Fractional CO2 laser therapy for vulvovaginal atrophy

The retrospective chart review comprised 139 women with vulvovaginal atrophy symptoms, who completed three laser sessions about 6 weeks apart at the Vulvar and Sexual Health clinic at Prohealth, Waukesha Memorial Hospital, in Wisconsin, from January 2016 to December 2019.

All patients were over the age of 18 years old (mean age 62) and nonpregnant.

Concomitant topical estrogen was reported in 53% of patients (n = 74). breast cancer diagnosis was documented in 27% (n = 38) and lichen sclerosus in 22% (n = 31).

Patients were surveyed prior to the first and third laser treatment via two validated questionnaires: the Female Sexual Function Index (FSFI) and the Vulvovaginal Symptoms Questionnaire (VSQ). A visual analog scale (VAS) was also filled out.

Treatment was delivered vaginally first using a vaginal probe followed by the vulvar treatment performed with a separate handpiece, using a square pattern. Lidocaine 2% was applied to the vulvar tissue 20 minutes prior to treatment. Laser settings for the vaginal and vulvar treatments mirrored previous studies.

The mean follow up was 13.8 weeks.

All FSFI scores improved: pretreatment 12.7 vs. posttreatment 19.0 (P < 0.001).

The VSQ also showed that 18 of 21 questions significantly improved (P < 0.05).

In addition, the VAS showed significant improvement in painful intercourse and vulvar and vaginal dryness: pretreatment 12.7 and 4.6, respectively vs. posttreatment 2.4 and 1.5 (both P < 0.001).

Furthermore, 17 additional women became sexually active after the second laser treatment. There were no major adverse events reported among any of the study participants.

“We were surprised that patients improved as early as after one or two treatments,” said principal investigator Sarit Aschkenazi MD, MS, medical codirector at Prohealth Waukesha Memorial Hospital. “Improvement occurred even in women with severe symptoms not responding to conventional therapy, such as topical estrogen, or those on aromatase inhibitors for breast cancer prevention. We were especially thrilled to see women with lichen sclerosis with very advanced skin atrophy show signs of improvement.”

The laser therapy is thought to work by delivering energy to the subcutaneous tissue, with minimal damage to the overlying epithelium. It stimulates the fibroblasts to produce more collagen and elastin fibers, as well as increases water content, skin folds, and epithelial thickness of the vaginal and vulvar skin, according to Aschkenazi.

“This is similar to the effects produced when the laser is applied to facial skin,” she said. “The laser has been used on facial skin for over a decade and has been documented to be safe. Skin biopsies have demonstrated these effects as well. All these changes are comparable to the changes which occur when estrogen is present in the tissue at premenopausal levels.”

The laser is showing to be a promising alternative treatment for a prevalent condition like vulvovaginal atrophy. “This is a new option when estrogen is not effective, contraindicated or undesired,” Aschkenazi said.

However, randomized control studies are needed to clearly determine the efficacy of the laser treatment, as well as establish the optimal number of treatment sessions, intervals and how often to repeat a booster.

“One treatment option to evaluate is to combine laser therapy with topical hormonal treatment, when not contraindicated, such as with estrogen therapy or topical dehydroepiandrosterone (DHEA) to prolong tissue improvement and achieve a synergistic effect at lower doses,” Aschkenazi said.

Although the laser was found safe in all study patients, Aschkenazi recommends using conventional treatment options for vulvovaginal atrophy symptoms first before adding laser therapy, and following treatment parameters to avoid any adverse effects. Those struggling from such symptoms also should maintain skincare by reducing skin irritants, tight undergarments, soap and scented feminine pads. “Adding nonhormonal moisturizers helps avoid the dryness associated with menopausal symptoms,” she said.

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Aschkenazi reports no relevant financial disclosures.

Gardner AN, Aschkenazi SO. The short-term efficacy and safety of fractional CO2 laser therapy for vulvovaginal symptoms in menopause, breast cancer, and lichen sclerosus. Menopause. Published online January 4, 2021. doi:10.1097/GME.0000000000001727