Ginecología Cosmética or Cosmetic Gynecology

Vulvo-Vaginal Atrophy

Er:YAG laser treatment of vulvovaginal atrophy rejuvenates atrophic vaginal tissue and significantly improves the patient’s quality of life

By Adrian Gaspar M.D.

Gynecology Department. Mendoza University. Argentina.

As a gynecologist working for more than a decade in the development of various therapies for vulvo-vaginal rejuvenation, I am very glad that IMCAS has recognized this medical segment as an important new area of its interest and has begun to include vulvo-vaginal rejuvenation sessions in its program. Last year’s first session attendance probably exceeded everyone’s expectations, and I am looking forward to listening to many more talks this year, when as many as four sessions are scheduled.

It is a great pleasure for me to be a part of this program and to be able to share some work I´ve been doing on vulvo-vaginal atrophy therapies.

Vulvo-vaginal atrophy is most commonly associated with the diminished estrogen levels that accompany menopause and aging. Almost 50% of postmenopausal women have symptoms of vulvo-vaginal atrophy, which include vaginal dryness and irritation, dyspareunia, recurrent urinary tract infections and the increased probability of vaginal tissue trauma during sex. Women suffering from vulvo-vaginal atrophy are mostly sexually dysfunctional and have significantly diminished quality of life.

A large range of possible treatments for management of vulvo-vaginal atrophy are available, from lifestyle modifications (change of diet, cessation of smoking, maintaining regular coital activity or masturbation), through to the use of moisturizers and lubricants, and to hormonal replacement therapy.

Local hormonal therapy is considered the gold standard for the treatment of vulvo-vaginal atrophy, but it has certain limitations, especially in a population of women with breast cancer, other genital malignancies, hormonal dependent cancers and the problem of an increase sensation of cancerphobia in our society. Now, more than ever, our patients refuse to receive hormones for a long period of time.

As the other existing therapies also have quite some limitations, there is a continuous quest for some better treatment options.

For the last 10 years, I have been deeply involved in the development of novel approaches for treatment of vulvo-vaginal atrophy, among which laser therapies have shown the best results. In our latest study comparing the efficacy and safety of Non-ablative ErYAG laser treatment with local estrogen therapy, we were observing the main atrophy symptoms: dryness, irritation, pain and leucorrhea, as well as the maturation value and ph value. We also took biopsy samples and analyzed morphological changes in vaginal mucosa. Both groups (laser and estrogen) showed improvement in atrophy, but laser therapy showed better and more long-lasting effects. Also, both groups tolerated the therapy well, and adverse effects were mild and transient. In all follow-ups (at 1, 3, 6 and 12 months), the improvements of atrophy symptoms were significantly better in the laser group, as well as with the improvements in maturation value and vaginal acidity (ph).

We observed remarkable changes in the morphology of the vaginal mucosa. Samples from the laser group showed that laser therapy significantly improves trophism and reversing the effects of atrophy: first, through an increase in the blood flow (initial vasodilation effect), which will principally improve the supply of oxygen and nutrients to the treated area, which is what we call A Real Rejuvenation; second, the warming effect induced by the Non-ablative Erbium laser will stimulate not only fibroblasts, but also keratynocites to work to repair the thermal changes produced by the laser. At this point, I would like to emphasize something: The less aggressive, the better the results over time.

This is the main reason why we abandoned what we had used in the past, the more aggressive ablative and micro-ablative laser techniques (used in the past and even now), and started using this new, less invasive and better procedure.

The outcome of this process will be an increase in all of the extracellular matrix components, including elastic and collagen fibers, as well as an improvement in vascularization of the lamina propria, also the turnover and glycogenic load of the epithelium.

While estrogen mostly increases the glycogen level in the vaginal epithelium and its turnover, it does so with less effect on the vascularization and changes in the lamina propria. This is the reason why vaginal atrophy symptoms tend to reappear when patients discontinue the topical hormonal treatment.

In our opinion, the only way to improve all symptoms of a vaginal atrophy is by improving either the local estrogen levels or the blood flow in the affected area. These two things (and the lack of use) are, among others, the three more important causes of vaginal atrophy.

We have demonstrated that, with the less aggressive non-ablative Erbium laser, the trophism of the mucosa can be improved, achieving long-lasting results (more than a year). This cannot be done with discontinuous local hormonal therapy.

Let me say, at the end, that after having been working with laser therapies for so many years and having treated hundreds of patients, I am quite confident that various laser therapies (among them, especially, with the ErYAG laser), it will soon become the treatment of choice for vulvo-vaginal atrophy. It´s only a matter of time.