SUFU 2018: Vaginal Rejuvenation: Fact or Fiction?

Austin, TX ( Dr. W. Stuart Reynolds moderated a point-counterpoint session entitled, “Vaginal Rejuvenation: Fact or Fiction?”  He describes how the term “vaginal rejuvenation” encompasses a broad range of conditions and interventions, but for the sake of this presentation, the CO2 fractionated laser will be the focus.  The laser is an ablative therapy for the vagina, using a fractionated technique, leaving areas in between treatment areas, similar to the theory of lawn aeration.  Standard treatment is 3 treatments, 6 weeks apart, and costs about $1000 per treatment.

Dr. Jennifer Anger spoke in support of vaginal rejuvenation.  She states it is best and most commonly used in women who cannot or will not use estrogen, if contraindicated to hormone therapy.  She also states that there is poor patient compliance with vaginal estrogen.  Many patients do not like hormonal options, so this laser provides a good alternative.  The research consists of mostly level 2 data, but shows there is improvement in symptoms, such as dyspareunia, vaginal burning, dryness, itching, soreness, and vaginal introital pain.  The condition of vulvodynia is difficult to treat; a study was done with laser on these patients and 67% of patients showed improvement in vulvodynia symptoms.  Another indication for its use is lichen sclerosis in women, with a prevalence of 1.7%.  Treatment of vaginal lichen sclerosis with laser obviates need for chronic topic steroids, but patients often necessitate more than 3 treatments, likely 5-7 treatments.  A third indication for the use of the CO2 fractionated laser is for urinary incontinence.  There have been some reports of use for stress urinary incontinence.  One study shows improvement OAB symptoms after laser treatment.  Dr. Anger then presented data showing patient satisfaction is high with the laser and the cost of treatment as well.  Research ongoing for role in UTI prevention, as laser treatment can decrease vaginal pH.

Dr. Ryan Krlin then spoke against vaginal rejuvenation with the CO2 fractionated laser.  He states most of the studies in support of the laser are observational, unstructured, with short follow up, using non-validated questionnaires, and industry sponsored.  He believes a large flaw of these studies is that they promote the laser a fix all, or panacea, for all conditions involving the vagina.   He states that vaginal laxity is vaguely defined and subjective in almost all the supportive studies.  He does not believe the laser can fix this.  He believes it is not clear if authors are correlating vaginal relaxation with POP.  Laser techniques in the research also are not standardized.  Their definitions of success are subjective, variable, with objective definitions lacking.  OBGYN groups in Australia, New Zealand, and Canada have taken a stance against vaginal laser procedures.  He also has concern that complication rates are not revealed in many studies, with no long term reporting.  Dr. Krlin also raises concern for vaginal scarring or adhesions, with the potential for worsening dyspareunia over the long term.  In his opinion, it is not a very cost effective treatment, when compared to vaginal estrogen cream.  Dr. Krlin advocates for more robust research on this topic. 

Presented by: W. Stuart Reynolds, MD, MPH, Moderator, Jennifer T. Anger, MD, MPH, FPMRS, Fact, and Ryan M. Krlin, MD, Fiction

Written by: Cristina Palmer, DO. Female Urology, Pelvic Reconstruction, Voiding Dysfunction Fellow, Department of Urology, UC Irvine Medical Center, Orange, California at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting (SUFU 2018), February 27-March 3, 2018, Austin, Texas