Vaginal laser
10 September 2024

The increase in life expectancy, together with changes in the lifestyle of women over 50, has added new challenges for all professionals involved in the care of women.
Women will spend a third of their lives in the menopause stage and this will lead to an increase in the number of patients with symptoms related to genitourinary syndrome of menopause. Currently, we know that approximately 50% of women will present symptoms. The impact of these symptoms on quality of life has been minimized for generations, both by women themselves and by their doctors.
Recent studies shed light on this situation and reveal that vaginal discomfort can end up interfering with sleep, mental health and sexual health, ultimately causing a decrease in the ability to enjoy life. Finally, we have studies that allow us to quantify the negative effect of these symptoms and it has been reported that for each increase in the severity of the symptoms, there is a significant decrease in the score of the quality of life indexes1.
With menopause, circulating estrogens decrease, their effects are mediated by the presence of a and b receptors in the urogenital tissues: vagina, vulva, urethra, bladder and trigone2.
When estrogens decrease, up to 50% of women present associated symptoms affecting all these levels: vaginal dryness, burning, irritation, poor lubrication, discomfort or pain, alterations in sexual activity and urinary symptoms such as urinary urgency, dysuria, and recurrent urinary tract infections2.
Of all these symptoms, the one that has proven to be the most bothersome for women is vaginal dryness, the prevalence of which increases as more years pass after menopause, affecting 49% of women who have been amenorrhoeic for one year and 55% of women who have been amenorrhoeic for more than 10 years. The next symptom that bothers women the most is dyspareunia, but this decreases with age. In the first 6 years of menopause, 26% of women identify it as the most uncomfortable symptom, while this percentage drops to 8% in women who have been menopausal for more than 20 years3.
The amount and severity of symptoms can be very different from one woman to another, but what is proven is that if they are not treated, the symptoms worsen2.
The type of treatment depends on the severity of the symptoms, the options available and the patient's preference.
First-line recommendations according to the North American Menopause Association include local treatments with creams and lubricants without estrogenic action and promoting sexual relations. The second line would include treatment with local and systemic estrogens, oral treatment with Tibolone or Ospemifene and local treatment with DHEA4.
All of these treatments have been shown to improve symptoms and show an optimal safety profile.
The use of local estrogens is still surrounded by controversy, and although most guidelines recommend their use, there are studies that question their effectiveness compared to placebo5. In a study published in 2018 in the journal JAMA, no difference was observed in the improvement of symptoms between women who underwent local treatment with estrogens, lubricants or placebo, although it is true that the placebo used contained many components used as vaginal lubricants. In addition, adherence rates to treatment are very low, and almost 70% of women end up voluntarily discontinuing treatment6. This same study, published in 2017, explained that 46% of women stopped the procedure due to the ineffectiveness of the treatment and 20% due to the discomfort it caused them6.
All these reasons have led to the development of new technologies in recent years to try to improve vaginal health. We will increasingly see more women at this stage of life, we will have to explore new treatments and try to find a way to provide well-being to our patients, solving the problems they present to us more efficiently. A challenge for our profession in the coming years.
Among the new therapies that seek to be applied within regenerative medicine, vaginal LASER is one of them.
The use of laser technology began 5 decades ago by plastic surgeons and gynecologists2 and has been extended to many uses in medicine: from laparoscopy, IVF laboratory procedures, photodynamic therapy and many others. There is much hope in the ability of new technologies based on the use of thermal energy to reverse the natural aging of cells and tissues2.
The laser is a polarized light (all wave fronts travel in parallel planes), monochromatic (light composed of a single color or a very narrow spectrum of colors) and coherent (the waves travel in an orderly fashion, in the same direction, the crests and valleys synchronized).
The first thing we considered before starting laser treatment for vaginal atrophy was to review the literature in search of evidence first on the biological effects of the laser at the vaginal level, what was the plausibility of the treatment at the histological level.
The interaction between an electromagnetic wave and a biological tissue depends on the wavelength and the optical properties of the tissue7. The CO2 laser is in the infrared spectrum, with a wavelength of 10600nm and a high absorption by water (the water molecule is the chromophore of the CO2 laser due to its wavelength, color) giving it a superficial action7. It has a thermal effect when transmitting energy.
The vaginal wall is made up of 4 layers:
- Superficial squamous epithelium. Stratified. Non-keratinized
- Own lamina
- Muscular layer: circular inner layer and outer layer of longitudinal fibers
- Adventitia: collagen and elastin
The CO2 laser acts on the adventitial layer. In this layer, collagen and elastin fibers participate in controlling the biomechanical properties of the vagina6. Collagen provides rigidity and plays the most important role in the mechanical resistance of the vagina and its strength. There are different subtypes of collagen, the most predominant in the vagina2:
- Collagen type I: large and strong fibers. Provides support and strength
- Collagen type III: small fibers with less tensile strength. Elastic properties
- Collagen type V: even smaller and weaker fibers
Different authors have published their experience after 3 sessions of fractional CO2 laser treatment at vaginal level separated by one month with good response and tolerance to the treatment.
At the histological level, the changes described8 after three sessions are:
- Thickening of the epithelium, achieving a level of maturation and peeling similar to premenopause
- New indentations that are introduced into the epithelium
- In the connective tissue: formation of new fibers and formation of figures with a morphology similar to fibroblasts8,2.
Figura 1
The images shown in (Figure 1) are from a study published in 2015 by Zerbinati and colleagues, in which samples were taken from the vaginal wall of 5 menopausal women with any of the following symptoms: vaginal dryness, burning, itching, dysuria or dyspareunia. The samples were taken before the start of treatment, at 30 and 60 days.
As can be seen in the hematoxylin and eosin stain before treatment, the vaginal epithelium is thinner, formed by only a few layers of tissue and the junction with the connective tissue is smooth. However, after treatment, the same stain shows how the epithelium has thickened, being now formed by multiple layers and the junction with the connective tissue is not smooth, but has multiple indentations.
The images shown below (figure 2, 3) illustrate the same concept by Salvatore et al.9, in a study in which laser treatment was applied to one of the vaginal walls of 5 women undergoing vaginal hysterectomy for prolapse. The excess vaginal wall was subsequently resected on the side treated with laser and on the untreated side, so that each woman acted as her own control. In this study, CO2 laser treatment was applied using 3 different protocols on the same patient.
Figure 2 shows on one hand the sample of the contralateral vaginal wall confirming the presence of an atrophic epithelium, and the other images correspond to the different protocols used, with image number 3, the one obtained using a somewhat more aggressive protocol (more stacks and less space between points), being the one that had a greater effect. A more ablative effect is observed and the presence of fibroblasts in the lamina propria is more evident, as attempted to be illustrated in figure number 2 using an electronic microscope.
Figura 2
Figura 3
Figura 4
Finally, in Figure 4, which belongs to another study by the same author12, the same concept can be observed: in image A, mucosa with atrophy and in image B, a sample from the same patient after 2 months of treatment with fractional laser. As can be seen, the epithelium is thicker and has more indentations and peeling, more similar to image C, which corresponds to the vaginal epithelium of a premenopausal woman.
Another interesting effect reported in the literature is the effect of laser on the microbiota. In an interesting study published in 2016, changes in pH and bacterial population were studied before and after treatment with CO2 laser in 56 women10.
As we already knew, estrogens are essential for the production of glycogen, which is the main support of lactobacilli. These bacteria compete with other pathogens and are essential to maintain a healthy vagina. In addition, thanks to the production of lactic acid, they help maintain an acidic vaginal pH, with values below 4.5.
When estrogens decrease during menopause, there is a change in the microbiota and this favors colonization by pathogenic germs, and an increase in vaginal pH. And this can cause vaginal discomfort and also urinary tract infections, since recent findings allow the colonization of the vagina by enterobacteria to be linked to recurrent UTIs10.
Figura 5
In the 56 women in the study, before the start of treatment the percentage of lactobacilli was 30%, and after treatment, the percentage rose to 79%.
All these effects described at the level of the epithelium and microbiota have a correlation with the improvement of symptoms according to several published studies11.
Bibliografía:
- M DiBonaventura, X Luo, M tMoffatt, A G Bushmakin, M Kumar, J Bobula. The association between vulvovaginal atrophy symptoms and quality of life among postmenopausal women in the United States and western Europe. J Womens Health (Larchmt) 2015 sep 24 (9): 713-22. doi:10.1089/jwh.2014.5177.
- Yona Tadir, Adrian Gaspar, Ahinoam Lev- Sagie, Macrene Alexiades, Red Alisond, Alberto Calligaro, Jorge A. Elias, Marco Gambiaciani, Jorge Gaviria, Cheryl Iglesia, Ksenia Selih-Martinec, Patricia L Mewesigwa, Urska B. Ogrinc, Stefano Salvatore, Paolo Scolio, Nicola Zerbinati, John Stuart Nelson.Light and energy based therapeutics for genitourinary syndrome of menopause: consensus and controversies. Lasers Surg Med 2017 February; 49 (2): 137- 159.
- Palma F, Xholli A, Cagnacci A, as the writing group of the AGATA study. The most bothersome symptom of vaginal atrophy: evidence from the observational AGATA study. Maturitas. 2018, 108: 18-23. doi: 10.1016/j.maturitas.2017.11.007
- S. Palacios, C Castelo-Branco, H Currie, V. Mijatovic, R. E. Nappi, J Simon, M Rees. Update on magement of genitourinary syndrome of menopause: A practical guide. Maturitas 82 (2015) 307-312
- C. M. Micthell, S.D. Reed, S Diem, J C.Larson, K M. Newton, K E. Ensrud, A Z. LaCroix, B Caan, K A. Guthrie. Efficacy of estradiol or vaginal moisturizer vs placebo for treating postmenopausal vulvovaginal symptoms. JAMA Intern Med. 2018 May 1 , 178 (5): 681 – 690. doi: 10.1001/jamainternmed.2018.0116
- Palma F, Xholil A, Cagnacci A. A writing group of the AGATA Study. Management of vaginal atrophy: a real mess. Results from the AGATA study. Gynecol Endocrinol. 2017; 33 (9): 702-707
- S.Salvatore, E. Pitsouni, F.del Leo, M.Parma, S. Athanasiou, M. Candiani. Sexual Function in suffering from genitourinary syndrome of menopause treated with fractioned CO2 laser. Sex Med Rev 2017 Oct 5 (4): 486-494. doi: 10.1016/j.sxmr.2017.07.003
- S.Salvatore , K França , T Lotti et al. Early Regenerative Modifications of Human Postmenopausal Atrophic Vaginal Mucosa Following Fractional CO2Laser Treatment. Open Access Maced J Med Sci. 2018;6(1):6–14. Published 2018 Jan 19. doi:10.3889/oamjms.2018.058
- S. Salvatore, U.L.R. Maggiore, S. Athanasiou, M. Origoni, M. Candiani, A. Calligaro, N. Zerbinati. Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study. Menopause. 2015; Aug 22 (8):pp 845-849. doi: 10.1097/GME.0000000000000401
- S. Athanasiou, E. Pitsouni E, S. Antonopoulou, D. Zacharakis, S. Salvatore, ME Falagas, T. Grigoriadis. The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women. Climateric. 2016 Oct, 19 (5): 512-8. doi: 10.1080/13697137.2016.1212006
- F. Behnia-Willison, S. Saraf, J. Miller, B. Mohamadi, A. S. Care, A. Lam, N. Willison, L. Behnia, S. Salvatore. Safety and long-term efficacy of fractional CO2 laser treatment in women suffering from genitourinary syndrome of menopause. Eur J Obstet Gynecol Reprod 2017, Jun; 213: 39-44. doi: 10.1016/j.ejogrb.2017.03.036.
- S.Salvatore, Nappi RE, Zerbinati N. A 12-week treatment with fractional laser for vulvovaginal atrophy: a pilot study. Climateric. 2014: 17: 363-369. doi: 10.3109/13697137.2014.899347