Menopause, wellbeing and health: A care pathway from the European Menopause and Andropause Society.

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.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/aogs.14353

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

Biological and psycho-relational factors contribute equally to the development of sexual symptoms and associated distress, a key element to diagnose female sexual dysfunctions (FSDs) in menopausal women. Consultation at midlife represents an optimal time to discuss sexual life, and healthcare providers have to be proactive in rising the conversation, as patients may not report their sexual concerns spontaneously. An accurate sexual history is essential to characterize the primary symptom, determine the impact on patient's quality of life and identify risk and precipitating factors. Among FSDs, hypoactive sexual desire disorder is very frequent at midlife together with genitourinary syndrome of menopause, a chronic condition negatively affecting the full sexual response. A multidimensional approach targeted to the patient's characteristics, goals and expectations is mandatory and should start from educative counselling and correction of modifiable risk factors. When specific treatments are required, they should include non-pharmacological and pharmacological options, often prescribed in combination to address concomitantly the biological and psychosocial components of FSDs. 

Menopause and female sexual dysfunctions

Key Points Question Are there differences in outcomes after carbon dioxide laser vs vaginal estrogen therapy in patients with genitourinary syndrome of menopause? Findings This systematic review and meta-analysis of 270 women from 6 randomized clinical trials found that vaginal laser therapy, compared with vaginal estrogen, was associated with similar improvement in genitourinary syndrome of menopause. Meaning Future noninferiority trials are needed to test whether vaginal laser therapy could be a potential treatment option for women with contraindications to vaginal estrogen.

https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2796567/jang_2022_oi_220925_1663173114.55751.pdf

Comparison of Severity of Genitourinary Syndrome of Menopause Symptoms After Carbon Dioxide Laser vs Vaginal Estrogen Therapy

Abstract Postmenopausal vulvovaginal pain and atrophy require appropriate and sensitive outcomes that correlate with the genital discomfort, symptoms and expected changes. In some studies, hormone and laser treatments do not detect benefits due to the fact that appropriate measuring tools were not used. While some studies have demonstrated placebo effects for both therapeutic approaches, others support that sham-intervention could be a therapeutic by creating a conditioning reflex. However, obtained results are directly related with the quality of outcomes: you get what you measure. It is imperative to follow the Core Outcomes in Menopause global initiative.

Vulvovaginal atrophy management with a laser: the placebo effect or the conditioning Pavlov reflex

IMPORTANCE The research of new therapeutic modalities, especially with energy-based devices, has been increasing nowadays for genitourinary syndrome of menopause (GSM) management. Microablative fractional CO2 laser has been used for pelvic floor dysfunction management. OBJECTIVE To conduct a systematic review and meta-analysis of randomized controlled trials to compare fractional CO2 laser therapy versus sham therapy for GSM management. EVIDENCE REVIEW We searched for the available randomized clinical trials in Cochrane Library, PubMed, ISI web of science, and Scopus during March 2021. We included randomized clinical trials that compared CO2 laser to sham among postmenopausal women with GSM diagnosis. We extracted the available data from included studies and pooled them in a meta-analysis model using RevMan software. Our main outcomes were total vaginal score assessment using the Vaginal Assessment Scale, sexual function using the Female Sexual Function Index, urinary symptoms using the Urogenital Distress Inventory-6, and satisfaction. FINDINGS Three studies met our inclusion criteria with a total number of 164 women. The CO2 laser was linked to a significant reduction in Vaginal Assessment Scale score when compared with the sham group (mean difference [MD] = -0.49, 95% CI [-0.75 to -0.22], P = 0.004). The CO2 laser was associated with a significant improvement in Female Sexual Function Index score in comparison with sham group (MD = 9.37, 95% CI [6.59-12.14], P < 0.001). In addition, a significant reduction in Urogenital Distress Inventory-6 score was reported among the CO2 laser group (MD = -6.95, 95% CI [-13.24 to -0.67], P = 0.03). More women were significantly satisfied among the CO2 laser group (risk ratio  = 1.98, 95% CI [1.36-2.89], P = 0.004). CONCLUSIONS AND RELEVANCE CO2 laser therapy is a promising alternative for GSM management. Further randomized trials with larger sample sizes are required to confirm our findings.

Vaginal CO2 laser therapy versus sham for genitourinary syndrome of menopause management: a systematic review and meta-analysis of randomized controlled trials

Yasser Khamis

Papers

Vaginal CO2 laser therapy versus sham for genitourinary syndrome of menopause management: a systematic review and meta-analysis of randomized controlled trials