Elsevier

Maturitas

Volume 80, Issue 3, March 2015, Pages 296-301
Maturitas

Vulvo-vaginal atrophy: A new treatment modality using thermo-ablative fractional CO2 laser

https://doi.org/10.1016/j.maturitas.2014.12.006Get rights and content

Highlights

  • Vulvo-vaginal atrophy is a progressive, chronic condition that manifests as involution of the vulvo-vaginal mucous membranes and tissues due to the menopausal drop in estrogen levels. It can worsen over the years and negatively influence quality of life.

  • The use of CO2 laser has been widely adopted in medicine, especially in dermatology and plastic surgery. It consists of a CO2 ray, which generates heat and vaporizes the water content of target cells.

  • Laser technology can be used to achieve vaginal “regeneration” with a minimally invasive procedure, thereby improving elasticity and hydration of the vaginal walls and relieving discomfort in menopausal women.

  • We report our experience about the application of the fractional CO2 Laser treatment to determine the safety and efficacy of this treatment in improving VVA symptoms in post-menopausal women.

Abstract

Objective

To evaluate the efficacy and feasibility of thermo-ablative fractional CO2 laser for the treatment of symptoms related to vulvo-vaginal atrophy (VVA) in post-menopausal women.

Methods

From April 2013 to December 2013, post-menopausal patients who complained of one or more VVA-related symptoms and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment (T1), vaginal status of the women was evaluated using the Vaginal Health Index (VHI), and subjective intensity of VVA symptoms was evaluated using a visual analog scale (VAS). At T1, treatment satisfaction was evaluated using a 5-point Likert scale.

Results

During the study period, a total of 48 patients were enrolled. Data indicated a significant improvement in VVA symptoms (vaginal dryness, burning, itching and dyspareunia) (P < 0.0001) in patients who had undergone 3 sessions of vaginal fractional CO2 laser treatment. Moreover, VHI scores were significantly higher at T1 (P < 0.0001). Overall, 91.7% of patients were satisfied or very satisfied with the procedure and experienced considerable improvement in quality of life (QoL). No adverse events due to fractional CO2 laser treatment occurred.

Conclusion

Thermo-ablative fractional CO2 laser could be a safe, effective and feasible option for the treatment of VVA symptoms in post-menopausal women.

Introduction

Before the climacteric period, the vagina is composed of thick layers of healthy cells, and estrogen encourages the growth and development of these cells; therefore, the vaginal epithelium remains multi-layered, and vaginal walls are supple and elastic [1], [2]. The progressive reduction in circulating estrogen, which occurs following the cessation of ovarian function during menopause, induces various metabolic and tissue changes, which are most prominent in the genital tract due to its particular sensitivity to variations in sex hormone levels [2], [3]. Vulvo-vaginal atrophy (VVA) is a progressive, chronic condition that manifests as involution of the vulvo-vaginal mucous membranes and tissues due to the menopausal drop in estrogen levels [4], [5].

Typical symptoms of VVA, which reflect these vulvo-vaginal morpho-functional changes, include vaginal dryness, itching, burning, irritation, dysuria and dyspareunia [6], [7]. In particular, the vaginal walls appear thinner and less elastic with loss of rugations. The entire vaginal canal becomes narrower and shorter. The vaginal surface appears dry and friable and often bleeds after minimal trauma. The vulvar area, particularly the clitoris, becomes atrophic and more vulnerable [8].

Vaginal atrophy can worsen over the years and negatively influence quality of life (QoL) [9]. Approximately 50% of postmenopausal women experience symptoms of VVA [10], [11], which can range from mild (annoying) to severe (very bothersome).

These symptoms may cause significant emotional distress and may result in sexual dysfunction. The burden of VVA on the individual and the population is greater than physicians may realize, especially due to socio-cultural barriers and a lack of access to health care in certain countries [12].

Because of the progressive aging of the general population, women may complain of vaginal aging symptoms (itching, burning, reduced lubrication, superficial and/or severe dyspareunia related to vulvovaginal atrophy) for more than one third of their lives [13].

Several therapeutic options are available to alleviate VVA symptoms, including non-hormonal products for mild cases, vaginal hormone therapy for persistent symptoms, and systemic hormonal replacement therapy (HRT) as a broader approach for severe symptoms [2], [14]. Lubricants have been demonstrated to decrease vaginal irritation during sexual activity but do not provide a long-term solution [15]. Few clinical data have indicated that vaginal moisturizers improve VVA symptoms [16]. Systemic HRT may be considered for climacteric symptoms in the absence of contraindications; however, this type of treatment is associated with more side effects than the local administration of HRT and is not recommended unless vasomotor symptoms need to be controlled [2], [14]. Several clinical trials have demonstrated the efficacy of low-dose local estrogen therapies in women with only VVA symptoms in the absence of contraindications. However, limited data are available on the long-term safety of these therapies, and no information is available on high-risk patients [2], [14], [17].

Moreover, the major drawback of this approach is the recurrence of symptoms once treatment has been suspended, and this treatment is only effective in the superficial layer of the vaginal walls [18].

In recent years, there has been a greater demand for a safe, long-term therapeutic option that can effectively treat the deeper layers of the vaginal mucosa in addition to the epithelium. By applying the principles of regenerative and anti-aging medicine to the vaginal mucosa, the use of fractional CO2 laser may be extended to treat patients with VVA [19].

As demonstrated in other areas of the body [20], [21], [22], [23], [24], this system induces the topical remodeling of connective tissue and the production of collagen and elastic fibers. Based on results that were obtained on the skin, we applied a fractional CO2 laser treatment that was specifically designed for the vaginal mucosa to determine the safety and efficacy of this treatment in improving VVA symptoms in postmenopausal women.

Section snippets

Patients

For this observational pilot study, post-menopausal patients who complained of one or more symptoms related to VVA and who underwent vaginal treatment with fractional CO2 laser from April 2013 to December 2013 were included in the study. The inclusion criteria consisted of menopausal status (including early forms), one or more vulvo-vaginal symptoms (e.g., itching, burning, reduced lubrication, superficial and/or severe dyspareunia), and non-response to previous estrogen or local therapies.

Results

A total of 48 patients were enrolled in the study; median age was 56 years. All demographic characteristics of the patients are reported in Table 1.

Duration of menopausal status was <2 years in 9 cases (18.7%), between 2 and 5 years in 22 cases (45.8%) and >5 years in 17 cases (35.4%). Duration of therapy prior to laser CO2 treatment was variable: <12 months in 8 patients (16.7%), between 12 and 24 months in 27 patients (56.2%), >24 months in 13 patients (27.1%).

In 22.9% of cases, patients had

Discussion

Over the past decade, the use of CO2 laser has been widely adopted in medicine, especially in dermatology and plastic surgery [20], [21], [22], [23], [24], [28]. This laser consists of a CO2 ray (infrared ray), which generates heat and vaporizes the water content of target cells.

The effect is specific to the superficial layer of skin and does not cause damage to surrounding tissue. In 2003, Capron et al. identified the principal mechanism of the laser-effect, which is based on the generation of

Conclusion

For the treatment of women with severe urogenital symptoms who do not benefit from lifestyle changes, vaginal moisturizers or local estrogen therapy, clinicians should consider the use of vaginal fractional CO2 laser treatment. Our results suggest that thermo-ablative fractionated CO2 laser could be a safe, well-tolerated and effective alternative for the relief of VVA symptoms in post-menopausal women.

Contributors

AP and GC performed the laser treatment, conceived and wrote the paper; FF and AS performed the acquisition of data; CT and GC performed the interpretation of data; SS performed the statistical analysis.

Competing interests

The authors declare no conflict of interest.

Funding

None.

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