importance, and local oestrogen is the most effective treatment to reverse urogenital aging and to improve symptoms of genitourinary syndrome as replacement therapy. In some women, topical oestrogen may be inconvenient, it may not achieve complete response, or it may be contra-indicated. Several non-hormonal therapies have been investigated, but few treatments have been reported as potentially able to reverse the urogenital aging process similarly to exogenous oestrogens. Laser seems the most promising, although further studies to define its safety and efficacy are mandatory. Vitamin D and E, and phytotherapy have returned conflicting results and require further confirmation. Lifestyle modifications, physiotherapy, and electrical stimulation represent inexpensive and applicable treatments that might slow urogenital aging. Among the hormonal non-oestrogenic therapies, the use of vaginal oxytocin and dehydroepiandrosterone have been found to be effective compared to placebo, as well as the use of oral ospemifene, which partially relieves vulvovaginal atrophy.
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Carbon Dioxide Laser Vulvovaginal Rejuvenation: A Systematic Review. COSMETICS 2021. [DOI: 10.3390/cosmetics8030056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Genitourinary syndrome of menopause (GSM) causes significant symptomatic aggravation that affects the quality of life (QoL). Vulvovaginal atrophy (VVA), the hallmark of GSM, is managed with topical non-hormonal therapy, including moisturizers and lubricants, and topical estrogen application. Patients not responding/being unsatisfied with previous local estrogen therapies are candidates for a noninvasive modality. Carbon dioxide (CO2) laser therapy, especially the fractionated type (FrCO2), has drawn considerable attention over the past two decades as a non-invasive treatment for GSM. This systematic review describes the accumulated evidence from 40 FrCO2 laser studies (3466 participants) in GSM/VVA. MEDLINE, Scopus and Cochrane databases were searched through April 2021. We analyze the effects of FrCO2 laser therapy on symptoms, sexual function, and QoL of patients with GSM/VVA. As shown in this review, FrCO2 laser therapy for GSM shows good efficacy and safety. This modality has the potential to advance female sexual wellness. Patient satisfaction was high in the studies included in this systematic review. However, there is a lack of level I evidence, and more randomized sham-controlled trials are required. Furthermore, several clinical questions, such as the number of sessions required that determine cost-effectiveness, should be addressed. Also, whether FrCO2 laser therapy may exert a synergistic effect with systemic and/or local hormonal/non-hormonal treatments, energy-based devices, and other modalities to treat GMS requires further investigation. Lastly, studies are required to compare FrCO2 laser therapy with other energy-based devices such as erbium:YAG laser and radiofrequency.
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Mension E, Alonso I, Tortajada M, Matas I, Gómez S, Ribera L, Anglès S, Castelo-Branco C. Vaginal laser therapy for genitourinary syndrome of menopause - systematic review. Maturitas 2021; 156:37-59. [PMID: 34217581 DOI: 10.1016/j.maturitas.2021.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Genitourinary syndrome of menopause (GSM) can have a great impact on the quality of life (QOL), and affects between 53.8% and 90% of postmenopausal women. The literature suggests that vaginal laser therapy could be an effective treatment for GSM symptoms, but its efficacy and safety have not been established and international societies do not endorse its use. Despite that, there has been an increase in the use of vaginal laser therapy globally over the last decade. OBJECTIVE The objective of this review is to evaluate the literature which assesses the efficacy and safety of the vaginal laser therapy in the treatment of GSM. METHODS A comprehensive literature search was conducted electronically using Embase and PubMed to retrieve studies assessing evidence for the efficacy and safety of vaginal laser therapy for GSM or vulvovaginal atrophy up to June 2021. RESULTS A total of 64 studies were finally included in the review. There were 10 controlled intervention studies, 7 observational cohort and cross-sectional studies and 47 before-after studies without a control group. CONCLUSION Vaginal laser seems to improve scores on the Visual Analogue Scale (VAS), Female Sexual Function Index (FSFI) and Vaginal Health Index (VHI) in GSM over the short term. Safety outcomes are underreported and short-term. Further well-designed clinical trials with sham-laser control groups and evaluating objective variables are needed to provide the best evidence on efficacy.
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Affiliation(s)
- Eduard Mension
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Inmaculada Alonso
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marta Tortajada
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Isabel Matas
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sílvia Gómez
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Ribera
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sònia Anglès
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Camil Castelo-Branco
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Sipos AG, Pákozdy K, Jäger S, Larson K, Takacs P, Kozma B. Fractional CO 2 laser treatment effect on cervicovaginal lavage zinc and copper levels: a prospective cohort study. BMC WOMENS HEALTH 2021; 21:235. [PMID: 34092217 PMCID: PMC8180012 DOI: 10.1186/s12905-021-01379-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The basic principle of vaginal laser therapy is the rejuvenation of the affected tissue. Zinc and copper are essential nutritional trace elements and have a key role in connective tissue homeostasis. We aimed to investigate the effect of vaginal, fractional CO2 laser treatment on cervicovaginal lavage (CVL) zinc and copper levels. METHODS Twenty-nine postmenopausal women with symptoms of vaginal dryness were enrolled in our prospective cohort study. Three treatments with MonaLisa Touch CO2 laser system were performed four weeks apart. At each treatment CVL was collected, Vaginal Health Index (VHI) was obtained, and Visual Analog Scale (VAS) for vaginal dryness was assigned by patients. Zinc and copper concentrations were measured with optical emission spectrometry before each treatment and six weeks after the 3rd treatment. RESULTS The VHI scores significantly improved after each laser treatment (mean ± SD VHI score, 13.03 ± 4.49 before vs. 15.55 ± 4.35 after the 1st, 17.79 ± 4.57 after the 2nd and 19.38 ± 4.39 after the 3rd treatment, P < 0.01). Similarly, VAS scores reflected improvement (mean ± SD VAS score 6.59 ± 2.86 before vs. 4.17 ± 2.86 after the 1st, 2.45 ± 2.43 after the 2nd and 1.41 ± 1.94 after the 3rd treatment, P < 0.01). CVL zinc levels were significantly higher compared to copper levels (0.06 ± 0.04 vs. 0.006 ± 0.006 mg/L, P < 0.01) at baseline. While copper levels remained the same through treatments, the CVL zinc level was significantly higher after the second laser treatment compared to the baseline. CONCLUSIONS Fractional CO2 laser treatment of the vagina impacts CVL zinc and copper levels differently. While CVL copper levels were not different after each laser treatment, zinc levels were significantly higher after the second treatment before returning to baseline values.
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Affiliation(s)
- Attila G Sipos
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, 98. Nagyerdei krt., Debrecen, 4032, Hungary
| | - Krisztina Pákozdy
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, 98. Nagyerdei krt., Debrecen, 4032, Hungary
| | - Szilvia Jäger
- Fempharma Ltd, Vígkedvű Mihály utca 21. 2/5., Debrecen, 4024, Hungary
| | - Kindra Larson
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 526, Norfolk, VA, 23507-2007, USA
| | - Peter Takacs
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 526, Norfolk, VA, 23507-2007, USA
| | - Bence Kozma
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, 98. Nagyerdei krt., Debrecen, 4032, Hungary.
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Abstract
OBJECTIVES This study aimed to investigate the correlation between cervicovaginal fluid zinc levels and participants' menopausal status and the presence of vulvovaginal symptoms of genitourinary syndrome of menopause. METHODS Women included in the study underwent a pelvic examination, collection of vaginal cytology, and cervicovaginal lavage was performed in a standardized fashion. The cervicovaginal lavage zinc content was determined. The vaginal health index was calculated, and the visual analog scale was obtained based on the participant's burning, itching, vaginal pain, dyspareunia, dryness, and dysuria. RESULTS One hundred twenty women participated in the study. Eighty-two participants were menopausal. The mean vaginal health index was 15 ± 6, while the total visual analog scale score was 14 ± 14. We found significant differences between cervicovaginal lavage zinc level and age group, menopausal status, presence of vaginal dryness, and vaginal atrophy. We also found a moderate positive correlation between Vaginal Maturation Value and cervicovaginal lavage zinc levels (r = 0.495, P value < 0.01) in the correlation analysis. However, in the multivariate regression model, including all significant factors, only vaginal atrophy remained significant. CONCLUSIONS We found a significant association between vaginal atrophy (vaginal maturation value < 50) and cervicovaginal lavage zinc levels. Zinc levels of cervicovaginal lavage could be used as a new marker of vaginal atrophy. : Video Summary:http://links.lww.com/MENO/A575.
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Treatment for vaginal atrophy using microablative fractional CO2 laser: a randomized double-blinded sham-controlled trial. ACTA ACUST UNITED AC 2021; 27:858-863. [PMID: 32345787 DOI: 10.1097/gme.0000000000001542] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of vaginal CO2 laser for the treatment of vaginal atrophy compared to the sham procedure. METHODS Between June 2016 and May 2017, postmenopausal women with moderate to severe intensity of any vaginal atrophy symptoms (VAS) were invited to participate in the study. A total of 88 women were randomized to receive treatment with either vaginal CO2 laser or sham procedures every 4 weeks for three sessions. Both the participants and the evaluators were blinded to the treatment. Vaginal Health Index (VHI) score (primary outcome), VAS score, and the item for vaginal dryness from the International Consultation on Incontinence Modular Questionnaire-Vaginal Symptoms questionnaire were compared between the two groups by intention-to-treat analysis at 12 weeks after treatment. RESULTS Eighty-eight women were enrolled into the study and nine women were lost to follow-up. After 12 weeks of laser treatment, the VHI, VAS, and International Consultation on Incontinence Modular Questionnaire-Vaginal Symptoms (item for vaginal dryness) scores were significantly improved. For VHI and VAS scores the mean difference between the laser group versus the sham group was 1.37 (95% CI: 0.12-2.63), P < 0.001 and -1.52 (95% CI: -2.21 to -0.82), P = 0.03, respectively. CONCLUSIONS This study demonstrated that the application of microablative fractional CO2 laser was effective in treating vaginal atrophy. It could be a promising alternative treatment for postmenopausal women with vaginal atrophy. : Video Summary:http://links.lww.com/MENO/A582.
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The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. ACTA ACUST UNITED AC 2021; 27:976-992. [PMID: 32852449 DOI: 10.1097/gme.0000000000001609] [Citation(s) in RCA: 190] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To update and expand the 2013 position statement of The North American Menopause Society (NAMS) on the management of the genitourinary syndrome of menopause (GSM), of which symptomatic vulvovaginal atrophy (VVA) is a component. METHODS A Panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on vaginal hormone therapies as well as on other management options available or in development for GSM. A search of PubMed was conducted identifying medical literature on VVA and GSM published since the 2013 position statement on the role of pharmacologic and nonpharmacologic treatments for VVA in postmenopausal women. The Panel revised and added recommendations on the basis of current evidence. The Panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees. RESULTS Genitourinary syndrome of menopause affects approximately 27% to 84% of postmenopausal women and can significantly impair health, sexual function, and quality of life. Genitourinary syndrome of menopause is likely underdiagnosed and undertreated. In most cases, symptoms can be effectively managed. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of symptoms. These include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hormone therapy, and the estrogen agonist/antagonist ospemifene. Long-term studies on the endometrial safety of vaginal estrogen, vaginal DHEA, and ospemifene are lacking. There are insufficient placebo-controlled trials of energy-based therapies, including laser, to draw conclusions on efficacy and safety or to make treatment recommendations. CONCLUSIONS Clinicians can resolve many distressing genitourinary symptoms and improve sexual health and the quality of life of postmenopausal women by educating women about, diagnosing, and appropriately managing GSM. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of treatments for the individual patient, and patient preference. Nonhormone therapies available without a prescription provide sufficient relief for most women with mild symptoms. Low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are effective treatments for moderate to severe GSM. When low-dose vaginal estrogen or DHEA or ospemifene is administered, a progestogen is not indicated; however, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data at present to confirm the safety of vaginal estrogen or DHEA or ospemifene in women with breast cancer; management of GSM should consider the woman's needs and the recommendations of her oncologist.
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Pelvic Radiation Therapy Induced Vaginal Stenosis: A Review of Current Modalities and Recent Treatment Advances. ACTA ACUST UNITED AC 2021; 57:medicina57040336. [PMID: 33915994 PMCID: PMC8066324 DOI: 10.3390/medicina57040336] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022]
Abstract
Radiation-induced vaginal stenosis (VS) is a common side effect of pelvic radiotherapy (RT). RT-induced VS may have various negative effects on women’s quality of life, in particular dyspareunia, decreased vaginal lubrication and difficulties in sexual intercourse. This narrative review provides the aspects of RT-induced VS pathogenesis, incidence, evaluation and associated risk factors. Available treatment modalities are discussed in the article, putting the focus on preliminary, although promising, experience in the use of hyaluronic acid and laser therapy in cancer survivors after pelvic RT.
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D'Oria O, Giannini A, Prata G, Scudo M, Logoteta A, Mondo A, Perniola G, Palaia I, Cascialli G, Monti M, Muzii L, Benedetti Panici P, DI Donato V. Non-invasive treatment of vulvovaginal atrophy in menopause with CO2 laser. Minerva Obstet Gynecol 2021; 73:127-134. [PMID: 32720802 DOI: 10.23736/s2724-606x.20.04612-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Genitourinary syndrome of menopause (GSM) may affect up to 90% of menopausal women, including vulvovaginal atrophy (VVA), burning, pain, bleeding, irritation, dyspareunia, anorgasmia, and urinary symptoms. Vaginal symptoms from lack of estrogens can have a significant impact on the sexual health and quality of life (QoL) in as many as 50% of postmenopausal women. Several therapeutic alternatives, both hormonal and non- hormonal, have been proposed. Microablative CO<inf>2</inf> laser is one of the three non-surgical energy-based therapies, with Erbium:YAG laser and temperature-controlled radiofrequency (RF). Microablative CO<inf>2</inf> laser induces morphological changes in vaginal tissues and results of several clinical trials suggest that this type of laser improves symptoms of GSM. Moreover, this treatment seems to be safe. Given the increasingly widespread use of laser CO<inf>2</inf> as a non-hormonal alternative treatment for GSM, the authors reviewed the current published literature evaluating this therapy, to compare efficacy and safety of different protocols.
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Affiliation(s)
- Ottavia D'Oria
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Andrea Giannini
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Giovanni Prata
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Maria Scudo
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy -
| | - Alessandra Logoteta
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Alessandro Mondo
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Innocenza Palaia
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Gianluca Cascialli
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Marco Monti
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Violante DI Donato
- Department of Maternal Child Health and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
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Cruff J, Khandwala S. A Double-Blind Randomized Sham-Controlled Trial to Evaluate the Efficacy of Fractional Carbon Dioxide Laser Therapy on Genitourinary Syndrome of Menopause. J Sex Med 2021; 18:761-769. [PMID: 33757774 DOI: 10.1016/j.jsxm.2021.01.188] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/12/2021] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite some prospective case series showing effectiveness of vaginal laser to treat genitourinary syndrome of menopause (GSM), there is a paucity of placebo-controlled level one evidence. AIM To assess the effect of fractional carbon dioxide (CO2) laser therapy to treat GSM against a sham comparator. METHODS We conducted a parallel, randomized, double-blind, sham-controlled trial to compare menopausal women treated with fractional CO2 laser against sham treatment for improvement in GSM-related dyspareunia. Three treatments were given 6 weeks apart, and participants attended a 6-month visit from study start for primary (proportion improved) and secondary (vaginal health index, VHI; visual analogue scale, VAS; modified global assessment, PGI-I; Female Sexual Function Index, FSFI; Day-to-Day Impact of Vaginal Aging, DIVA; Urinary Distress Inventory short-form, UDI-6) assessments. OUTCOMES The primary endpoint was a 2-stage improvement in GSM-related dyspareunia from baseline to 6 months determined by a severity scale, and the proportion of subjects who achieved this were compared between groups. RESULTS Thirty participants were randomized to laser (n = 14) or sham (n = 16). In the treatment arm, 13 attended all treatments, and 1 attended at least 2 while in the sham arm, 14 attended all treatments, and 2 attended at least 2 treatments. Twelve (86%) in the treatment arm and 16 (100%) in the sham arm attended the 6-month visit. There were no differences in the proportion improved between treatments and controls (64% vs. 67%, respectively, P = 1.000). Both arms showed significant within-group improvements based on VHI and VAS, but not between groups. Similar findings were observed on sexual impact questionnaires with improvements within both groups from baseline to 6 months but not by median differences between the groups at 6 months. There were no adverse events in either of the arms. CLINICAL IMPLICATIONS Further well-powered research is needed to determine efficacy of fractional CO2 laser for the treatment of GSM, especially in light of a potential placebo effect. STRENGTHS & LIMITATIONS We present a sham-controlled double-blinded randomized trial using validated tools; the main limitation included an underpowered proportion of sexually active participants for the primary outcome. CONCLUSION This study was underpowered to draw conclusions regarding the efficacy of fractional CO2 laser therapy in the treatment of GSM. We did observe improvements in the sham-arm to suggest a possible placebo contribution. Further well-powered level one research is needed to demonstrate the therapeutic effect of this novel modality. Cruff J, Khandwala S, A Double-Blind Randomized Sham-Controlled Trial to Evaluate the Efficacy of Fractional Carbon Dioxide Laser Therapy on Genitourinary Syndrome of Menopause. J Sex Med 2021;18:761-769.
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Affiliation(s)
- Jason Cruff
- Department of Obstetrics/Gynecology-Female Pelvic Medicine & Reconstructive Surgery, Marshfield Clinic Health System, Marshfield, WI, USA.
| | - Salil Khandwala
- Advanced Urogynecology of Michigan, P.C., Dearborn, MI, USA; Department of Female Pelvic Medicine & Reconstructive Surgery, Beaumont Health, Wayne, MI, USA
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Lou W, Chen F, Xu T, Fan Q, Shi H, Kang J, Shi X, Zhu L. A randomized controlled study of vaginal fractional CO 2 laser therapy for female sexual dysfunction. Lasers Med Sci 2021; 37:359-367. [PMID: 33723687 DOI: 10.1007/s10103-021-03260-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
The purpose of this study is to evaluate the efficacy and safety of vaginal fractional CO2 laser therapy for female sexual dysfunction (FSD). A total of 84 women at high risk of sexual dysfunction were randomly divided into two groups. Women in the laser group received vaginal fractional CO2 laser therapy. Others in the Kegel group were advised to participate in Kegel exercise training. Sexual distress and sexual function were evaluated by using the Female Sexual Distress Scale-Revised (FSDS-R) and the Chinese version Female Sexual Function Index (CVFSFI), respectively. Adverse events were recorded during the 12-month follow-up. At the end of the 6th and 12th months, the lubrication scores of the CVFSFI in the laser group (4.55±0.05, 4.58±0.09) were significantly higher than those in the Kegel group (4.19±0.15, 4.20±0.14) (P<0.05). The satisfaction scores in the laser group (4.43±0.08) were higher than those in the Kegel group (4.20±0.16) at the end of the 6th month (P<0.05). The self-contrast test in the laser group showed significant improvement in lubrication, pain, satisfaction and total scores after CO2 laser therapy (p<0.05). These improvements were maintained for 1 year. The improvement of FSDS-R in the laser group (10.0±0.2) was more evident than in the Kegel group (11.1±0.4) at the end of the 12th month. There were no major adverse events reported during laser therapy. Vaginal fractional CO2 laser therapy can effectively improve sexual function without any serious adverse events. It might be an effective and relatively safe treatment option for improving vaginal mucosa status in sexually active women with sexual dysfunction.
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Affiliation(s)
- Wenjia Lou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Fei Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Tao Xu
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Qingbo Fan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Honghui Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jia Kang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Xinwen Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China.
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Energy-Based Devices for Functional Vaginal Problems: Issues and Answers. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00302-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Abstract
Vaginal rejuvenation is a marketing term that encompasses surgical and medical treatments for functional vaginal/vulvar problems including but not limited to genitourinary syndrome of menopause (GSM), sexual dysfunction, vaginal laxity, and stress urinary incontinence (SUI) and for esthetic concerns including dissatisfaction with vulvovaginal appearance. Multiple treatment options have become available for indications of functional vaginal problems. Noninvasive management options including the use of more novel treatments such as energy-based devices have gained interest. Previously, studies regarding the efficacy and safety of the energy-based devices for functional vaginal problems were mostly limited to cohort studies without sham treatment, control groups, randomization, or double blinding. As a result of this insufficient data in 2018, the FDA released a statement of warning against the use of energy-based devices in the treatment of functional vaginal problems or vaginal cosmetic procedures (Https://Www.Fda.Gov/Medical-Devices/Safety-Communications/Fda-Warns-Against-Use-Energy-Based-Devices-Perform-Vaginal-Rejuvenation-or-Vaginal-Cosmetic. 1–4, 2018).
Purpose of Review
This article reviews the most current treatment modalities in the realm of vaginal rejuvenation therapy with an emphasis on the efficacy and safety of the energy-based devices.
Recent Findings
In the most recent literature, there have been studies with improvements in study design that support the efficacy and the short-term safety of the energy-based devices.
Summary
More recent studies with improved study design evidence that the use of energy-based devices results in improvements in functional vaginal problems and that serious adverse events appear to be rare. The availability of these devices as treatment options for functional vaginal problems has the potential to impact patient by improving their symptoms and quality of life. Caution still remains however regarding their safety following a longer period of time after their use.
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Sarmento ACA, Lírio JF, Medeiros KS, Marconi C, Costa APF, Crispim JC, Gonçalves AK. Physical methods for the treatment of genitourinary syndrome of menopause: A systematic review. Int J Gynaecol Obstet 2021; 153:200-219. [PMID: 33354773 DOI: 10.1002/ijgo.13561] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/13/2020] [Accepted: 12/21/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Genitourinary syndrome of menopause (GSM) negatively affects sexual function and quality of life. Techniques like laser and radiofrequency are being used to manage GSM, particularly in women with contraindications for hormone therapy. OBJECTIVES To verify whether the physical methods of laser and radiofrequency can be recommended as safe and effective options for the treatment of GSM/urinary urgency or incontinence in pre- and postmenopausal women. SEARCH STRATEGY Databases were comprehensively searched using combinations of the following keywords in any language: "postmenopause"; "genitourinary syndrome of menopause"; "vaginal atrophy"; "radiofrequency"; and "laser." SELECTION CRITERIA Full articles of case-control, cross-sectional, cohort, randomized clinical trials, and quasi-randomized or controlled clinical trials were included. DATA COLLECTION AND ANALYSIS All authors independently evaluated the design of the studies for quality of reporting, risk of bias, and quality of evidence. MAIN RESULTS Of the included 49 studies, 37 were on the CO2 laser, 10 on the Erbium laser, and two on radiofrequency. CONCLUSIONS Laser and radiofrequency therapy could be promising and safe therapeutic options for GSM/urinary incontinence. However, the study findings cannot be generalized until new randomized clinical trials are performed that confirm the strength of the evidence. This review has been registered with PROSPERO: CRD42020141913.
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Affiliation(s)
- Ayane C A Sarmento
- Health Sciences Postgraduate Program, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | - Juliana F Lírio
- Departments of Gynecology and Obstetrics, State University of Campinas, Campinas, Brazil
| | - Kleyton S Medeiros
- Health Sciences Postgraduate Program, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | - Camila Marconi
- Department of Biological Science, Federal University of Paraná, Curitiba, Brazil
| | - Ana P F Costa
- Health Sciences Postgraduate Program, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | - Janaina C Crispim
- Department of Clinical Analysis and Toxicology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Ana K Gonçalves
- Health Sciences Postgraduate Program, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil.,Department of Obstetrics and Gynecology, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
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Quick AM, Zvinovski F, Hudson C, Hundley A, Evans C, Stephens JA, Arthur E, Ramaswamy B, Reinbolt RE, Noonan AM, VanDeusen JB, Wesolowski R, Stover DG, Williams NO, Sardesai SD, Faubion SS, Loprinzi CL, Lustberg MB. Patient-reported sexual function of breast cancer survivors with genitourinary syndrome of menopause after fractional CO2 laser therapy. Menopause 2021; 28:642-649. [PMID: 33534429 DOI: 10.1097/gme.0000000000001738] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of this pilot study was to evaluate the change in sexual function following treatment with fractional CO2 laser therapy in breast cancer (BC) survivors with genitourinary syndrome of menopause (GSM). METHODS A single-arm feasibility study of BC survivors with symptoms of GSM, including dyspareunia and/or vaginal dryness, was conducted. Participants who received three treatments with fractional CO2 laser and 4-week follow-up were contacted for patient-reported outcomes and adverse events at 12 months. Sexual function was measured using the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale Revised (FSDS-R). Descriptive statistics were calculated for patient demographics and disease characteristics for the set of participants who agreed to long-term follow-up and those who were lost to follow-up. FSFI and FSDS-R scores were summarized at baseline, 4 weeks and 12 months, as well as the change from baseline, and were compared using a Wilcoxon signed rank test. RESULTS A total of 67 BC survivors enrolled, 59 completed treatments and 4-week follow-up; 39 participated in the 12 month follow-up. The overall FSFI score improved from baseline to 4-week follow-up (median Δ 8.8 [Q1, Q3] (QS) (2.2, 16.7)], P < 0.001). There were improvements at 4 weeks in all domains of the FSFI (P < 0.001 for each) including desire (median Δ 1.2; QS [0.6, 1.8]), arousal (median Δ 1.2; QS [0.3, 2.7]), lubrication (median Δ 1.8 (0, 3.3), orgasm (median Δ 1.2; QS [0, 3.6]), satisfaction (median Δ 1.6 (0.4, 3.2)), and pain (median Δ 1.6 (0, 3.6). The FSDS-R score also improved from baseline to 4-week follow-up (median Δ -10.0; QS [-16, -5] P < 0.001) indicating less sexually related distress. The scores of the FSFI and FSDS-R remained improved at 12 months and there were no serious adverse events reported. CONCLUSIONS In BC survivors with GSM, the total and individual domain scores of the FSFI and the FSDS-R improved after fractional CO2 laser therapy.
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Affiliation(s)
| | | | | | | | - Cynthia Evans
- The Ohio State University Medical Center, Columbus, OH
| | - Julie A Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH
| | | | | | | | - Anne M Noonan
- The Ohio State University Medical Center, Columbus, OH
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Ruffolo AF, Casiraghi A, Marotta E, Degliuomini R, Parma M, Athanasiou S, Benini V, Candiani M, Salvatore S. Does the Time of Onset of Urinary Symptoms Affect Microablative Fractional CO 2 Laser Efficacy in Postmenopausal Women? Lasers Surg Med 2021; 53:953-959. [PMID: 33476052 DOI: 10.1002/lsm.23378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/28/2020] [Accepted: 12/31/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the safety and efficacy of transvaginal fractional microablative CO2 laser therapy (MLT) on urinary symptoms in postmenopausal women with genitourinary syndrome of menopause (GSM) in relation to the timing of their onset; if prior to or after menopause. Secondary, the efficacy of MLT on vulvovaginal atrophy (VVA)-related symptoms. STUDY DESIGN/MATERIALS AND METHODS This is a retrospective analysis of prospectively collected data. Postmenopausal women affected by at least one urinary symptom (urinary frequency, urgency incontinence, stress urinary incontinence) and VVA symptom each (dryness, dyspareunia, itching, burning) were enrolled. Our population was divided into two groups in relation to the onset of urinary symptoms, prior to or after menopause. Women were treated with three CO2 MLT laser sessions, administered at a 4-week interval. For urinary symptoms evaluation, we used the following disease-specific questionnaires previously validated in Italy: the Urogenital Distress Inventory score (UDI-6) and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). For each single VVA symptom, we assessed patient's severity perception with a 10-point visual analog scale. Time points of the study were at entry (T0) and at 16 weeks since the first treatment (T1). Collected data were analyzed with the Pearson χ 2 test for categorical variables and the Wilcoxon rank-sum test (for non-normally distributed data), and statistical significance was defined with a P-value <0.05. RESULTS Sixty-one women were enrolled in this study. Overall, at T1 MLT brought to a significant improvement in urinary symptoms (P < 0.05) in women with urinary symptoms started after the menopause (Group B), contrary to the ones with urinary symptoms started before the menopause (Group A). Specifically, urinary frequency significantly improved only in Group B (P < 0.05), while urgency incontinence, significantly reduced in both groups (P < 0.05). Stress urinary incontinence did not significantly improve in both groups (P > 0.05). Secondary, all VVA symptoms showed a statistically significant improvement (P < 0.05) at 16 weeks from baseline; no differences were registered between groups. No adverse events were recorded. CONCLUSION This study confirms the safety and efficacy of CO2 MLT for GSM symptoms. When urinary symptoms are considered, it seems that MLT might have a higher efficacy when symptoms started after menopause, in particular when they are part of the OAB syndrome. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.
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Affiliation(s)
- Alessandro F Ruffolo
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Arianna Casiraghi
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Elena Marotta
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Rebecca Degliuomini
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Marta Parma
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Stavros Athanasiou
- First Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, 20132, Greece
| | - Vittoria Benini
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Massimo Candiani
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Stefano Salvatore
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, 20132, Italy
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Efficacy of fractional CO2 laser treatment in postmenopausal women with genitourinary syndrome: a multicenter study. ACTA ACUST UNITED AC 2021; 27:43-49. [PMID: 31794500 DOI: 10.1097/gme.0000000000001428] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Genitourinary syndrome of menopause (GSM), especially vulvovaginal atrophy (VVA), is one of the most common conditions among women in either natural (4%-47%) or medically induced (23.4%-61.5%) menopause. The aims of this study are to assess the efficacy and effectiveness of CO2 laser in postmenopausal women with clinical signs and symptoms of GSM, in particular VVA, and to evaluate both possible early and late side effects related to this kind of treatment. METHODS This retrospective, multicenter study was conducted after collecting data from a pre-existing database. We performed three to four CO2 laser treatments on all the women enrolled in this protocol. We used a fractional CO2 laser system (SmartXide VLR, Deka m.e.l.a., Florence, Italy) with a VulvoVaginal Laser Reshaping (VLR) scanning system and appropriate handpieces for the vaginal area. All women before and after the treatment were assessed. The pre- and post-treatment averages of the symptoms, the standard deviation, and the P values were calculated. RESULTS Six hundred forty-five women who met the inclusion criteria were considered. In all the parameters examined (dyspareunia, vaginal orifice pain, dryness/atrophy, itching, burning, pH) statistically significant data were found between the pretreatment and the post-treatment (dryness: before = 8.30, after = 2.97 [P < 0.0001], dyspareunia: before = 8.70, after = 3.51 [P < 0.0001]; burning: before = 6.12, after = 1.78 [P < 0.0001]; vaginal orifice pain: before = 8.07, after = 2.94 [P < 0.0001]; itching: before = 6.09, after = 1.32 [P < 0.0001]). CONCLUSIONS Our results show the effectiveness and a good degree of tolerance of treatment with the CO2 laser system in postmenopausal women with GSM.
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Quick AM, Dockter T, Le-Rademacher J, Salani R, Hudson C, Hundley A, Terstriep S, Streicher L, Faubion S, Loprinzi CL, Coleman JS, Wang KC, Lustberg M. Pilot study of fractional CO 2 laser therapy for genitourinary syndrome of menopause in gynecologic cancer survivors. Maturitas 2020; 144:37-44. [PMID: 33358206 DOI: 10.1016/j.maturitas.2020.10.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/19/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The objectives of this study were to evaluate the feasibility and efficacy of fractional CO2 laser therapy in gynecologic cancer survivors. METHODS This was a pilot, multi-institutional randomized sham-controlled trial of women with gynecologic cancers with dyspareunia and/or vaginal dryness. Participants were randomized to fractional CO2 laser treatment or sham laser treatment. The primary aim was to estimate the proportion of patients who had improvement in symptoms based on the Vaginal Assessment Scale (VAS). Secondary aims included changes in sexual function assessed using the Female Sexual Functioning Index (FSFI) and urinary symptoms assessed using the the Urinary Distress Inventory (UDI-6). RESULTS Eighteen women participated in the study, ten in the treatment arm and eight in the sham arm. The majority of participants had stage I (n = 11, 61.1 %) or II (n = 3, 16.7 %) endometrial cancer with adenocarcinoma histology (n = 9, 50 %). In total, 15 (83.3 %) of the participants completed all treatments and follow-up visit. There was no difference in the change in the median VAS score from baseline to follow-up. However, there was an improvement in change in the median total FSFI score with treatment compared with sham (Δ 6.5 vs -0.3, p = 0.02). The change in the median UDI-6 score was lower in the treatment arm (Δ -14.6 vs -2.1, p = 0.17), but this was not statistically significant. There were no reported serious adverse events. CONCLUSIONS Fractional CO2 laser therapy is feasible in gynecologic cancer survivors, with preliminary evidence of safety. In addition, there was preliminary evidence of improvement in sexual function compared with sham treatment. Clinicaltrial.gov Identifier: NCT03372720 (OSU-17261; NCI-2017-02051).
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Affiliation(s)
- Allison M Quick
- The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital, Columbus, OH, United States.
| | - Travis Dockter
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | | | - Ritu Salani
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Catherine Hudson
- The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Andrew Hundley
- The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | | | - Lauren Streicher
- Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL, United States
| | | | | | - Jenell S Coleman
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Karen C Wang
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Maryam Lustberg
- The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital, Columbus, OH, United States
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Li J, Li H, Zhou Y, Xie M, Miao Y, Wang L, Zhao Y, Ying T, Hu Y, Chen Y, Chen Y, Sun X, Wang J. The Fractional CO 2 Laser for the Treatment of Genitourinary Syndrome of Menopause: A Prospective Multicenter Cohort Study. Lasers Surg Med 2020; 53:647-653. [PMID: 33211334 PMCID: PMC8246931 DOI: 10.1002/lsm.23346] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/10/2020] [Accepted: 10/15/2020] [Indexed: 11/25/2022]
Abstract
Background and Objectives Genitourinary syndrome of menopause (GSM) is a common condition affecting of most postmenopausal women, which greatly impacks the quality of life,and need to treat. This prospective multicenter cohort study aimed to compare the efficacy and safety of the fractional carbon dioxide (CO2) laser with that of topical estrogen for vaginal treatment and relieving symptoms of genitourinary syndrome of menopause (GSM). Study Design/Materials and Methods This study included 162 postmenopausal patients who received vaginal laser or topical Estriol cream therapy between January 2017 and May 2019 at eight study centers in China. The degree of GSM‐related symptoms (vaginal burning, dryness, and dyspareunia) was evaluated using the Vaginal Health Index score (VHIS) and Visual Analog Scale (VAS) at baseline, 1, 3, 6, and 12 months posttreatment. The primary endpoint was the improvement in vaginal burning, dryness, and dyspareunia at 6 months after treatment. Multivariate logistic regression was used to compare the rate of improvement in the two groups. Results At baseline, the laser and control groups showed no significant difference in the mean age, time after menopause, and the VHIS (all P > 0.05). In the laser group, compared with baseline, significant differences were seen in the VHIS after the first or second treatment session and at 1, 3, 6, and 12 months posttreatment (P < 0.01). In the control group, compared with baseline, the VHIS showed significant differences after 1, 3, and 6 months of treatment (P < 0.05). However, there was no significant difference after 3 and 6 months of follow‐up between the two groups (P > 0.05). The VHIS scores were significantly higher after 1 month (16.63 ± 2.79 vs. 15.57 ± 2.43) and 12 months (15.72 ± 2.59 vs. 12.12 ± 4.08) of treatment in both the groups (P < 0.05). At 6 months after treatment, both groups showed improvement in vaginal burning, vaginal dryness, and dyspareunia (P > 0.05). The VAS findings at 6 months posttreatment were significantly different when compared with the pretreatment findings (P < 0.001). There were no significant adverse effects in the two groups. Conclusions Fractional CO2 laser vaginal treatment could be a safe and effective option for treating symptoms of GSM, including vaginal burning, dryness, and dyspareunia. The improvement in symptoms was comparable with that seen with topical estrogen therapy and lasted for at least 6–12 months posttreatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC
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Affiliation(s)
- Jingran Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Xizhimen, South Street, Beijing, Beijing, 100044, China
| | - Huan Li
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Lianhua Road, Shenzhen, Guangdong, 518036, China
| | - Yanfei Zhou
- Department of Obstetrics and Gynecology, Changsha Hospital for Maternity and Child Healthcare, Chengnan East Road, Changsha, Hunan, 410007, China
| | - Meiqing Xie
- Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Yanjiang West Road, Guangzhou, Guangdong, 510120, China
| | - Yali Miao
- Department of Obstetrics and Gynecology, West China Second University Hospital, Renmin South Road, Chengdu, Sichuan, 610041, China
| | - Luwen Wang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Street, Zhengzhou, Henan, 450008, China
| | - Yan Zhao
- Department of Obstetrics and Gynecology, Puyang Oilfield General Hospital, Daqing Road, Puyang, Henan, 457000, China
| | - Ting Ying
- Department of Obstetrics and Gynecology, Liuzhou Maternity and Child Healthcare Hospital, Sanzhong Road, Liuzhou, Guangxi, 545001, China
| | - Yan Hu
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Lianhua Road, Shenzhen, Guangdong, 518036, China
| | - Yu Chen
- Department of Obstetrics and Gynecology, Changsha Hospital for Maternity and Child Healthcare, Chengnan East Road, Changsha, Hunan, 410007, China
| | - Yaxiao Chen
- Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Yanjiang West Road, Guangzhou, Guangdong, 510120, China
| | - Xiuli Sun
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Xizhimen, South Street, Beijing, Beijing, 100044, China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Xizhimen, South Street, Beijing, Beijing, 100044, China
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A Systematic Review of Nonsurgical Vulvovaginal Restoration Devices: An Evidence-Based Examination of Safety and Efficacy. Plast Reconstr Surg 2020; 146:552e-564e. [PMID: 33141529 DOI: 10.1097/prs.0000000000007236] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The efficacy and safety of vulvovaginal restoration devices were called into question in a U.S. Food and Drug Administration statement on July 30, 2018, claiming that women are being harmed by laser and other energy-based devices. The goal of this systematic literature review was to assess existing data, determine gaps in evidence, and propose opportunities for continued investigation pertaining to laser and energy-based vaginal restoration techniques. METHODS A review of literature using PubMed, Cochrane Library databases, Embase, MEDLINE, and the Cumulative Index to Nursing and Allied Health Literature was conducted on January 9, 2019, and articles up to this point were considered. For inclusion, studies had to be available or translated in English and relate to clinical medicine, direct patient care, and nonsurgical energy-based vulvovaginal procedures. RESULTS The authors found five level I studies, 19 level II studies, four level III studies, and 46 level IV studies that used 15 different devices. Various degrees of improvement of symptoms were reported in all studies. Adverse events/side effects were noted in two of the 13 radiofrequency device studies, 15 of the 23 erbium:yttrium-aluminum-garnet device studies, and 17 of the 37 carbon dioxide device studies. The majority of adverse events were considered mild. CONCLUSIONS The majority of studies resulted in mild to no adverse side effects. However, there is a large gap in level I evidence. As a result, the authors emphasize the necessity of supplemental data surrounding this subject and suggest that additional randomized sham-controlled studies be conducted to further investigate vulvovaginal restoration devices in an effort to address women's health issues.
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Toplu G, Serin M, Unveren T, Altinel D. Patient reported vaginal laxity, sexual function and stress incontinence improvement following vaginal rejuvenation with fractional carbon dioxide laser. J Plast Surg Hand Surg 2020; 55:25-31. [PMID: 33030095 DOI: 10.1080/2000656x.2020.1828897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this study, we have evaluated the efficiency of fractional carbon dioxide laser in the treatment of vaginal laxity and urinary incontinence. Thirty patients with vaginal laxity, sexual dysfunction and urinary incontinence complaints were treated with fractional carbon dioxide laser. Results were evaluated with patient questionnaires relating to comfort during the procedure and general satisfaction following the procedure. In the survey regarding comfort during the procedure, 90% (n:27) of the patients reported that they were comfortable during the procedure. The survey on the level of general satisfaction six months following the procedure revealed high-moderate level of satisfaction in 86% (n:26) of the patients. 66% (n:20) of the patients reported improved vaginal tightness and 63% (n:19) of the patients reported improvement in the quality of their sexual activity. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire(PISQ-12) scores six months following the procedure were not significantly different when compared to the scores prior to the procedure. The average of Questionnaire for Urinary Incontinence Diagnosis(QUID) score prior to the procedure and six months following the procedure was 7.5 and 0.9 respectively (p < 0.05). Fractional carbon dioxide laser treatment results in high level of satisfaction and improvement in vaginal laxity, sexual dysfunction and urinary incontinence symptoms in patients with genitourinary syndrome.
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Affiliation(s)
- Gaye Toplu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Attending Physician, University of Health Sciences, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Merdan Serin
- Department of Plastic, Reconstructive and Aesthetic Surgery, Attending Physician, University of Health Sciences, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Toygar Unveren
- Attending Physician in Plastic, Reconstructive and Aesthetic Surgery, Istanbul, Turkey
| | - Dincer Altinel
- Department of Plastic, Reconstructive and Aesthetic Surgery, Attending Physician, University of Health Sciences, Istanbul Training and Research Hospital, Istanbul, Turkey
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Ghanbari Z, Sohbati S, Eftekhar T, Sahebi L, Darvish S, Alasiri S, Deldar Pasikhani M. Fractional CO2 Laser for Treatment of Vulvovaginal Atrophy: A Short Time Follow-up. J Family Reprod Health 2020; 14:68-73. [PMID: 33603796 PMCID: PMC7865202 DOI: 10.18502/jfrh.v14i2.4347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: The aim of this study was to evaluate the safety and efficacy of fractional CO2 laser for treatment of vulvovaginal atrophy. Materials and methods: In this clinical trial study, we evaluated the laser effect on vulvovaginal atrophy in 47 women aged 43-80 years. Each woman was treated with fractional CO2 laser, SmartXide2V2LR, DEKA, Monalisa Touch, vaginal 360o probe and cosmetic probe. The severity of vulvovaginal atrophy symptoms was evaluated before first session of laser and every 4 weeks after laser treatment until 12 weeks. Adverse effects including pain and itching were assessed at all visits. The statistical analysis was performed using SPSS version 23. Results: The response to laser therapy for vaginal dryness was significantly (p <0.001) improved. Also, the response to laser therapy for each symptom include dyspareunia, vaginal discharge, itching and urge urinary incontinence was statistically significant (p <0.001) based on visual analogue scale (VAS). Conclusion: It seems vaginal fractional CO2 laser can be applied as an effective and safe treatment method in genitourinary syndrome of menopause (GSM). It is necessary to conduct studies with long-term follow-up.
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Affiliation(s)
- Zinat Ghanbari
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Samira Sohbati
- Department of Obstetrics & Gynecology, Kerman University of Medical Sciences, Kerman, Iran
| | - Tahereh Eftekhar
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Leyla Sahebi
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soodabeh Darvish
- Department of Obstetrics & Gynecology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Safa Alasiri
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Marayam Deldar Pasikhani
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Guo JZ, Souders C, McClelland L, Anger JT, Scott VCS, Eilber KS, Ackerman AL. Vaginal laser treatment of genitourinary syndrome of menopause: does the evidence support the FDA safety communication? Menopause 2020; 27:1177-1184. [PMID: 32796292 DOI: 10.1097/gme.0000000000001577] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Genitourinary syndrome of menopause (GSM) is a chronic, progressive condition frequently manifesting as vaginal dryness and pain with intercourse. Survey data indicate this is a highly prevalent, likely underreported, condition that profoundly affects quality of life for millions of women. Vaginal lasers demonstrate promise as an effective, nonhormone therapeutic alternative for GSM; however, the risks associated with them may have been overstated. OBJECTIVE Despite reports of improved sexual and vaginal comfort without serious safety concerns, the Food and Drug Administration (FDA) issued a 2018 safety communication warning against it. We conducted a systematic literature review and surveyed both the FDA Manufacturer and User Facility Device Experience (MAUDE) and Bloomberg Law Databases to evaluate risks associated with laser treatment for GSM. EVIDENCE REVIEW A systematic literature review identified articles published before September 2019. The MAUDE database was searched by name from 2009 to 2019 for safety claims for 24 vaginal laser devices. The Bloomberg Law database was searched for product liability claims against any vaginal laser device manufacturer before July 2019. FINDINGS Literature review revealed 3 publications detailing 29 presumptive laser-associated complications, only 5 of which (17.2%) reported worsening symptoms after treatment. The MAUDE database contained 120 complaints; only 30 (25%) detailed potential adverse patient events, most frequently pain (n = 12) and burning (n = 10). The Bloomberg law database contained no claims asserting harm from device use. CONCLUSIONS AND RELEVANCE Lacking strong evidence indicating significant patient risk for vaginal laser treatment of GSM, the FDA safety communication appears unsubstantiated and implies gender bias. Identified complications suggest most reported "adverse events" represent lack of treatment effect. The well-documented benefits and low risk of adverse event suggest laser therapy for GSM is reasonable with appropriate pretreatment counseling. Additional randomized, well-controlled clinical trials are needed to further elucidate both the safety and efficacy of this nonhormone therapy.
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Affiliation(s)
- Julia Z Guo
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - Colby Souders
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Lynn McClelland
- University of California Los Angeles School of Law, Los Angeles, CA
| | - Jennifer T Anger
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Victoria C S Scott
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karyn S Eilber
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - A Lenore Ackerman
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Pagano T, Travaglino A, Raffone A, Vallone R, Buonfantino C, De Rosa P, Locci M, Guadagno E, Insabato L, Salvatore S, De Placido G. Fractional Microablative CO 2 Laser-Related Histological Changes on Vulvar Tissue in Patients With Genitourinary Syndrome of Menopause. Lasers Surg Med 2020; 53:521-527. [PMID: 32797701 DOI: 10.1002/lsm.23311] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Fractional CO2 laser has been proposed as an effective treatment for the genitourinary syndrome of menopause (GSM). However, the effects of laser treatment on vulvar tissue have never been assessed. We aimed to assess histological changes related to fractional CO2 laser in vulvar tissue from GSM patients. STUDY DESIGN/MATERIALS AND METHODS A single-center observational prospective cohort study was performed enrolling all GSM patients from July 2017 to October 2018. Patients underwent three outpatient vulvovaginal applications of fractional CO2 laser and vulvar biopsy before and after treatment. Rates of histological changes in vulvar tissue, the difference in means of Vulva Health Index (VuHI), Vaginal Health Index (VHI), Visual Analogue Scale scores for GSM symptoms, and procedure-related pain, and rate of patient's overall satisfaction with treatment were assessed. Univariate comparisons between continuous variables were performed by using the paired t-test (α error = 0.05). RESULTS Of 20 enrolled patients, 18 underwent all laser applications, and 15 underwent both vulvar biopsies. 93.3% of patients showed remodeling of vulvar connective tissue; 80% showed improvement in vulvar epithelium trophism and 86.7% showed neovascularization. Differences in means between before and after treatment were significant for VuHI, VHI, and all GSM symptoms. Means ± standard deviation of the degree of pain at each laser application were 4.4 ± 0.9, 3.7 ± 1.6, and 2.9 ± 1.9. The rate of overall satisfaction with the treatment was 72.2%. CONCLUSIONS Fractional CO2 laser leads to a restoration of the normal architecture of vulvar tissue, with significant improvement in GSM-related signs and symptoms, and overall satisfaction with the treatment in most GSM patients. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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Affiliation(s)
- Tiziana Pagano
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Roberta Vallone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Cira Buonfantino
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Pasquale De Rosa
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Mariavittoria Locci
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Elia Guadagno
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Luigi Insabato
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
| | - Stefano Salvatore
- Division of Obstetrics and Gynaecology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, 20132, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe De Placido
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, 80131, Italy
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