Bretas et al.  have recently published data of fourteen sexually active postmenopausal women with vulvovaginal atrophy, aged 45 to 65 with aim of evaluating the clinical response and collagen remodeling in the vaginal wall after three monthly sessions of carbon dioxide (CO2) laser application. Women filled out clinical questionnaires (Vaginal Health Index [VHI], the Female Sexual Function Index [FSFI] and the International Consultation on Incontinence Questionnaires Short Form [ICIQ-SF]), gynecological examinations and histological techniques before and after 20 weeks of treatment. Biopsies were taken from the lateral vaginal wall at baseline week 0 (left wall) and week 20 (right wall). Tissue samples were stained with hematoxylin and eosin, Periodic Acid-Schiff (PAS), Picrosirius Red Stain and Orcein dyes. Immunohistochemical study was used to quantify collagens I and III in the samples. Mean age of participants was 54.4 ± 4.5 years, with an average time of amenorrhea of 7.6 ± 5.1 years. After 20 weeks of treatment with laser, total FSFI and VHI scores increased whereas ICIQ-SF scores decreased. Vaginal pH did not significantly change. Histological studies showed significant increases in the total and superficial epithelial cell layers, and type III collagen fibers. Immunohistochemical studies confirmed the significant increase in collagen III. The authors conclude that histological findings evidenced a reversal of epithelial atrophy and collagen remodeling of the vaginal wall confirmed by immunohistochemical analysis.
The management of vulvovaginal atrophy is a major issue for both patients and those taking care of postmenopausal women. Despite different available treatments, the eradication of the problem is not feasible with the current available options. In addition, if clinical problems are untreated, the evolution is progressive due to the presence of other co-morbid conditions. Bretas et al.  reported the results of a pilot study based on the monthly vaginal application of CO2 laser (three sessions) to postmenopausal women aged 54 (menopause onset 7 years average); in addition of including both clinical and histological assessments. This approach is relevant because it included the subjective perception of the patient and there was also a histological assessment of effect of the laser application. The used questionnaires were well-know and validated tools for those working in the field of assessing vaginal and urinary symptoms. In addition, vaginal biopsies were performed to women before and after the complete treatment. The used histological techniques such as hematoxylin-eosin, PAS and others are considered standards.
The clinical response after treatment was favorable as determined by an increase in VHI and FSFI scores, in addition to the improvement of urinary continence. Also, after treatment there was an increase of vaginal pH, epithelial cells, and collagen type III. The authors have documented the article with very nice photos comparing the characteristics of the vaginal mucose before and after the treatment. The immunohistochemical photos post-treatment provide support of the improvement of the vaginal epithelium thickness and the increased production of collagen type III.
Bretas et al.  document their findings with validated histological techniques and analogous clinical exams and questionnaires reporting differences before and after treatment. These results contrast with a recent publication of Li et al.  reporting a lack of benefit of laser vaginal applications as compared to a sham intervention. This study was a randomized clinical trial of Australian women with similar age, similar type of used laser and three applications, although performed 4 to 8 weeks apart. The study aimed at determining the efficacy of fractional carbon dioxide laser for the treatment of vaginal symptoms associated with menopause. The authors reported no significant benefit among participants and found no differences in the severity of symptoms, quality of life, and histological characteristics. Furthermore, in this particular study there were 16 adverse events in the laser treated patients and 17 in the sham treated women, including vaginal pain/discomfort, spotting, discharge, and lower urinary tract symptoms. Contrary to this, no adverse effects were reported in a multicentric Italian study  that evaluated the effects of vaginal erbium laser on sexual function in postmenopausal women suffering from the genitourinary syndrome of menopause. The treatment improved sexual function among participants which was evidenced by an increase of the scores of the used sexual function assessing tools.
The controversy regarding the management of vulvovaginal atrophy continues [3-5] as well as for the effects of vaginal laser application basically due to the lack of being able to compare studies in addition to having standard criteria for evaluating outcomes.
Iván Altamirano-Barcia, MD, MSc
Deputy Director, Hospital Alfredo G. Paulson, Complejo Hospitalario
Alejandro Mann, Junta de Beneficencia de Guayaquil, Guayaquil-Ecuador
Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil Ecuador
- Bretas TLB, Issa MCA, Fialho SCAV, Villar EAG, Velarde LGC, Pérez-López FR. Vaginal collagen I and III changes after carbon dioxide laser application in postmenopausal women with the genitourinary syndrome: a pilot study. Climacteric. 2021 Jul 22:1-9.
- Li FG, Maheux-Lacroix S, Deans R, et al. Effect of Fractional Carbon Dioxide Laser vs Sham Treatment on Symptom Severity in Women With Postmenopausal Vaginal Symptoms: A Randomized Clinical Trial. JAMA. 2021;326(14):1381-1389.
- Gambacciani M, Albertin E, Torelli MG, et al.; Italian Vaginal Erbium Laser Academy. Sexual function after vaginal erbium laser: the results of a large, multicentric, prospective study. Climacteric. 2020;23(sup1):S24-S27.
- Salvatore S, Pitsouni E, Grigoriadis T, et al. CO2 laser and the genitourinary syndrome of menopause: a randomized sham-controlled trial. Climacteric. 2021;24(2):187-193.
- Pérez-López FR, Phillips N, Vieira-Baptista P, Cohen-Sacher B, Fialho SCAV, Stockdale CK. Management of postmenopausal vulvovaginal atrophy: recommendations of the International Society for the Study of Vulvovaginal Disease. Gynecol Endocrinol. 2021;37(8):746-752.
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