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Lami A, Alvisi S, Baldassarre M, Zanella S, Amati V, Seracchioli R, Meriggiola MC. Safety and efficacy of non-ablative CO 2 laser treatment of vulvo-vaginal atrophy in women with history of breast cancer. Arch Gynecol Obstet 2024; 309:1575-1583. [PMID: 38253692 DOI: 10.1007/s00404-023-07323-y] [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: 09/17/2023] [Accepted: 11/27/2023] [Indexed: 01/24/2024]
Abstract
PURPOSE Breast cancer survivors (BCS) suffer severe vulvo-vaginal atrophy (VVA) and some of the most effective therapies are contraindicated. In literature we have no data about the non-ablative CO2 laser on these women. The aim of this study was to examine its efficacy, safety and acceptability in BCS. MATERIALS AND METHODS The enrolled women underwent 3 sessions of laser therapy (t0, t1, t2) and a one-month follow up examination (t3). At each time point we measured objective signs of VVA via VHI (Vaginal Health Index) and VuHI (Vulvar Health Index) and subjective parameters (Dryness, Burning, Itching, Dysuria) via visual analog scales (VAS). In sexually active women we evaluated the sexual function with FSFI (Female Sexual Function Index), FSDS (Female Sexual Distress Score) scores and MENQOL (menopause quality of life questionnaire). RESULTS We enrolled 26 BCS. The mean VHI, VuVHI, dryness and burning VAS scores improved significantly and this improvement was not influenced by the initial VVA grade. MENQOL sexual domain, Lubrication, Orgasm and Pain domains and FSFI total score improved significantly, while Desire, Arousal and Satisfaction domains of FSFI and FSDS did not. At t0 women using Aromatase Inhibitors suffered more severe vaginal dryness than women using Tamoxifen or no therapy, but the three subgroups improved without differences. No adverse event and minimum discomfort were reported. CONCLUSIONS The non-ablative CO2 laser is a safe and effective treatment of VVA and has positive effects on sexual function in BCS regardless the use of adjuvant therapies and the initial grade of VVA.
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Affiliation(s)
- Alessandra Lami
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Via Massarenti 13, 40138, Bologna, Italy.
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - Stefania Alvisi
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Via Massarenti 13, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Center for Applied Biomedical Research (CRBA), University of Bologna, Bologna, Italy
| | - Sara Zanella
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Veronica Amati
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Via Massarenti 13, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Via Massarenti 13, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maria Cristina Meriggiola
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Via Massarenti 13, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Center for Applied Biomedical Research (CRBA), University of Bologna, Bologna, Italy
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von Hippel C, Dibble KE, Rosenberg SM, Bollman-Jenkins M, Weiss M, Partridge AH. Taking their wellbeing into their own hands: Self-educated and peer-recommended techniques used by women with breast cancer to improve sexual functioning during treatment and in survivorship. PLoS One 2023; 18:e0293298. [PMID: 37967086 PMCID: PMC10650983 DOI: 10.1371/journal.pone.0293298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/09/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVE Coping with sexual dysfunction during and after breast cancer treatment is a persistent challenge for many women, even with clinician-offered standard sexual rehabilitative therapies (i.e., lubricants, counseling). This study sought to explore how women with breast cancer supplement clinician recommendations with self-discovered and peer-recommended techniques for improving sexual functioning and provide insight into how well they work. METHODS Adult women with stage I-IV breast cancer were recruited to participate in a one-time online survey via Breastcancer.org. Thematic analysis identified emergent domains and themes focused on techniques for improving sexual function during and after treatment. Frequencies were calculated to quantify technique sources and perceived efficacy levels. RESULTS Of 501 women responding to the survey, mean age was 53 years (range 30-79). Overall, 34.7% reported using a technique they discovered themselves or that was recommended by someone other than a clinician to improve sexual functioning. Four main themes regarding techniques included: 1) pain reduction, 2) intimacy and relationship enhancement, 3) desire and arousal enhancement, and 4) emotional coping. Most women discovered coping techniques without the help of clinicians, and 45.7% of women rated their techniques as moderately or more effective when used in addition to or instead of standard techniques offered by clinicians. CONCLUSIONS Our study provides insight into how women with breast cancer successfully cope with sexual dysfunction symptoms during and after treatment. To fully understand and share patients' innovative techniques for coping with these symptoms, clinicians should foster open discussion about the potential for dysfuction and treatment for these symptoms, as well as avenues of peer-supported discussion to promote coping self-education and discovery.
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Affiliation(s)
- Christiana von Hippel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Kate E. Dibble
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Shoshana M. Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Medicine, Harvard Medical School, Boston, MA, United States of America
| | | | - Marisa Weiss
- Breastcancer.org, Ardmore, PA, United States of America
| | - Ann H. Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Medicine, Harvard Medical School, Boston, MA, United States of America
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Lubián-López DM, Butrón-Hinojo CA, Menjón-Beltrán S, González-Mesa E, Tapiador-Albertos S, Rodríguez-Jiménez B, Fiol-Ruiz G. Effects of Non-Ablative Solid-State Vaginal Laser (SSVL) for the Treatment of Vulvovaginal Atrophy in Breast Cancer Survivors after Adjuvant Aromatase Inhibitor Therapy: Preliminary Results. J Clin Med 2023; 12:5669. [PMID: 37685736 PMCID: PMC10488849 DOI: 10.3390/jcm12175669] [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: 05/14/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND One of the side effects of anti-estrogen treatments in breast cancer survivors (BCSs), especially with aromatase inhibitor (AI) treatment, is the frequent appearance of vulvo-vaginal atrophy (VVA). We aim to evaluate the efficacy, safety and feasibility of a new type of non-ablative Solid-State Vaginal Laser (SSVL) treatment in BCSs with VVA. METHODS A total of 30 BCSs with a history of AI use and symptoms of VVA were treated with a non-ablative SSVL (LASEmaR 1500™-EUFOTON)in this non-randomized pilot study. The effects of the laser have been evaluated at baseline, 10 wk and 24 wk using a visual analogue scale (VAS), the Vaginal Health Index (VHI), the Vulvar Health Index (VuHI), the Female Sexual Function Index (FSFI), the EORTC QLQ-BR23, the Vaginal Maturation Index (VMI) and vaginal pH. RESULTS At 10-week follow-up vs. baseline there were no statistically significant differences in FSFI, lubrication and EORTC QLQ-BR23. In all the subjective (dyspareunia, VHI, VuHI, FSFI, QLQ) and objective parameters (VMI and pH) there was a statistically significant improvement at the 6-month follow-up. Satisfaction was very high (4.7 out of 5), with 95.7% of patients being satisfied, more than or very satisfied. CONCLUSIONS Preliminary results of SSVL treatment of VVA and dyspareunia in BCSs after AI treatment suggest clinical improvement, without relevant side effects and with a high degree of satisfaction.
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Affiliation(s)
- Daniel M. Lubián-López
- Department of Obstetrics and Gynecology, University Hospital of Jerez de la Frontera, 11407 Cádiz, Spain;
- Department of Obstetrics and Gynecology, Viamed Bahía de Cádiz Hospital, 11130 Cádiz, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Cádiz, 11003 Cádiz, Spain
| | - Carmen A. Butrón-Hinojo
- Department of Obstetrics and Gynecology, University Hospital of Jerez de la Frontera, 11407 Cádiz, Spain;
- Department of Obstetrics and Gynecology, Viamed Bahía de Cádiz Hospital, 11130 Cádiz, Spain
| | - Salomón Menjón-Beltrán
- Department of Obstetrics and Gynecology, Regional University Hospital of Granada and Inagor Women’s Clinic, 18001 Granada, Spain;
| | - Ernesto González-Mesa
- Department of Obstetrics and Gynecology, Regional University Hospital of Málaga, 29001 Málaga, Spain;
| | - Silvia Tapiador-Albertos
- Department of Obstetrics and Gynecology, Alboran CMM Women’s Clinic, 04001 Almería, Spain; (S.T.-A.); (B.R.-J.); (G.F.-R.)
| | - Bibiana Rodríguez-Jiménez
- Department of Obstetrics and Gynecology, Alboran CMM Women’s Clinic, 04001 Almería, Spain; (S.T.-A.); (B.R.-J.); (G.F.-R.)
| | - Gabriel Fiol-Ruiz
- Department of Obstetrics and Gynecology, Alboran CMM Women’s Clinic, 04001 Almería, Spain; (S.T.-A.); (B.R.-J.); (G.F.-R.)
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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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Machado AC, Judice LMDPP, Riccetto CLZ, Toledo LGM. Applicability of vaginal energy-based devices in urogynecology: evidence and controversy. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023S129. [PMID: 37556648 PMCID: PMC10411715 DOI: 10.1590/1806-9282.2023s129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/21/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE This study aimed to analyze the evidence and controversies about the use of vaginal energy-based devices (laser and radiofrequency) for treatment of genitourinary syndrome of menopause, recurrent urinary tract infection, urinary incontinence, and genital prolapse through a literature review. METHODS A search of literature databases (PubMed, Medline) was performed for publications in December 2022. Keywords included genitourinary syndrome of menopause, vaginal laxity, vaginal/vulvovaginal atrophy, urinary tract infection, urgency incontinence, frequency, urgency, stress urinary incontinence, genital prolapses AND energy-based devices, AND vaginal laser, AND vaginal radiofrequency, AND CO2 laser, AND Er:YAG laser. Publications in English from the last 7 years were reviewed and selected by the authors. RESULTS The literature regarding vaginal energy-based devices in the treatment of urogynecological conditions is primarily limited to prospective case series with small numbers and short-term follow-up. Most of these studies showed favorable results, improvement of symptoms with low risk, or no mention of serious adverse events. Consensus statement documents from major medical societies suggest caution in recommending these therapies in clinical practice until more relevant data from well-designed studies become available. CONCLUSION The potential of the vaginal laser and radiofrequency as a therapeutic arsenal for the evaluated urogynecological conditions is great, but qualified research must be done to prove their efficacy and long-term safety, define application protocols, and recommend the use of these technologies in clinical practice.
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Affiliation(s)
- Alessa Cunha Machado
- Hospital da Mulher Nise da Silveira – Maceió (AL), Brazil
- Sociedade Brasileira de Urologia, Departamento de Disfunção Miccional, Disciplina de Urologia Feminina – Rio de Janeiro (RJ), Brazil
| | - Lívia Maria da Paz Portela Judice
- Sociedade Brasileira de Urologia, Departamento de Disfunção Miccional, Disciplina de Urologia Feminina – Rio de Janeiro (RJ), Brazil
- Hospital Universitário de Brasília – Brasília (DF), Brazil
| | - Cássio Luis Zanettini Riccetto
- Sociedade Brasileira de Urologia, Departamento de Disfunção Miccional, Disciplina de Urologia Feminina – Rio de Janeiro (RJ), Brazil
- Universidade Estadual de Campinas, Faculty of Medical Sciences, Department of Urology – Campinas (SP), Brazil
| | - Luis Gustavo Morato Toledo
- Sociedade Brasileira de Urologia, Departamento de Disfunção Miccional, Disciplina de Urologia Feminina – Rio de Janeiro (RJ), Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Department of Urology – São Paulo (SP), Brazil
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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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Jugulytė N, Žukienė G, Bartkevičienė D. Emerging Use of Vaginal Laser to Treat Genitourinary Syndrome of Menopause for Breast Cancer Survivors: A Review. Medicina (B Aires) 2023; 59:medicina59010132. [PMID: 36676756 PMCID: PMC9860929 DOI: 10.3390/medicina59010132] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/03/2023] [Accepted: 01/07/2023] [Indexed: 01/12/2023] Open
Abstract
Breast cancer treatment, such as chemotherapy and endocrine therapy, can cause earlier and more sudden menopausal symptoms. Genitourinary syndrome of menopause (GSM) is one of the most bothersome side effects of breast cancer treatment, resulting in sexual dysfunction and impaired quality of life. GSM includes genital, urinary, and sexual symptoms. However, alleviating symptoms of GSM for breast cancer survivors may be challenging due to ineffectiveness, contraindications, and low adherence to treatment. The most recent data show the feasibility and safety of vaginal laser to treat GSM for breast cancer survivors. This narrative review provides the aspects of GSM in breast cancer patients, putting the focus on the efficacy and safety of vaginal laser therapy.
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Affiliation(s)
- Nida Jugulytė
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
- Correspondence:
| | - Guoda Žukienė
- Clinic of Obstetrics and Gynaecology, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
| | - Daiva Bartkevičienė
- Clinic of Obstetrics and Gynaecology, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
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Smith T, Kingsberg SA, Faubion S. Sexual dysfunction in female cancer survivors: Addressing the problems and the remedies. Maturitas 2022; 165:52-57. [DOI: 10.1016/j.maturitas.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/11/2022] [Accepted: 07/16/2022] [Indexed: 10/31/2022]
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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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