SUFU 2021: Vaginal Lasers Should Be Part of Every Female Pelvic Medicine and Reconstructive Surgery Practice

( Vaginal laser therapy is a thermal therapy. There are three main types of vaginal laser:
  1. Functionated CO2 (Femlift Alma, MonaLisa Touch)
  2. Radiofrequency (ThermaVa, ReVivie, Venus Fuiore, Viveve System, Protégé Intima, Pelleve, Ellma)
  3. Er:YAG (IntimasLase, Petit Lady Lutronic)
Functionated CO2 vaginal laser therapy is most common in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) practice. It is minimally ablative, shown to be safe, precise, and efficient for skin resurfacing. It destroys the epidermis/dermis in micro treatment zones inducing wound healing. New collagen and elastin fiber are formed. It is meant to restore vaginal collagen, hydration, and elasticity. It is indicated for postmenopausal women with genitourinary syndrome of menopause (GSM) (vaginal atrophy) and also used for vaginal laxity, incontinence, sexual dysfunction. The wavelength is 10,600 mm. Dr. Nirit Rosenblum provided pictures of the post-laser histological results after 1 month after Mona Lisa treatment a biopsy of the vaginal mucosa showed thickening of the epithelium, lengthening of the papilla, increased glycogen storage, and increased fibroblast activity. The thermal effect reaches 0.2 mm in depth. This treatment is done in 3 sessions at intervals of 4 to 6 weeks with booster treatments at 18 months. Evidence for vaginal lasers is quite poor and she presented the Mounir 2020 meta-analysis publication which found mostly prospective observational studies which showed improvement in the quality of life and vaginal atrophy symptoms. Adverse events were minimal and transient.

Er:YAG laser: Photothermal affect up to 0,5 mm in depth. Causes a mechanical pull of deeper tissue layers stimulating both collagen genesis and angiogenesis. It is indicated for postmenopausal women with GSM and also marketed for pre-menopausal women with vaginal laxity. The wavelength is 2940 mm.  As in previous laser treatment, the evidence is poor as there are only small case studies with short follow-up. A prospective, multicenter, longitudinal Vaginal Erbium Laser Academy Study followed women (n=205) up to 24 months, significant improvement in vaginal dryness and dyspareunia up 12 months after treatment but a decline in clinical improvement at that point.

Radiofrequency (RF): Electromagnetic wave generates heat upon meeting tissue impedance. This leads to the stimulation of collagen production by activating both heat and shock proteins and an inflammatory cascade in the tissue. Marketed for women, both for aesthetic (plastic surgery practices) and functional therapy.  It is not approved for vaginal laxity treatment. One multi-center prospective randomized sham-controlled study with Viveve (monopolar radiofrequency). The primary endpoint was vaginal laxity at 6 months. Used a non-validated questionnaire for outcome measure. At 6 months, 43.5% of the RF group vs 19.6 of the sham group reported no vaginal laxity. But the study did not include the safety and complications. There was a significant placebo effect in the sham group.

Dr. Rosenblum noted that vaginal laser therapy has been looked at as a treatment for recurrent UTIs in women. One prospective case series of 53 women looked at the use of the CO2 laser treatment on the vaginal microbiome in postmenopausal women. The study did not assess UTI in these women. It appears that overall evidence for vaginal laser therapy is not there as there are no randomized controlled trials for GSM therapy, no long-term studies, and none that compare laser therapy to transvaginal estrogen treatment. There is no evidence for use of this therapy for stress incontinence or overactive bladder. These treatments can be used in those women with GSM refractory to vaginal estrogen and in GYN cancer patients where vaginal estrogen therapy is contraindicated. Informed consent with the setting of treatment goals is critical. Most insurers do not cover vaginal laser therapy. Dr. Rosenblum feels that the FPMRS is the most qualified specialist to provide this therapy, much more so than the plastic surgeon.

Presented by: Nirit Rosenblum, MD, Clinical Associate Professor, Department of Urology, Clinical Associate Professor, Department of Obstetrics and Gynecology at NYU Grossman School of Medicine, Co-Director, Female Pelvic Medicine Fellowship Program, NYU Langone Health

Written by: Diane K. Newman, DNP, ANP-BC, FAAN, Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania and Co-Director of the Penn Center for Continence and Pelvic Health during the 2021 Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) Winter Meeting


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