Fractional CO2 laser treatment for vulvovaginal atrophy symptoms and vaginal rejuvenation in perimenopausal women

Vaginal CO2 laser therapy for genitourinary syndrome in breast cancer survivors-VagLaser study protocol: a randomized blinded, placebo-controlled trial

BACKGROUND

Vaginal CO2 laser therapy is a new treatment option for genitourinary syndrome of menopause. Its potential is particularly interesting in breast cancer survivors, where existing treatment options often are insufficient as hormonal treatment is problematic in these women. The objective of this study is to investigate the effectiveness of vaginal laser treatment for alleviation of genitourinary syndrome of menopause in breast cancer survivors treated with adjuvant endocrine therapy. The secondary objective is to explore the importance of repeated vaginal laser treatment and the long-term effects in this patient population.

METHODS

VagLaser consist of three sub-studies; a dose response study, a randomized, participant blinded, placebo-controlled study and a follow-up study. All studies include breast cancer survivors in adjuvant endocrine therapy, and are conducted at the Department of Obstetrics and Gynecology, Randers Regional Hospital, Denmark. The first participant was recruited on 16th of February 2023. Primary outcome is vaginal dryness. Secondary subjective outcomes are vaginal pain, itching, soreness, urinary symptoms and sexual function. Secondary objective outcomes are change in vaginal histology (punch biopsy), change in vaginal and urine microbiota, and change in vaginal pH.

DISCUSSION

More randomized controlled trials, with longer follow-up to explore the optimal treatment regimen and the number of repeat vaginal laser treatments for alleviation the symptoms of genitourinary syndrome of menopause in breast cancer survivors treated with endocrine adjuvant therapy, are needed. This study will be the first to investigate change in vaginal and urine microbiota during vaginal laser therapy in breast cancer survivors.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06007027 (registered 22 August, 2023).

PROTOCOL VERSION

Version 1, Date 13.11.2023.

The 50 most cited articles and science mapping analysis of vaginal tightening

INTRODUCTION AND HYPOTHESIS

The study was aimed at exploring the 50 most cited articles related to vaginal tightening.

METHODS

The papers were searched through the Thomson Reuters Web of Science on 30 July 2022, and were ranked by the total number of citations. The included articles were analyzed for author, journal, country, number of citations, keywords, subject matter, and level of evidence. The search output was also imported into VOSviewer.

RESULTS

The 50 most cited articles were cited a combined total of 2,558 times. The papers were published between 1990 and 2020, of which 86% were published between 2010 and 2020. They included 38 original articles, 8 reviews, 3 editorial articles, and 1 letter. Most articles were published in gynecology-related journals (n=30, 60%). The articles covered a wide range of topics, the most common being laser/radiofrequency treatment, vaginal tightening procedures, and urinary incontinence. The majority presented findings supported by level IV or V evidence. Through co-occurrence analysis, high-frequency words and countries were displayed well.

CONCLUSIONS

The study shed light on frequently read articles and influential topics about vaginal tightening. The highly cited literature mainly focused on laser or radiofrequency treatments and gynecologists currently dominate the highly cited literature on vaginal tightening. The articles related to surgical treatments are low in number and evidence level so far. The co-occurrence analysis reveals the hot research content and active countries in the field. In general, the study provides useful evidence for future research and educational materials.

Efficacy of Fractional CO2 Laser Treatment for Genitourinary Syndrome of Menopause in Short-Term Evaluation-Preliminary Study

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.

The efficacy and safety of a single maintenance laser treatment for stress urinary incontinence: a double-blinded randomized controlled trial

INTRODUCTION AND HYPOTHESIS

To evaluate the efficacy and safety of a single carbon dioxide (CO₂) laser maintenance treatment in women previously treated successfully with laser for stress urinary incontinence (SUI), who have demonstrated a decline in treatment effect.

METHODS

Women aged 40-70 years who experienced temporary significant improvement in symptoms following CO₂ laser treatments for SUI were randomized to either the treatment group or the sham treatment control group. Cough test results, 1-h pad weights and scores on the Urogenital Distress Inventory (UDI6), the International Consultation of Incontinence Questionnaire (ICIQ-UI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were obtained at baseline and 3 and 6 months.

RESULTS

Of 183 women screened, 131 were included in the final analysis. Demographic characteristics and baseline measures in the outcome tests were similar between the groups. Statistically significant improvements were demonstrated in the study compared to the control group at 3 months post-treatment in positive cough test (44.4% vs. 79.4%, P = 0.002), mean pad weight test (2.3 g ± 1.3 vs. 5.6 ± 1.1, P < 0.001), mean UDI-6(24.7 ± 12.1 vs. 45.1 ± 13.6 SD, P = 0.004), mean ICIQ-UI (16.5 ± 4.3 vs. 10.3 + 3.8, P = 0.003) and mean PISQ-12 (21.3 ± 6.8 vs. 36.6 ± 7.5, P = 0.003). However, values at 6 months post-treatment were similar to those at baseline.

CONCLUSIONS

Our results suggest that a single maintenance laser treatment for reducing symptoms of SUI is transiently effective, well tolerated and safe. This treatment modality provides alternative non-surgical therapy for women with SUI.

Ladylift® non-ablative laser technology for the treatment of menopausal vestibulodynia and genitourinary syndrome

Introduction

Genitourinary syndrome of menopause (GSM) affects up to 48% of pre-menopause women and up to 90% of menopausal women. Many menopausal women with dyspareunia have significant vestibular tenderness due to oestrogen deficiency, which increases the density of sensory nerve fibres in the vulva and the vagina. For this reason, GSM is recognized as one of the causes of provoked vestibulodynia. Few therapies have proven to be effective for provoked vestibulodynia. Many studies have shown the efficacy of laser CO₂ therapy, proving its cost-effectiveness and safety for vaginal health.

Material and methods

In this article we tested a new non-ablative solid-state laser: Ladylift®. The main difference between Ladylift® and other laser technologies is the use of a non-ablative laser wavelength of 1470 nm, without causing ablative thermal injury on the surface of the mucosa. We enrolled 18 post- menopausal women presenting to a private clinic with GSM symptoms and provoked vulvodynia.

Results

The treatment protocol consists of 4 sessions of laser, 2 weeks apart, of the duration of 4 minutes. Benefits to menopause symptoms, reported with a numeric rating scale, and to epithelium trophism reported with the vaginal health index were apparent since the first session. Patients undergoing laser therapy have had evident benefit both from the point of view of pain and from that of vaginal health.

Conclusions

All the women tolerated the therapy well without any adverse effects. However, the beneficial effect tended to gradually decrease over time, suggesting the need to perform more therapy sessions.

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

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

New Innovations for the Treatment of Vulvovaginal Atrophy: An Up-to-Date Review

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.

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

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.

Efficacy of interventions to manage sexual dysfunction in women with cancer: a systematic review

IMPORTANCE

Cancer and its treatment negatively affect female sexual health and function. The prevalence of female sexual dysfunction after cancer is between 33% and 43%. Numerous studies have addressed treatment options for sexual dysfunction in women with cancer, but it still remains a challenge to select the most efficacious option for patients.

OBJECTIVE

To compile and appraise recent evidence of any interventions for managing sexual dysfunction in female cancer survivors.

EVIDENCE REVIEW

A literature search of the electronic databases MEDLINE, EMBASE, PsycINFO, and Cochrane Central Register of Controlled Trials (January 2011 to February 2021) was conducted using general search terms of "women", "cancer", "intervention", "sexual dysfunction". We included randomized controlled trials (RCTs) and uncontrolled before-after studies that evaluated the efficacy of intervention for female sexual dysfunction in women with history of cancer. Methodological quality of studies was assessed using Risk of Bias (RoB) 2.0 for RCTs and National Institutes of Health (NIH) assessment tools for uncontrolled before-after studies.

FINDINGS

Thirty-six studies were included for qualitative synthesis (14 RCTs (n = 1284), 17 uncontrolled trials (n = 589), and 5 cohort studies (n = 497). Only four studies were at low risk of bias. Topical interventions (vaginal gels or creams) were able to alleviate vaginal dryness and dyspareunia, with intravaginal dehydroepiandrosterone (DHEA) (6.5 mg) gel showing evidence of improved sexual function. Evidence for estriol-lactobacilli vaginal tablets was unreliable due to a small-scale study. Psychoeducational therapy (internet-based cognitive behavioral therapy [CBT]) studies typically were at high risk of bias, but all displayed significant improvements of sexual function. Both laser therapy (fractional CO2 and erbium) and multimodal approach studies were at concerning risk of bias, although suggesting beneficial effects on sexual function.

CONCLUSIONS AND RELEVANCE

The most reliable evidence for improvement was from a study of DHEA vaginal gel, but in general, gels or creams were useful in reducing dyspareunia. Pharmacological, psychoeducational, laser therapy, and multimodal approaches demonstrated potential in managing cancer-related sexual issues, but most were small in size (10-70 participants), with moderate to high risk of bias. Therefore, large-scale, double-blind, RCTs with long-period follow-up, and at low risk of bias are needed to show efficacy for these interventions.

Efficacy of CO2 laser treatment in postmenopausal women with vulvovaginal atrophy: A meta-analysis

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.

Fractional CO2 laser treatment as adjunctive therapy to topical steroids for managing vulvar lichen sclerosus

Objectives

Uncontrolled vulvar lichen sclerosus (VLS) is often associated with distressful symptoms of genital itch, irritation, and pain and can lead to a pathological process including anatomical changes, scarring, and an elevated risk of cancer in the genital area. First‐line topical corticosteroid as monotherapy is frequently not adequate to fully suppress disease activity and control symptoms. This study evaluated the efficacy of fractional CO₂ laser treatments as adjunctive therapy where recalcitrant VLS had been improved, but not adequately controlled, with topical corticosteroid treatment. Outcomes were evaluated up to 12 months after a series of CO₂ laser treatments delivered via a fractional handpiece.

Materials and Methods

Women with a diagnosis of VLS supported by histologic findings on biopsy and/or clinical signs on physical examination received up to five monthly laser treatments. Subjects maintained existing topical corticosteroid and any exogenous hormone treatment during the study. Investigators assessed severity (0 = not present, 1 = mild, 2 = moderate, or 3 = severe) of clinical signs and architectural changes present before adjunctive study interventions and at follow‐up visits. Subjects reported the presence of clinical symptoms and impact on quality of life on 4‐ or 5‐point Likert scales. The validated Female Sexual Function Index (FSFI) was used to assess changes in sexual function. Four subjects were biopsied before adjunctive laser treatment and at follow‐up.

Results

Twelve females, 11 postmenopausal, with a mean age of 57 ± 10 years received three to five monthly CO₂ laser treatments. Significant improvement in all prominent clinical signs and architectural changes were reported at the 3‐ and 6‐month follow‐ups after the treatment series. Significant improvement was maintained at the 12‐month follow‐up, with 89% of subjects showing at least one‐point improvement in elasticity compared to baseline; 86% in lichenification; 88% in sclerosis; and 80% in whitening and parchment‐like skin. Labial fusion and the extent of disease improved in 50% of patients. Ulcerations present in three subjects at baseline resolved after treatment. Subjects reported 86% improvement in dyspareunia and 83% in skin tearing. Quality of life improved significantly after treatment (p < 0.01). The 6‐month follow‐up FSFI showed significant improvement in sexual function compared to baseline (p < 0.05), with a mean point improvement of 4.5. Histology findings after treatment showed some positive improvement, as a decrease in dermal hyalinized zone thickness. There were no treatment complications or adverse events related to the treatment.

Conclusions

Fractional CO₂ laser treatment outcomes showed improvement in predominant clinical signs and architectural changes in VLS recalcitrant to topical corticosteroid treatment. Adjunctive laser treatment relieved symptoms and improved quality of life as well as sexual function. Fractional CO₂ laser treatment may provide an advanced treatment modality for the management of recalcitrant VLS with improved patient care and sustainable outcomes. Further study in a larger population and with CO₂ laser treatment to both vulvar tissue and the vaginal canal should be explored.

Carbon Dioxide Laser Vulvovaginal Rejuvenation: A Systematic Review

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.

Vaginal laser therapy for genitourinary syndrome of menopause - systematic review

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.

Non-invasive treatment of vulvovaginal atrophy in menopause with CO2 laser

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.

Physical methods for the treatment of genitourinary syndrome of menopause: A systematic review

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.

Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements

Postmenopausal atrophic vaginitis, along with vasomotor symptoms and sleep disorders, is one of the most troublesome symptoms of menopause. However, many women do not manage this symptom properly due to insufficient knowledge of the symptoms or sexual embarrassment. With appropriate treatment, many postmenopausal women can experience relief from discomforts, including burning sensation or dryness of the vagina and dyspareunia. Topical lubricants and moisturizers, systemic and local estrogens, testosterones, intravaginal dehydroepiandrosterones (DHEAs), selective estrogen receptor modulators, and energy-based therapies are possible treatment modalities. Systemic and local estrogen therapies effectively treat genitourinary syndrome of menopause (GSM), but they are contraindicated in patients with breast cancer, for whom lubricants and moisturizers must be considered as the primary treatment. Intravaginal DHEA and ospemifene can be recommended for moderate to severe GSM; however, there is insufficient data on the use of intravaginal DHEA or ospemifene in patients with breast cancer, and further studies are needed. Energy-based devices such as vaginal laser therapy reportedly alleviate GSM symptoms; however, the U.S. Food and Drug Administration warning has recently been issued because of complications such as chronic pain and burning sensations of the vagina. To summarize, clinicians should provide appropriate individualized treatment options depending on women's past history, symptom severity, and chief complaints.

A Systematic Review of Nonsurgical Vulvovaginal Restoration Devices: An Evidence-Based Examination of Safety and Efficacy

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.

Fractional CO2 Laser for Treatment of Vulvovaginal Atrophy: A Short Time Follow-up

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.

The Effect of the CO2 Fractional Laser or Premarin Vaginal Cream on Improving Sexual Function in Menopausal Women: A Randomized Controlled Trial

Introduction: Sexual dysfunction is a complex problem in postmenopausal women with a prevalence rate of 68%-86%. This study aimed to evaluate the effect of a fractional CO₂ laser or vaginal cream on the improvement of sexual function in menopausal women. Methods: This is a two-group clinical trial study. Postmenopausal women with the inclusion criterion were enrolled and randomly divided into 2 groups of intervention (n=25) and control group (n=25). In the intervention group, CO₂ laser therapy was performed every month for three months, and in the control group, Premarin vaginal cream was applied (0.625 mg, 3 nights a week for 3 months. Vaginal health index (VHI) scoring and Female Sexual Function Index (FSFI) questionnaires were completed before and three months after the treatment. Results: The effects of the laser treatment were greater than the Premarin group with respect to improvement in sexual desire, orgasms, sexual satisfaction, less pain during sexual relations, and overall sexual function (P <0.05). Conclusion: It seems that the fractional CO₂ laser may be more effective than hormonal therapy in improving sexual function in postmenopausal women.

The Efficacy and Safety of CO2 Laser Treatment for Sexual Function and Vaginal Laxity Improvement in Pre-Menopausal Women

BACKGROUND AND OBJECTIVES

Vaginal laxity lacks standardized diagnosis and severity criteria. It is considered as a subjective complaint that reflects decreased sexual satisfaction due to vaginal loosening. Treatment modalities have included physiotherapy and plastic surgery. Recently, laser treatments have also gained popularity as a means of relieving gynecological complaints such as pelvic organ prolapse, stress urinary incontinence, and genitourinary syndrome of menopause. The aim of the current study was to evaluate the efficacy of CO₂ laser treatment in women for whom a decrease in sexual sensation during intercourse and vaginal loosening were their primary complaints.

STUDY DESIGN/MATERIALS AND METHODS

For this prospective study, women with reported vaginal laxity and decreased sensation during intercourse were recruited from the Sexual Dysfunction Clinic in our health care campus. Each participant received three outpatient treatments with laser therapy, according to the same protocol. Treatment efficacy was assessed by changes in the Vaginal Health Index (VHI) and Female Sexual Function Index (FSFI).

RESULTS

Overall, 84 pre-menopause women, with a mean age of 47.7 years, were included in the study. Mean VHI and FSFI were increased significantly at 3 months post-treatment and decreased again at 6 months post-treatment: 11.8 ± 1.6, 13.5 ± 1.1, and 11.8 ± 1.2, respectively, P = 0.013; and 21.3 ± 1.7, 29.9 ± 1.6, and 22.5 ± 1.8, respectively, P = 0.022. The rate of sexual intercourse doubled during the period of maximal treatment effect (P < 0.0001).

CONCLUSIONS

CO₂ laser treatment has both a statistically and clinically significant effect on participants' complaints and sex-life, which wanes by 6 months post-treatment. Laser therapy seems to be safe in the short term, with no serious adverse events reported in the current study. Further studies are warranted to determine the long-term safety and the efficacy of maintenance laser treatments. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Safety evaluation of fractional CO2 laser treatment in post-menopausal women with vaginal atrophy: A prospective observational study

OBJECTIVES

To evaluate the safety of and patient satisfaction with fractional CO₂ laser for the treatment of vulvo-vaginal atrophy (VVA) in postmenopausal patients.

STUDY DESIGN

Patients affected by VVA were considered for the study. All women were treated using a Lumenis AcuPulse DUO (Lumenis, Yokneam, Israel) in fractionated mode with a 28 mm probe, FemTouch™. Pain during different steps of the procedure (introduction, rotation and extraction of probe and laser impulse transmission) was evaluated on a 7-point Likert scale. The occurrence of side-effects was evaluated at the end of the procedure, and in the three-month follow-up (after the last treatment) complications were classified as 'early' (occurring within 30 days) or late (after 30 days). Participant satisfaction was measured on a 7-point Likert scale (1= strongly disagree, 7= strongly agree). The institutional review board approved the study protocol.

RESULTS

Fifty-three women were enrolled in the study. No severe complications occurred after a median follow-up of six months. One patient (1.9 %) reported dizziness immediately after treatment, which completely resolved within 15 min. A minor bleeding occurred related to tip introduction and rotation. One patient (1.9 %) aborted the procedure because of discomfort on probe introduction but decided to repeat the procedure after two weeks. Two patients (3.7 %) reported symptoms of dysuria within 7 days of the procedure. The mean overall pain score at first treatment, evaluated on the 7-point Likert scale, was 3.57 ± 1.50. The mean pain scores related to probe introduction and rotation were 3.13 ± 1.37 and 2.32 ± 1.08, whereas pain scores for extraction and laser impulse transmission were 1.23 ± 0.27 and 1.13 ± 0.37 respectively. Mean overall pain score (1.27; CI 95 % 0.83-1.71, p < 0.001) and pain scores related to probe introduction (0.54; CI 95 % 0.18-0.90, p = 0.001) and probe rotation (0.46; CI 95 % 0.12-0.90, p = 0.003) all statistically significantly decreased between the first and third treatment (Fig. 1). Mean pain scores related to laser activation (0.01; CI 95 % -0.06 - 0.20, p = 0.07) and extraction (0.08; CI 95 % -0.04-0.19, p = 0.31) did not change over the course of treatment. Overall, patient satisfaction with the procedure was high: 89.7 % of patients would highly (value 5-7) recommend the procedure and 94.9 % would be ready to repeat the procedure to maintain results. Discomfort related to treatment was lower than expected for 41 % of patients (value 5-7) and as expected for 48.7 % (value 3-4).

CONCLUSION

Fractional CO₂ laser for treatment of VVA seems a safe therapeutic option. No severe complications occurred. A minority of patients reported mild complications, but these resolved without the need for treatment. Most discomfort was related to probe introduction and rotation. Overall, patients were highly satisfied, and they would repeat laser treatment.

Measuring Quality of Life in Female Genital Cosmetic Procedure Patients: A Systematic Review of Patient-Reported Outcome Measures

BACKGROUND

In the subspecialty of female genital cosmetic procedures, patient satisfaction and quality of life are key outcome measures. As such, valid and reliable patient-reported outcome measures (PROMs) examining these outcomes are essential.

OBJECTIVES

The authors sought to identify and scrutinize all PROMs developed for female patients undergoing genital cosmetic procedures.

METHODS

The authors performed a systematic literature review utilizing MEDLINE, PreMEDLINE, Ebase, Embase, OVID, CINAHL, Cochrane Library, PsycINFO, PubMed, and Google Scholar to identify PROMs developed and validated for utilization in female genital cosmetic procedure patients. Instruments identified were assessed according to international guidelines for health outcome measures development and validation.

RESULTS

The authors identified 50 outcome questionnaires employed in the female genital cosmetic procedure literature. Of these, 26 were ad hoc instruments (ie, had not been formally developed and tested) and 22 were generic instruments (ie, intended for use in broad groups of people, not only specific patient groups). Only 2 instruments have been validated in a female genital cosmetic procedure patient population. These were the Genital Appearance Satisfaction scale and the Cosmetic Procedure Screening Scale-Labiaplasty. Although both these scales had undergone fairly rigorous psychometric development and validation, both had content limitations.

CONCLUSIONS

There is a lack of specific, valid, and reliable satisfaction and quality-of-life PROMs in the field of female genital cosmetic procedures. Future research should involve the development of such measures to more accurately assess the outcomes and benefits of these procedures.

Effect of the Fractional CO2 Laser on the Quality of Life, General Health, and Genitourinary Symptoms in Postmenopausal Women With Vaginal Atrophy: A Prospective Cohort

Introduction: After menopause women experience vaginal atrophy related to hormonal changes and estrogen deficiency. The purpose of this paper was to evaluate the effect of the fractional CO₂ laser on the quality of life, vaginal atrophy symptoms, and urine incontinency in menopause women. Methods: This prospective study was conducted among 140 women from 2017 to 2018 in Yas hospital, Tehran University of Medical Sciences. They encountered the fractional microablative CO2 laser system three times at four-week intervals. The short form of the Health Questionnaire (SF-12) and the Female Sexual Functional Index (FSFI) questionnaire were utilized to assess the participants' quality of life. Also, the standard measuring tools including the vaginal health index (VHI) and International Consultation on Incontinence Questionnaire (ICIQ) Form were used to evaluate the vaginal atrophy symptoms. Results: The quality of life improved significantly in somatic, social function, and mental health. In the sexual context, arousal and satisfaction status improved significantly. Also, the frequency of urinary incontinence, enuresis, urgency, and the leak improved significantly (P<0.05). Among the scale variables for urinary function, it was seen that the urgency impact had no improvement. All vaginal indices improved (P<0.05). Conclusion: The fractional CO₂ laser can be effective in treating vaginal atrophy and urinary symptoms. Besides, it improved the quality of life and the sexual function of post-menopausal women.

Therapies for the management of genitourinary syndrome of menopause

Introduction

The genitourinary syndrome of menopause is a new term that describes various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation) and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function), but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections).

Methods

We conducted a systematic scoping review of data in women therapies with genitourinary syndrome of menopause or vulvovaginal atrophy in peer-reviewed, English-language publications in the last 20 years.

Results

The terms vulvovaginal atrophy and atrophic vaginitis, which were generally used up until recently, had a limitation because they did not cover the full spectrum of symptoms and did not imply that the symptoms are related to a decreased sex steroid level in menopause. The concept of genitourinary syndrome of menopause was recently introduced and has been gaining widespread use. Since genitourinary syndrome of menopause may have a profound negative impact on the quality of life of postmenopausal women, patients should be made aware of these problems and treated with an appropriate effective therapy. Therefore, in this review we introduce therapies for this syndrome, both local and systemic, and discuss the importance of genitourinary syndrome of menopause comprehension and the need to have an active treatment of this syndrome in postmenopausal women.

Conclusion

The increasing number of therapies for menopausal symptoms opens up new options. In addition, new products have been designed and developed by pharmaceutical companies as new possibilities for patients who did not have any treatment available and also to improve compliance.

Blue light-emitting diode in healthy vaginal mucosa-a new therapeutic possibility

A healthy female genital mucosa has an ecosystem that remains in balance through interactions between endogenous and exogenous factors. The light-emitting diode (LED) is a device that emits light at different wavelengths, with varying color and effects. Blue light in humans is most commonly used for antimicrobial purposes and has been already applied to treat facial acne and gastric bacteria. Although blue LED therapy in humans has been reported, its properties against vaginal infections have not yet been investigated. This study aims to test the safety and effects of 401 ± 5 nm blue LED on healthy vaginal mucosa. Phase I clinical trial involving 10 women between 18 and 45 years old with healthy vaginal mucosa. The participants were illuminated by 401 ± 5 nm blue LED for 30 min and anamnesis, oncotic cytology, and pH measurement were made again after 21/28 days of treatment. In the re-evaluation, adverse effects were investigated. The mean age was 27 ± 5.4 years and one of the women was excluded due to interruption of use of oral contraceptives. Oncotic cytology done before and after therapy showed that the composition of the microflora remained normal in all participants. Vaginal pH remained unchanged in eight of the women and had a reduction in one woman (5.0-4.0). No adverse effects were observed during or after illumination. 401 ± 5 nm blue LED did not generate any adverse effects or pathogenic changes in the microflora and vaginal pH. The effects of 401 ± 5 nm blue LED still need to be tested in vulvovaginal pathogens. Trial registration number: NCT03075046.

The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example, they lack a control group, patients are not randomized, follow-up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored. Because of these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration after LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, although short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document

BACKGROUND

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology is controversial.

AIMS

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review.

MATERIALS & METHODS

This project was developed between January and September 2018. The development of this document followed the ICS White Paper Standard Operating Procedures.

RESULTS

Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and studies are industry sponsored. Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women.

DISCUSSION

The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking.

CONCLUSION

At this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

Treatment to External Labia and Vaginal Canal With CO2 Laser for Symptoms of Vulvovaginal Atrophy in Postmenopausal Women

Background

Increasingly, women have sought alternatives to traditional options (lubricants, estrogen products, and hormone replacement therapy) for unwelcome vaginal changes of menopause.

Objectives

This study evaluated whether a series of three monthly fractional CO₂ laser treatments significantly improves and maintains vaginal health indices of elasticity, fluid volume, pH level, epithelial integrity, and moisture. Self-reported symptoms of vaginal atrophy were also measured. Biopsy samples after a series of three treatments were evaluated for histological changes to vaginal canal tissue.

Methods

Forty postmenopausal women were treated extravaginally and internally with a fractional CO₂ laser. Objective measurements of vaginal health index, as well as subjective measurements of symptoms of vulvovaginal atrophy (VVA), urinary incontinence, and sexual function were reported at baseline. Follow-up evaluations were at one, three, six, and 12 months after the third treatment.

Results

Vaginal health index improved significantly after the first treatment and was maintained with mean improvement of 9.6 ± 3.3 (P < 0.001) and 9.5 ± 3.3 (P < 0.001) at the 6- and 12-month follow ups, respectively. Vaginal symptoms of dryness, itching, and dyspareunia improved significantly (P < 0.05) at all evaluations. Histological findings showed increased collagen and elastin staining, as well as a thicker epithelium with an increased number of cell layers and a better degree of surface maturation.

Conclusions

Fractional CO₂ laser treatments were well tolerated and were associated with improvement in vaginal health and amelioration of symptoms of VVA. Histological changes in the epithelium and lamina propria, caused by fractional CO₂ laser treatments, correlated with clinical restoration of vaginal hydration and pH to premenopausal levels.

Level of Evidence: 4

Genitourinary syndrome of menopause - is the problem solved? State of the art 2018

Vulvovaginal atrophy accompanied by lower urinary tract dysfunction related to low levels of estrogen and androgens is labeled as genitourinary syndrome of menopause (GSM). Although this condition affects most postmenopausal women worldwide, it seems to be underdiagnosed and undertreated. Women should be properly advised to choose an adequate treatment modality to improve their quality of life, sexual relationships and social activity. The aim of this article to is increase knowledge of GSM. The current treatment options, both hormonal and non-hormonal, are reviewed. Topical estrogen therapy still remains the gold standard, but the demand for individually tailored therapy is growing. New treatment modalities are continuously included in clinical practice. They should consider the whole personality of a woman as well as cultural and social factors. Further studies on GSM and on the effectiveness of various treatment options are necessary to achieve this purpose.

Diagnosis and Treatment of Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM), formerly referred to as vulvovaginal atrophy or atrophic vaginitis, is a common chronic condition that requires a collaborative treatment plan between a health care provider and a woman to relieve symptoms and improve quality of life. Many women are not aware that symptoms can be controlled with treatment. Current treatment options approved for GSM include vaginal moisturizers, lubricants, and hormones. For women with GSM symptoms that are unresponsive to nonhormonal therapy, low-dose vaginal estrogen therapy is the preferred pharmacologic treatment. Clinicians should be trained to routinely ask appropriate questions during the history to elicit sufficient information to assess for GSM. Physical examination findings may further confirm suspicion of GSM.

Menopause Symptom Management in the United Kingdom

Menopause is a complex time in a woman's life. It is an increasingly a midlife event, when health care professionals should be aiming to optimize a woman's health for the next 30 years or so. Nurses need to be able to give up-to-date information and evidence for all forms of treatment based on a background of complex and ever-changing research. This article covers the main presenting complaints and treatments, from lifestyle to hormone replacement therapy, by drawing on guidelines from national bodies.