Genital Laser

What is genitourinary syndrome of menopause (GSM)?

GSM is the current name for what used to be called vulvovaginal atrophy (thinning and drying of the tissues). It is the collection of symptoms and findings that appear in the vulva, vagina, urinary tract and bladder as oestrogen and the other sex hormones decline. It is largely due to the natural process of ageing, and to menopause in particular.

Symptoms

Vaginal dryness, burning, irritation, reduced lubrication, laxity, a feeling of discomfort and pain. These in turn can lead to vaginal infections, inflammation of the bladder, burning on passing urine and pain during intercourse.

What happens in the tissue?

• The surface cells multiply less.
• Glycogen production falls.
• Because the pH rises so much, the Lactobacilli that make up the normal vaginal flora disappear.
• The blood supply decreases.

The overall result is less vaginal secretion and less moisture.

In addition, the outer lips, which are full in youth, lose volume and flatten with age. The function of the outer lips is to surround and protect the other external genital structures; when they lose volume, the inner lips, the vagina and the urinary tract are left unprotected. This too contributes to infection, inflammation of the bladder, pain and discomfort.

How common is it?

Up to 50% of women who have gone through menopause experience at least one complaint due to GSM, and this affects quality of life and sexual life.

Frequencies reported after menopause:

• Vaginal dryness: 27–55%
• Pain during intercourse: 32–42%
• Urinary tract infection: 4–15%

What are the options?

The approaches listed in the source are:

1. Moisturisers and lubricants — used during intercourse.
2. Hormone therapy — prescribed if there is nothing that stands in the way. For details you can see the Body-Identical Hormone Therapy page.
3. Local (topical) oestrogen preparations.
4. Alongside these, tools such as hyaluronic acid, PRP or laser are also used.

To be known first: the regulators' warning

What do the studies show?

GSM and vaginal dryness: clinical studies and studies based on tissue examination with fractional CO2 and Er:YAG lasers report significant improvement compared with placebo in vaginal dryness, burning, itching, pain during intercourse (dyspareunia) and pain on passing urine (dysuria).

This matters particularly for people in whom the use of oestrogen is inadvisable — for example those who have had breast cancer.

Stress urinary incontinence: when laser energy is applied to the front wall of the vagina, the heat effect is reported to produce about 30% shrinkage and tightening in the supporting tissue beneath the urinary tract, giving the bladder neck support like a hammock. However, the warning above applies to this use as well.

What changes in the tissue?

The laser beam is absorbed by the water molecules in the vaginal tissue. Through the small areas of heat that this creates, the following changes are reported:

• The surface tissue thickens: the thinned and fragile surface cell layer (epithelium) increases in thickness.
• The flora is re-established: glycogen (the cells' sugar store) accumulates at the surface. This feeds the protective Lactobacillus bacteria, returns the acidity of the vagina to its pre-menopausal level and reduces the risk of recurrent infection.
• Collagen and elastic fibre production increases: the heat stimulates the cells that produce collagen (fibroblasts); the elasticity and supporting strength of the tissue increase.
• The blood supply increases: new small vessels develop; blood flow and tissue nourishment improve, and natural lubrication is regained.

How does a laser work?

Most medical lasers work on the principle of a targeted photo-thermal effect. When the laser beam reaches the target tissue it may be reflected, absorbed or transmitted — what is wanted is for it to be absorbed by the tissue.

Tissue components that are able to absorb light of a particular wavelength are called chromophores (the tissue component that absorbs the light). There are three main chromophores: haemoglobin, melanin and water.

The appropriate wavelength, beam diameter, energy flow and pulse frequency are chosen according to the tissue component to be treated.

Water-targeted lasers

• Er:YAG laser — emits invisible infrared light at a wavelength of 2940 nm. Because its target chromophore is water, it is a tissue-removing (ablative) laser. It acts mainly on the upper skin layer.
• CO2 laser — developed in 1964, it is one of the oldest gas lasers and is still considered one of the most useful types. It reaches both the upper and the middle skin layer.

Fractional versions of both lasers have been developed. In fractional technology the energy is delivered not to the whole surface of the tissue but to spot areas; the intact tissue in between acts as the source of healing. This is a more measured approach than classic ablative use.

How is it carried out?

• Number of sessions: the common protocol is 3 sessions 4–6 weeks apart. In some situations this may go up to 5 sessions.
• Anaesthesia: it is done in the outpatient setting and usually does not require anaesthesia; a local numbing cream may be applied to the entrance.
• Continuity: because the collagen production stimulated by the laser declines over time, a single reminder session once a year is recommended; depending on the state of the tissue the whole course may need to be repeated every two years.

What to expect afterwards

The complaints are usually mild and temporary:

• First 24 hours: mild redness, swelling and slight pinpoint bleeding may be seen in the treated area.
• First 7–10 days: there may be mild stinging, soreness, itching, tingling and mild burning on passing urine.
• Discharge: for the first few days a light pink watery discharge is expected, followed by a heavy, clear discharge lasting 7–15 days. This is the result of the shedding surface cells — it is not a sign of infection.
• Flu-like symptoms: on the day of the procedure there may be tiredness, a slight fever, sweating and muscle and joint pain. This is due to the controlled healing process that has started in the tissue.

Rare serious situations

• Adhesions in the vagina (synechiae): very rare — reported only 3 times in more than 9,000 applications. It is generally seen when excessively high energy is applied in people with advanced thinning, and can easily be released in the outpatient setting.
• Lasting damage: excessively aggressive application, or a procedure carried out while an infection is present, may lead to scar tissue, spread of the infection, worsening of pain or changes in sensation. The overall risk is below 1%.

Who is it not performed on?

Genital laser should not be applied in the following situations:

• Active infection: vaginitis, urinary tract infection, thrush, or a tissue change (lesion) due to active HPV or herpes — because of the risk of spread, this must be treated first.
• Abnormal cell findings or cancer: an abnormal smear result within the past year, gynaecological cancer, or bleeding whose cause has not been established.
• Pregnancy and the first 3 months after birth.
• Advanced prolapse: moderate or advanced prolapse, or large bladder/bowel prolapse. In these situations the tears in the muscle and connective tissue cannot be repaired with a laser — the only option is surgery.
• Active inflammatory skin disease in the area: lichen sclerosus, lichen planus or psoriasis.
• Uncontrolled diabetes or severe immune deficiency — these impair wound healing.
• Use of blood thinners, or the use of oral isotretinoin for acne within the past 12 months.
• Light sensitivity, body image disorder or unrealistic expectations.

Safety

The emphasis of the source text is clear: the lasers used must be as safe for the operator as they are effective and safe for the patient. Operators must be trained in protecting themselves with goggles appropriate to the wavelength being used.

It is noted that with ablative lasers the healing time can be long and there is a risk of darkening of colour and of scarring; for this reason cooling before and after the procedure is important.