Laser Vaginal Tightening Complications: Report of Three Cases

Laser for genitourinary syndrome of menopause: what we know and what we need to know

Energy-based treatments, including the fractional CO2 laser, have been widely used for treatment of genitourinary symptoms associated with menopause. With the availability of data from seven double-blind sham-controlled randomized trials, the evidence does not support the fractional CO2 laser as an efficacious treatment for genitourinary syndrome of menopause (GSM). A 2024 meta-analysis of these trials demonstrated that the symptom with greatest absolute improvement was dyspareunia at 16.3%, although not statistically significant. This improvement is far less than previously anticipated based on prospective data that suggested promising improvements of more than 90% satisfaction following laser treatment. Other data, including those from unblinded studies which are subject to a placebo effect, and outcomes that are not participant-reported including the appearance of the vagina on examination and histology, are not reliable in determining efficacy of laser treatment for GSM. While there may be a clinical effect of laser over sham treatments for GSM, the effect is unlikely to be clinically meaningful. Until we define and demonstrate a minimal clinically important difference in a robust and appropriately powered study, the laser should not be used in a clinical context for GSM.

CO2 surgical laser for treatment of stress urinary incontinence in women: a randomized controlled trial

BACKGROUND

Stress urinary incontinence is a common condition that can be treated conservatively and/or surgically. Given the risks of surgery, developing effective nonsurgical treatment options would be beneficial. Some studies have suggested that laser therapy may improve or cure stress urinary incontinence. However, there is a lack of sham-controlled randomized controlled trials to judge treatment efficacy.

OBJECTIVE

This study aimed to compare the effects of CO₂ vaginal laser vs sham therapy for treating stress urinary incontinence.

STUDY DESIGN

This was a multicenter, participant-blinded, sham-controlled, parallel group (1:1) superiority randomized controlled trial performed in outpatient clinics in 2 hospitals. We included women aged 18 to 80 years with objective and subjective stress urinary incontinence. Participants had undertaken or declined supervised pelvic floor muscle training. Intervention was performed using a CO₂ fractionated vaginal laser. Participants underwent 3 treatments, 4 weeks apart, with increasing energy and density settings. Sham treatment was performed using an identical technique with a deactivated pedal. The primary outcome was the subjective stress urinary incontinence rate (proportion with leak with cough, sneeze, or laughter) at 3 months after completion of treatment. Secondary outcomes included objective stress urinary incontinence, change in the disease-specific patient-reported outcomes, health-related quality of life, and adverse effects. Categorical outcomes were compared using the chi square test and continuous outcomes using analysis of covariance, adjusting for the baseline score.

RESULTS

There were 52 participants who received laser and 49 who received sham treatment. One participant in each group withdrew from the study before the endpoint, and 2 participants in the laser group did not participate in the follow-up visits. Participant mean age was 53 (34-79) years. Mean body mass index was 26.1 (18.1-49.6); 90% were vaginally parous. At 3 months, there was no difference between the sham and active treatment arm in subjective stress urinary incontinence (46 [96%] vs 48 [98%]; relative risk, 0.98 [95% confidence interval, 0.91-1.05]; P=.55) or in objective stress urinary incontinence (37 [80%] vs 33 [80%]; relative risk, 0.99 [95% confidence interval, 0.81-1.23]; P=.995). Patient-reported outcomes and health-related quality of life were also comparable between the groups. Vaginal bleeding occurred in 3 participants after laser and 1 participant after sham treatment. Pain during treatment did not differ between laser and sham treatment.

CONCLUSION

We were unable to show an improvement in stress urinary incontinence after CO₂ vaginal laser therapy compared with sham treatment.

New Method for Genital Aesthetic Surgery: An Easy-To-Learn Two-Step Approach With Acellular Dermal Matrix (ADM)

BACKGROUND

Vaginal laxity, usually accompanied with prolapse symptoms, affects women's sexual satisfaction and quality of life. Vaginal tightening surgery aims to reinforce the peri-vaginal muscle strength and restore the normal vaginal anatomy.

OBJECTIVES

The objective of this study was to introduce a new surgical approach with vaginal tightening using acellular dermal matrix (ADM).

METHODS

In this retrospective study, we analyzed data from 80 patients with vaginal laxity who underwent surgery from April 2017 to April 2021. Three-dimensional transvaginal ultrasound (3D-TVS) and the Female Sexual Function Index (FSFI) were evaluated among the patients.

RESULTS

The mean age of the patients was 44.6 years. The mean patient follow-up was 13.2 months. No infection, rectovaginal fistula, or implant explantation occurred. 3D-TVS demonstrated a significant reduction of introital diameter on a maximum Valsalva maneuver (2.3 cm vs. 4.1 cm; p<0.05) and the reconstruction of acute vaginal angulation. FSFI orgasm subscore increased significantly.

CONCLUSIONS

Vaginal tightening with ADM is a minimally invasive surgery with safety and efficacy for patients with vaginal laxity.

Effect of Fractional Carbon Dioxide Laser vs Sham Treatment on Symptom Severity in Women With Postmenopausal Vaginal Symptoms: A Randomized Clinical Trial

IMPORTANCE

Postmenopausal vaginal symptoms are common and frequently detrimental to a woman's quality of life. Fractional carbon dioxide vaginal laser is increasingly offered as a treatment, but the efficacy remains unproven.

OBJECTIVE

To determine the efficacy of fractional carbon dioxide laser for treatment of vaginal symptoms associated with menopause.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, randomized, sham-controlled trial with 12-month follow-up was undertaken at a single tertiary referral hospital in Sydney, Australia. Enrollment commenced on September 19, 2016, with final follow-up on June 30, 2020. Participants were postmenopausal women with vaginal symptoms substantive enough to seek medical treatment. Of 232 participants approached, 85 were randomized.

INTERVENTIONS

Three treatments using a fractional microablative carbon dioxide laser system performed 4 to 8 weeks apart, with 43 women randomized to the laser group and 42 to the sham group.

MAIN OUTCOMES AND MEASURES

The co-primary outcomes were symptom severity assessed using a visual analog scale (VAS; range, 0-100; 0 indicates no symptoms and 100 indicates the most severe symptoms) and the Vulvovaginal Symptom Questionnaire (VSQ; range, 0-20; 0 indicates no symptoms and 20 indicates the most severe symptoms) at 12 months. The minimal clinically important difference was specified as a 50% decrease in both VAS and VSQ severity scores. There were 5 prespecified secondary outcomes, including quality of life (range, 0-100; higher scores indicate better quality of life), the Vaginal Health Index Score (range, 5-25; higher scores indicate better health), and vaginal histology (premenopausal or postmenopausal status).

RESULTS

Of 85 randomized participants (mean [SD] age, 57 [8] years), 78 (91.7%) completed the 12-month follow-up. From baseline to 12 months, there was no significant difference between the carbon dioxide laser group and the sham group in change in symptom severity (VAS score for overall vaginal symptoms: -17.2 vs -26.6; difference, 9.4 [95% CI, -28.6 to 47.5]; VAS score for the most severe symptom: -24.5 vs -20.4; difference -4.1 [95% CI, -32.5 to 24.3]; VSQ score: -3.1 vs -1.6; difference, -1.5 [95% CI, -5.9 to 3.0]). There were no significant differences between the laser and sham group in the mean quality of life score (6.3 vs 1.4; difference, 4.8 [95% CI, -3.9 to 13.5]) and Vaginal Health Index Score (0.9 vs 1.3; difference, -0.4 [95% CI, -4.3 to 3.6]) or in histological comparisons between laser and sham treatment groups. There were 16 adverse events in the laser group and 17 in the sham group, including vaginal pain/discomfort (44% vs 68%), spotting, discharge, and lower urinary tract symptoms. No severe adverse events were reported in either group.

CONCLUSIONS AND RELEVANCE

Among women with postmenopausal vaginal symptoms, treatment with fractional carbon dioxide laser vs sham treatment did not significantly improve vaginal symptoms after 12 months.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12616001403426.

[Management of vulvovaginal atrophy: Physical therapies. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

INTRODUCTION

For some patients, local hormonal or non-hormonal treatments for genitourinary syndrome of menopause (SGUM) are contraindicated or insufficiently effective. Different physical therapies such as vaginal laser therapy, radiofrequency therapy, photobiomodulation therapy and local injection of hyaluronic acid, autologous fat (lipofilling) and platelet rich plasma (PRP) have been proposed as alternatives.

OBJECTIVE

The objective of this review was to elaborate guidelines for clinical practice regarding the physical therapies proposed for management of vulvovaginal atrophy (AVV).

METHODS

A systematic review of the literature on AVV management with physical therapies was conducted on Medline between January 2014 and December 2020.

RESULTS

Regarding vaginal laser therapy, there are few randomized controlled trials and no formal conclusions can be drawn. The fractional CO2 laser did not demonstrate its superiority over local estrogen therapy. The ERBIUM:YAG laser has not been studied in randomized controlled trials. The lack of follow-up on the vaginal laser and the series of cases reporting risks of vaginal stenosis or chronic pain do not encourage recommending it as a first-line treatment. The literature concerning other physical treatments of AVV is weak concerning the genital area.

CONCLUSION

CO2 or ERBIUM:YAG vaginal lasers are not the first-line treatment for AVV (grade C). In patients with a contraindication to local hormonal treatments, treatment with vaginal CO2 laser or ERBIUM:YAG may be considered after information about the risks (burn, stenosis, pain) (expert opinion). The other physical treatments of SGUM have to be evaluated.

Experience of Vaginoplasty for Enhancement of Sexual Functioning in a Center in Turkey: A Before and After Study

Objective The number of vaginal rejuvenation procedures for improvement of sexual function is dramatically increasing worldwide. The objective of this study was to present our experience with women who presented to our clinic with the complaint of sexual dysfunction or desire to enhance sexual function or orgasm. Methods Demographic and descriptive data of the patients were evaluated. In addition, sexual dysfunction of the patients who underwent vaginoplasty in our center were evaluated before and after vaginoplasty procedure using Golombok Rust Inventory of Sexual Satisfaction (GRISS) scale and the scores were compared before and after the procedure, which is used in the evaluation of sexual dysfunction by relationship counsellors and clinics. Results A total of 250 women who described a sensation of a wide or floppy vagina with lost or decreased ability to achieve orgasm were included in the study. The mean age of the patients was 38.51±9.126 years. Of all women, 85.2% were college graduates. A history of normal vaginal delivery was found in 77.8% of the participants. The mean GRISS scores of "Infrequency", "Non-communication", "Dissatisfaction", "Non-sensuality", "Avoidance", "Anorgasmia" and "overall GRISS" scores were statistically significantly decreased, while the mean vaginismus score was significantly increased (p<0.01). Conclusion Highly satisfying outcomes regarding patient satisfaction were obtained from vaginoplasty procedures that we have performed.

The efficacy of erbium-doped yttrium aluminum garnet (Er:YAG) laser in the treatment of decreased sexual sensation: a randomized, placebo-controlled trial

Vaginal laxity, a common cause of decreased sexual sensation, is a common problem affecting the quality of life of women worldwide. Recently, lasers and energy-based devices (EBDs) have been applied in the treatment of this condition. The aim of this study was to compare the efficacy and safety of Er:YAG laser and placebo in treating decreased sexual sensation in Asians. Forty-two patients with decreased sexual sensation were randomized into 2 groups: intervention (laser treatment) and control (placebo treatment). Both groups received two treatments, at 1-month interval. Subjective and objective evaluations were done at baseline, 1-, 3-, and 6-month follow-ups. Pain score and adverse effects were also recorded. In the laser group, there was significant improvement in the patients' vaginal tightness satisfaction at 1- and 3-month follow-ups (P = 0.002 and 0.004) and also in the patients' overall satisfaction at 1- and 3-month follow-ups (P = 0.003 and 0.001). Pelvic floor muscle contraction was significantly better in the laser group after the first treatment (P = 0.043). No serious adverse effects were noted. Er:YAG laser provides improvement of sexual sensation for an average of 3 months following treatment. Mild and transient adverse effects such as leukorrhea, dryness, dysuria, vaginal itching, and spot bleeding were noted in the laser group, and these were not significantly different from the control group.

[Vaginal LASER therapy for genito-urinary disorders: A systematic review and statement from the Committee for Female Urology and Pelviperineology of the French Association of Urology]

INTRODUCTION

Vaginal LASER therapy is increasingly used in the field of urogynecology, but several points remain unclear. Our goal was to produce a systematic review of available evidence and provide a critical appraisal of available data.

METHODS

A systematic review until march 2020 was conducted using PubMed/MEDLINE, Cochrane and Embase databases. All studies about vaginal LASER use in the field of urogynecology were included.

RESULTS

Forty studies have been included (8 for genitourinary syndrome of menopause, 19 for stress urinary incontinence, 3 for overactive bladder, 7 for urogenital prolapse, 3 for other indications). Data were heterogeneous, and level of evidence was weak or very weak. Few studies were comparative, and only 3 were randomized). Mild improvement of symptoms and quality of life and limited satisfaction were seen for genitourinary syndrome, stress urinary incontinence, overactive bladder and prolapse. Few adverse events were reported. However, major methodological biases were noted regarding efficacy and safety evaluation. No long-term results were available.

CONCLUSIONS

While Vaginal LASER therapy seem to provide encouraging results, the level of evidence supporting its use was weak, especially regarding long-term outcomes. Studies of better quality are warranted before any recommendation can be made. Current use should be limited to clinical research.

The Fractional CO2 Laser for the Treatment of Genitourinary Syndrome of Menopause: A Prospective Multicenter Cohort Study

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

Vaginal laser treatment of genitourinary syndrome of menopause: does the evidence support the FDA safety communication?

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.

The Efficacy of Vaginal Laser and Other Energy-based Treatments on Genital Symptoms in Postmenopausal Women: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review examined energy-based treatments of the vagina for postmenopausal vaginal symptoms.

DATA SOURCES

We performed a systematic review from April 2017 (the end date of our previous review) to April 2020, searching Medline, Embase, and Scopus.

METHODS OF STUDY SELECTION

The inclusion criteria were all randomized studies, prospective studies with >10 cases, and retrospective studies with >20 cases published in English or French that assessed change in postmenopausal vaginal symptoms and/or sexual function in women after energy-based vaginal treatments. Meta-analyses were performed on randomized data.

TABULATION, INTEGRATION, AND RESULTS

Of the 989 results retrieved, 3 randomized studies, 16 prospective studies, and 7 retrospective studies were included in the review, representing data from 2678 participants. Pooled data from 3 randomized controlled trials show no difference between vaginal laser and topical hormonal treatments for change in vaginal symptoms (-0.14, 95% confidence interval -1.07 to 0.80) or sexual function scores (2.22, 95% confidence interval -0.56 to 5.00). Furthermore, no difference among vaginal laser, topical hormone, and lubricant was demonstrated in sexual function (p = .577). As in our previous review, non-randomized data support energy-based treatments in improving vaginal symptoms, sexual function, and clinician-reported outcomes. No severe adverse events were reported in the included studies. Significant heterogeneity of data arising from differing measures and reported outcomes continues to be an issue, with data remaining low quality, with high risk of bias, and no double-blind or placebo-controlled randomized trials yet reported, although 1 has now completed recruitment.

CONCLUSION

There are 3 randomized trials comparing energy-based systems with hormonal treatment, with no clinical difference in these 2 approaches. Although prospective data continue to show promising outcomes, without strong evidence from well-powered, double-blind placebo-controlled trials to determine the efficacy of treatment compared with placebo, the use of energy-based treatments should continue to be undertaken in research studies only, with high-quality studies essentially free from bias (International Prospective Register of Systematic Review registration number: 178346).