Laser Therapy in the Genital Area of Women

Laser therapy in the genital area of women, i.e. in the area of vulva and vagina (vulva: external, primary sexual organs of women; vagina: vagina), is an innovative, minimally invasive, non-surgical and non-hormonal procedure for the treatment of mostly recurrent (recurring) diseases in the intimate area that are difficult to treat. Laser procedures have been known for decades as a safe and effective treatment, especially for the restoration of skin lesions. CO2 and erbium:Yag lasers (Er:Yag lasers) are used in the intimate area. Although these two lasers differ in wavelength, the effects are very similar, making them comparable in effectiveness. Recently, there has been an increasing amount of literature showing the effectiveness of these procedures also for the therapy of vulvovaginal dysfunctions (dysfunctions of the external, primary female reproductive organs and the vagina), concerning sexuality, especially in premenopausal and menopausal women. Mild forms of urinary incontinence (bladder weakness) and descensus symptoms (descensus symptoms) can also improve, although there are not yet enough studies on this. Impressive is the minimal side effect rate of this method and the possibility to use it after chemo- or radiation therapy. In contrast to the ablative procedures (techniques that destroy tissue by heat or cold) that have been widely used to date, the epidermis (epidermis; outer cell layer of the skin) is not ablated over a large area, but only needle-prick-like microwounds are created that are surrounded by healthy skin. This means rapid healing of these microwounds with only the slightest side effects (see below).

Indications (areas of application)

  • Vulvovaginal atrophy (changes in the skin of the vagina (vagina) and vulva (totality of the external primary sexual organs) that may occur in women with decreasing estrogen levels) with symptoms such as burning, itching, dryness: during menopause, after childbirth, after irradiation or chemotherapy
  • Frequent urinary tract infections
  • Mild to moderate incontinence (bladder weakness; urine leakage).
  • Mild to moderate descensus vaginae (vaginal prolapse).
  • Dyspareunia (pain during sexual intercourse).
  • Contraindications or intolerance of hormone therapy (eg, after breast cancer / breast cancer).
  • Lichen sclerosus et atrophicus – rarely occurring, chronic inflammatory disease of the connective tissue, which is probably one of the autoimmune diseases to be counted.
  • Painful scars after episiotomy (episiotomy).
  • Vulvodynia (insensations and pain of the external primary sex organs), vulva vestibulitis syndrome (“Burning Vulva”: pain at the vaginal entrance, which is noticeable with touch, sexual intercourse or even when inserting a tampon).

Contraindications

  • Acute inflammation
  • Premalignant (tissue changes that histopathologically show signs of malignant (malignant) degeneration)/malignant (malignant) disease
  • Previous vaginal mesh surgery.

Before treatment

Before the start of treatment should be an educational and counseling discussion between the doctor and the patient. The content of the conversation should be the goals, expectations and the possibilities of treatment, as well as side effects and risks. Above all, there must be a detailed discussion of other therapeutic options, including previously performed therapies. Before the treatment, a local anesthetic is applied in the external area, as a slight burning sensation may occur here. The treatment in the vagina is practically painless. Preparatory measures do not need to take place.

The procedure

Vagina (vaginal): after insertion of a sterile laser probe made slippery with baby oil, the vaginal skin is lasered at defined intervals in an outward 360° rotational movement, each 1 cm apart. The treatment takes about 5 minutes and is painless. Occasionally, a slight, not disturbing, warming is perceived. The sensation of the application is similar to that of a vaginal ultrasound.Vulva (external, primary female genital organs): Either as a supplement to intravaginal treatment (treatment within the vagina) or in the case of localized complaints in the external genital area (see indications), treatment with a microscanner, which can be attached to the same device, is applied over the pathologically (pathologically) altered areas. Since this procedure can be painful, the affected area is anesthetized (numbed) with an ointment. Mode of action

The mode of action of lasers (erbium YAG laser, CO2 laser) used for urogynecological indications is based on hyperthermia (overheating) and coagulation. Hyperthermia performs tissue tightening and regeneration of epidermal and subepidermal structures by heating the tissue to 45-60 °C or by coagulation and ablation (tissue ablation) at 60-90 °C via activation of heat shock proteins and denaturation of collagen fibers:

  • Stimulation of the extracellular matrix (intercellular substance) in terms of nutrient uptake and fluid retention.
  • New formation of
    • Elastic and collagen fibers
    • Capillaries

Depending on the energy setting, the focus is on the effect of hyperthermia or coagulation and ablation. Combined settings are possible. The wavelength of the CO2 laser is 10.6 µm, the Er: Yag laser 2940 nm. Both are absorbed by the tissue water. That of the Erbium YAG laser is about 15 times higher than that of the CO2 laser. Fractional laser applications

In contrast to the ablative forms of laser therapy, in which the epidermis is removed over a wide area and a wound area is created that depends on the size of the ablated area, fractionated therapy, which is used exclusively in the urogynecological field, creates tiny pinprick-like micro-wounds with healthy skin areas in between. Since only about 20-40% of the treated skin area is lasered, leaving the rest intact, there are few side effects and healing is rapid. The laser energy penetrates the epithelium and reaches the subepithelial tissue layer (vagina: lamina propria). The underlying fibromuscular skin layers are not reached, i.e. they are spared. Depending on the laser energy, the penetration depth is a maximum of about 200-700 µm (0.2-0.7 mm). This ensures that surrounding tissue is not damaged. The targeted injury stimulates skin regeneration via the release of heat shock proteins and various growth factors (e.g. TGF-Beta). The consequence is the restoration of a healthy epithelium and the underlying subepithelial layer, in the vagina the lamina propria, with normal function. Therefore, many authors speak of a so-called rejuvenation (“rejuvenation”) of the vagina. Incidentally, this also affects urethral function, since the urethra develops developmentally from the same tissue as the external genitalia and vagina. Through these measures, fluid, water-binding glycoproteins and hyaluronic acid are stored, and the formation of collagen and elastic fibers is stimulated. Especially important is the formation of new capillaries, which guarantees a long-term supply of oxygen and nutrients. The vagina regains its normal acidic pH, it is elastic, stretchable and moist. During sexual arousal, fluid is squeezed out of the lamina propria, which ensures lubrication during intercourse. In addition, the pelvic floor strengthens, the sphincters of the urethra and bladder show improved function. All these effects have been demonstrated microscopically and by controlled studies (1-6,11). Mode of action: Laser therapy versus local other therapeutic measures.

Medical devices and hormone therapies are used:

  • Medical devices: Lubricants (lubricants), moisturizers (moisturisers), emollients (emollients) – work for hours to a maximum of one to two days, depending on the product
  • Local hormone therapies (e.g., hormone-containing ointments) include the use of estrogens, DHEA (dehydroepiandrosterone), and the selective estrogen receptor modulator ospemifene. Estrogens, unlike the other options, are preferred and have been used for many years. Therefore, only this therapy will be discussed in this framework.

Compared to hormone therapy, which is not desired in many women or even z.If laser therapy is contraindicated due to a malignant disease, for example, the two types of therapy do not differ in their effectiveness in some cases; in other cases, laser therapy is more effective and lasts much longer. The effect after 3-4 sessions at intervals of 4-6 weeks lasts for about a year and then should be repeated once. Vaginal estrogen therapy (vaginal treatment with estrogens), in order to be consistently effective, must be continued two to three times a week on a permanent basis. Otherwise, the positive effect quickly wears off. Apart from this, quite a few women suffer from an unpleasant discharge, itching and irritation of the mucous membrane. When comparing the regeneration effects of the laser with those of local estrogen applications (vaginal treatment), the effects on the epithelium are roughly comparable (increase in cell layers, glycogen storage). However, in the underlying subepithelial connective tissue layer (lamina propria), the effect of the laser is much more pronounced (incorporation of fluid, formation of elastic and collagen fibers, etc.). However, it is particularly important that laser therapy induces (stimulates) the formation of new vessels in comparison with estrogen therapy. This not only means a better supply of oxygen and nutrients, but is also associated with a long-lasting effect of the laser, i.e. a significantly improved quality of life. Results

Well over 2,000 patients were examined in more than 40 studies (as of 2020). Many studies were prospective non-randomized observational studies without control groups and partly with small numbers of participants and a short follow-up period. Some of the study parameters varied widely and persisted [review 17, 19]:

  • For bladder dysfunction, from
    • Validated questionnaires: ICIQ-SF (international consultation on incontinence questionnaire short form).
    • Objectifiable parameters: pad test, urodynamic parameters: e.g., increase in urethral pressure.
    • Comparison between surgery and laser: TOT (transobturator tape) versus Erb YAG laser therapy.
  • In vulvovaginal atrophy from.
    • validated questionnaires:
      • FSFI (female sexual function index)
      • VAS (visual analog scale)
      • VHI (vaginal health index)
    • Histology
    • Long-term data

Currently (2020), there are only two randomized controlled trials. With different weighting, virtually all available studies have in common a significant improvement in symptoms with only minor side effects. An international randomized trial is currently underway:

  • ClinicalTrials.gov: NCT03098992.

After treatment

After treatment, you can immediately return to your usual life. Special therapeutic measures are not necessary. Moisturizing creams and other familiar local measures are possible. For external treatment, short-term cooling with cooling pads is occasionally recommended. There should be no sexual intercourse for 3-4 days.

Possible complications

Side effects are minimal and usually last only 3-4 days:

  • Discharge, minor (brown, pink, watery).
  • Sensitivity to touch
  • Dysuria (difficult, impaired [and painful] bladder emptying).
  • Inflammation
  • Itching/edema/redness/swelling
  • (spotting)

Benefits of laser therapy

  • Virtually painless therapy
  • Without pretreatment
  • Without significant side effects
  • Without anesthesia
  • Without aftercare
  • Hormone-free
  • Can be performed on an outpatient basis in a few minutes

Critical evaluation

Currently, often still missing [overview 17, 19]:

  • Large and randomized trials
    • Compared to previous therapies
    • With long-term results
  • A comparison of the different laser systems
  • Uniform therapy regimen for laser therapy in the genital area.
    • Ablative
    • Thermal non-ablative
    • ablative + thermal combined

Résumé

Despite many unanswered questions, laser therapy is a therapy with great prospects for the future because success rates are relatively high with good patient compliance and few side effects (see above: benefits of therapy)