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

Effect of lattice CO2 laser combined with Kegel exercise mild moderate stress urinary incontinence and postpartum depression anxiety

BACKGROUND

Postpartum stress urinary incontinence (SUI) symptoms affect a patient's daily activities and quality of life and increase the negative emotions that they experience. At present, there is no research on the effect of fractional CO2 laser treatment combined with Kegel exercise on postpartum SUI and postpartum depression and anxiety.

AIM

To investigate the effect of lattice CO2 laser treatment combined with Kegel exercise on mild to moderate postpartum SUI and its influence on postpartum depression and anxiety.

METHODS

Using a retrospective study, data from 82 cases of mild to moderate postpartum SUI in Huzhou Maternal & Child Health Care Hospital from January to April 2024 were retrospectively collected. The cases were divided into groups according to the different treatment methods, namely Group S (41 cases, only receiving lattice CO2 laser treatment) and Group L (41 cases, receiving lattice CO2 laser combined with Kegel exercise treatment). The baseline data of the two groups were compared. In addition, we analyzed and compared the scores of the international commission on urinary incontinence questionnaire short form (ICI-Q-SF), incontinence quality of life questionnaire (I-QOL), Edinburgh postnatal depression scale (EPDS), and postpartum specific anxiety scale (PSAS) before treatment, at the end of treatment, and 3 months after the end of treatment between the two groups. Furthermore, the clinical efficacy and adverse reactions of the two groups were analyzed and compared at the end of treatment and 3 months after the end of treatment.

RESULTS

There was no significant difference in the baseline data and the ICI-Q-SF, I-QOL, EPDS, and PSAS scores between the two groups before treatment. However, at the end of treatment, the ICI-Q-SF, I-QOL, EPDS, and PSAS scores between Groups L and S were significantly different. The overall effective rate of treatment in Group L was significantly higher than that in Group S. During the 3-month follow-up after treatment, it was found that the ICI-Q-SF, EPDS, and PSAS scores of Group L were still lower than those of Group S. In comparison, the I-QOL score and total effective rate of treatment were still higher in Group L than those in Group S, and this difference was significant. There was no significant difference in the adverse reactions between Group L and Group S.

CONCLUSION

The combination of dot lattice CO2 laser and Kegel exercise has a significant therapeutic effect on mild to moderate postpartum SUI. It can prolong the duration of therapeutic effects, improve a patient's quality of life, and alleviate postpartum depression and anxiety.

Energy-based interventions for genitourinary syndrome of menopause: a systematic review of randomized controlled trials and prospective observational studies

IMPORTANCE

Hormone treatments for genitourinary syndrome of menopause (GSM) symptoms have limitations. There is interest in nonhormone therapies, including energy-based interventions. Benefits and harms of energy-based interventions are not currently well known.

OBJECTIVE

The aim of this study was to assess the benefits and harms of energy-based therapies (eg, CO 2 laser, Er:YAG laser, and radiofrequency) for GSM. Outcomes of interest are the eight "Core Outcomes in Menopause" and include the following: dyspareunia, vulvovaginal dryness, vulvovaginal discomfort/irritation, dysuria, change in most bothersome symptom, quality of life, treatment satisfaction, and treatment adverse effects.

EVIDENCE REVIEW

Eligible studies included English language randomized controlled trials (RCT) or prospective observational studies of energy-based treatments with ≥8 weeks follow-up in postmenopausal women with ≥1 GSM symptom and studies of any design reporting adverse effects ≥12 months postintervention. Ovid/MEDLINE, Embase, and CINAHL were searched from inception to December 11, 2023 using vocabulary and natural language terms, along with free-text words. Two authors extracted data and assessed the quality of included studies.

FINDINGS

We identified 32 unique studies (16 RCT; 1 quasi-RCT; 15 nonrandomized). Ten RCT and the quasi-RCT were rated low to moderate risk of bias (RoB) and underwent data extraction. Included studies evaluated CO 2 laser (k = 7), Er:YAG laser (k = 3), or radiofrequency and CO 2 laser (k = 1). CO 2 laser compared with sham (k = 4) may result in little to no difference in dysuria, dyspareunia, or quality of life (low certainty of evidence [COE]). CO 2 laser compared with vaginal conjugated estrogens cream (k = 2) may result in little to no difference in dyspareunia, dryness, discomfort/irritation, dysuria, or quality of life (low COE). Treatment effects on all other outcomes and effects of Er:YAG laser or radiofrequency on any outcome are very uncertain (very low COE). Studies noted few adverse events and no serious adverse events.

CONCLUSIONS AND RELEVANCE

CO 2 laser resulted in little to no difference in outcomes compared with sham or vaginal estrogen; the evidence is very uncertain on the effect of energy-based interventions versus all other comparators for all other outcomes. Adverse event reporting was limited. There is a need for further evidence assessing energy-based interventions.

Practical Guidance on the Use of Vaginal Laser Therapy: Focus on Genitourinary Syndrome and Other Symptoms

Genitourinary syndrome of the menopause (GSM) is a chronic, often progressive condition, characterised by symptoms relating to oestrogen deficiency including; vaginal dryness, burning, itching, dyspareunia, dysuria, urinary urgency and recurrent urinary tract infections. GSM affects up to 70% of breast cancer survivors with a tendency to particularly severe symptoms, owing to the effects of iatrogenic menopause and endocrine therapy. Patients and clinicians can be reluctant to replace oestrogen vaginally due to fear of cancer recurrence. Vaginal laser is a novel therapy, which may become a valuable nonhormonal alternative in GSM treatment. There are currently 6 published studies regarding Erbium:YAG laser treatment for GSM, 41 studies regarding CO2 laser treatment for GSM and 28 studies regarding vaginal laser treatment for GSM in breast cancer survivors. Number of participants ranges from 12 to 645. The majority of studies describe a course of 3 treatments, but some report outcomes after 5. Significant improvements were reported in vaginal dryness, burning, dyspareunia, itch, Vaginal Health Index Scores (VHIS), Quality of Life, and FSFI (Female Sexual Function Index). Most studies reported outcomes at short-term follow-up from 30 days to 12 months post-treatment. Few studies report longer-term outcomes with conflicting results. Whilst some studies suggest improvements are sustained up to 24 months, others report a drop-off in symptom improvement at 12-18 months. Patient satisfaction ranged from 52% to 90% and deteriorated with increasing time post-procedure in one study. The findings in this review must be validated in robust randomised sham-controlled trials of adequate power. There remain a number of unanswered questions in terms of which laser medium to use, optimal device settings, ideal interval between treatments, pre-treatment vaginal preparation, as well as safety and efficacy of repeated treatments long term. These issues could be addressed most efficiently with a mandatory registry of vaginal laser procedures.

Lasers in Gynecology

The first published reports on the use of laser for cervical pathology date back to 1973. Technical advancements in flexible and rigid laser fibers revolutionized video laser laparoscopy in the 1990s. Fractionated lasers have been used to treat vulvovaginal symptoms associated with genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence. Review of available data suggests that fractionated lasers can improve both subjective and objective signs of vaginal atrophy and lichen sclerosus, but the evidence is weak because most of the trials are underpowered, are at risk for bias, and lack long-term follow-up. There is no strong evidence to support fractionated laser therapy for urinary incontinence or low-level laser therapy for chronic pelvic pain. Although short-term, single-arm trials suggest benefit of fractionated laser therapy for genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence, additional adequately powered, prospective, randomized, and longer-term comparative trials are needed before lasers can be recommended for these specific conditions. The purpose of this Clinical Expert Series is to review basic laser biophysics and the mechanism of action for modern fractionated lasers as relevant to the gynecologist. We also summarize safety and effectiveness data for lasers used for some of the most commonly studied gynecologic conditions: the vulvovaginal atrophy component of genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence.

Sexual Dysfunction and Dyspareunia in the Setting of the Genitourinary Syndrome of Menopause

Sexual dysfunction is a common consequence of the genitourinary syndrome of menopause (GSM). In this book chapter, we discuss the pathophysiology, prevalence, evaluation, and evidence-based management of sexual dysfunction in patients affected by GSM. Additionally, we present an algorithm to guide clinicians in the management and treatment of sexual dysfunction in this setting based on available evidence and best practices.

Clinical Practice Guidelines for Managing Genitourinary Symptoms Associated With Menopause

Genitourinary syndrome of menopause encompasses the group of urogenital signs and symptoms resultant from hypoestrogenism, including genital dryness, burning or irritation, sexual discomfort, pain or dysfunction, and urinary urgency, dysuria, and recurrent urinary tract infections. Genitourinary syndrome of menopause can have a profound impact on well-being, functioning, and quality of life in postmenopausal women. Treatment includes vaginal moisturizers and lubricants geared towards providing symptomatic relief; hormonal treatments which promote epithelial thickening and production of vaginal secretions; and pelvic floor physical therapy along with behavioral therapies that address pelvic floor hypertonicity and psychosocial factors.

Clinical and laboratory results in vaginal wall restoration using a fractional-pixel-CO2 laser: histological findings and changes in the Ki67 protein and telomere length

Thermal deposition of laser energy in the vaginal epithelium in genitourinary syndrome of menopause (GSM) results in clinical and biological effects, but many cellular and molecular changes indicating cell proliferation or senescence inhibition are unknown. The aim of this study is to evaluate the clinical efficacy of the fractional-pixel-CO2 laser in the possible improvement of GMS signs and symptoms that can be correlated with histological changes or with cellular or molecular indicators of restoration. A detailed prospective study was designed to assess 17 women diagnosed with GSM who were treated intravaginally with two laser sessions. Seven non-treated women diagnosed with GSM were used as controls. Three validated outcome questionnaires for assessment of quality of sexual life and urinary incontinence were performed. Vaginal biopsies were collected before the first laser treatment and 4 months following the second session. Histological status, elastin, collagen, and hyaluronic acid content of the biopsies were also evaluated. Cell proliferation was assessed by Ki67 staining. Telomere length (TL) was measured by qPCR. The results show an improvement of the clinical symptoms of GSM (p < 0.05), vaginal epithelium recovery and enhancement of collagen (p < 0.05), elastic fibers (p < 0.005), and hyaluronic acid (p < 0.0005) content in the lamina propria after fractional-pixel-CO2 laser treatment. The laser treatment induced a significant rise on the TL of vaginal epithelial cells (VECs), and a positive correlation was found between the improvements of the collagen and hyaluronic acid content and TL changes (r = 0.82, p < 0.05; r = 0.38, p < 0.05). The percentage of proliferative Ki67-positive VECs was increased in patients whose vaginal TL lengthened after laser treatment (p < 0.05). In conclusion, the results indicate that laser treatment may induce restoration of the vaginal epithelium which is associated to increased TL and proliferation in the VECs. Performing a TL assay could be a suitable tool to evaluate the efficacy of vaginal laser treatment.

Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review

OBJECTIVE

To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM).

DATA SOURCES

MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators.

METHODS OF STUDY SELECTION

We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group.

TABULATION, INTEGRATION, AND RESULTS

Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function.

CONCLUSION

Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.

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.

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.

Long-Term Follow-Up of Fractional CO2 Laser Therapy for Genitourinary Syndrome of Menopause in Breast Cancer Survivors

(1) Background: The objective of this study was to determine the long-term efficacy of fractional CO₂ laser therapy in breast cancer survivors. (2) Methods: This was a single-arm study of breast cancer survivors. Participants received three treatments of fractional CO₂ laser therapy and returned for a 4 week follow-up. Participants were contacted for follow-up at annual intervals. The Vaginal Assessment Scale (VAS), the Female Sexual Function Index (FSFI), the Female Sexual Distress Scare Revised (FSDS-R), the Urinary Distress Inventory (UDI), and adverse events were collected and reported for the two-year follow-up. The changes in scores were compared between the four-week and two-year and the one-year and two-year follow-ups using paired t-tests. (3) Results: In total, 67 BC survivors were enrolled, 59 completed treatments and the four week follow-up, 39 participated in the one-year follow-up, and 33 participated in the two-year follow-up. After initial improvement in the VAS from baseline to the four week follow-up, there was no statistically significant difference in the VAS score (mean Δ 0.23; 95% CI [−0.05, 0.51], p = 0.150) between the four week follow-up and the two-year follow-up. At the two-year follow-up, the FSFI and FSDS-R scores remained improved from baseline and there was no statistically significant change in the FSFI score (mean Δ −0.83; 95% CI [−3.07, 2.38] p = 0.794) or the FSDS-R score (mean Δ −2.85; 95% CI [−1.88, 7.59] p = 0.227) from the one to two-year follow-up. The UDI scores approached baseline at the two-year follow-up; however, the change between the one- and two-year follow-ups was not statistically significant (mean Δ 4.76; 95% CI [−1.89, 11.41], p = 0.15). (4) Conclusions: Breast cancer survivors treated with fractional CO₂ laser therapy have sustained improvement in sexual function two years after treatment completion, suggesting potential long-term benefit.

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.