Summary
Vulvar lichen sclerous (VLS) is an important concern after the menopause and is caused by chronic vulvar inflammation associated to low levels of estrogen. Pruritus and burning sensation in the affected areas of depigmentation are usually the most frequently reported symptoms, causing dyspareunia and sexual dysfunction. Topic corticoid treatment, although effective, is often discontinued after a long time due to the low adherence [1,2]. In this sense, alternative treatments have been proposed such as microablative fractional radiofrequency (MFR). In a recent pilot study, Kamilos et al. [3] assessed the effects of MFR (including clinical response and histomorphometrics) in 26 postmenopausal women with symptomatic and histologically confirmed VLS divided into three groups according to previous management with corticosteroids: G1, no previous corticosteroid treatment; G2, treated with corticosteroid for up to 5 years; and G3, treated for more than 5 years. After each session they were examined for their symptoms on a visual analog scale and completed a satisfaction questionnaire. Morphometric findings of vulvar biopsies were performed at enrollment and after the last treatment session in 11 cases. After two to three MFR sessions, most participants in all groups became either ‘‘asymptomatic’’ or ‘‘much better’’ than prior to treatment and were ‘‘very satisfied’’ or ‘‘satisfied’’ with the intervention. Upon enrollment, pruritus and burning sensation were the most frequently reported symptoms. Nearly 40% of women in all groups reported complete remission of symptoms. The improvement was rated as moderate or higher by 80%, 76%, and 66% of participants in groups 1, 2, and 3, respectively. The symptomatic improvement persisted for a mean of 11 months (range, 7–16) after the treatment. Type III collagen concentration significantly increased and was associated with important symptom improvement. The authors conclude in their pilot study that may be an effective and safe treatment for symptomatic VLS.
Commentary
It is recommended that the indication for the MFR procedure be conveyed in a clear and transparent way to patients, who should be instructed on the limitations of the method. For the successful application of this procedure, it is also important and necessary that qualified health professionals receive adequate practical training before using the device. Despite being promising, MFR is still in the experimental stage; thus, further studies are necessary to evaluate the long-term benefits and risks for patients with vulvar diseases [1,2,4]. Prior to this commented pilot study, Kamilos et al. [5] reported for the first time the use of MRF for the management of symptoms in fourteen Brazilian women with the genitourinary syndrome of menopause, obtaining significant symptomatic improvement [5]. Radiofrequency acts promoting regeneration in the dermis through fibroblast stimulation with consequent collagen and elastic fibers synthesis. However, the number of patients was low and the authors did not use an adequate control group with topic estrogen, which is a great concern about the study. In 2021, Sarmento et al. [6] conducted a randomized trial on the effects of MFR on vaginal health, microbiota, and cellularity in postmenopausal women. Their preliminary results indicated that MFR considerably improved the vaginal microenvironment, similar to that expected in women with adequate estrogen concentrations. According to the authors, their findings suggest that radiofrequency can improve the vaginal symptoms of the genitourinary menopausal syndrome, and could be of benefit for women with VLS.
The benefits of MFR observed in the present commented pilot study [3] included improved trophism of the vulvar skin and mucosa. Intra-vaginal MFR can extend these benefits to the vaginal wall in patients with VLS associated with vaginal atrophy. A strong point the pilot study was the inclusion of participants without previous corticosteroid treatment (not easy find) which serving as controls can potentially better demonstrate the effects of the intervention. Additionally, the fractioned radiofrequency demonstrated as an innovative, easy-to-use intervention with a rapid recovery period. MFR produced a relevant and persistent improvement in symptoms, which was associated with patient satisfaction. These findings suggest that MFR can be considered as the therapeutic option or can be used to complement medical treatments for VLS. A study limitation was that we did not compare MFR with other types of thermal energy treatments and the small number of included patients (pilot study). Although VLS is a chronic disease, there is always hope for complete disease remission. Further studies are needed to compare MFR with other VLS treatments and to assess the long-term effects of the intervention.
Finally, one can say that MFR seems to be effective in the long-term relief of symptoms of VLS, especially pruritus, burning sensation, dry-ness, and dyspareunia.
José Maria Soares-Jr, MD, PhD
Professor of Gynecology, Department of Obstetrics and Gynecology
Medical Faculty, Sao Paolo University, Sao Paolo, Brazil
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