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Summary

Gambacciani et al. [1] performed a prospective pilot study to evaluate the effects of associating a neodymium:yt-trium–aluminum–garnet (Nd:YAG) laser with a vaginal erbium laser (VEL), as a non-ablative photothermal therapy for superficial dyspareunia in postmenopausal women (PMW) suffering of the genitourinary syndrome of menopause (GSM). Two groups of sexually active PMW reporting superficial dyspareunia were selected: one (n= 15, VEL) was treated using an erbium:yttrium–aluminum–garnet laser crystal with a wavelength of 2,940 nm; and the other group (n =15, VEL + Nd:YAG) was treated with VEL and after by Nd:YAG laser treatment. Treatment consisted of three laser applications at 30-day intervals. Symptoms were assessed before, after each laser application and after 1 and 3 months from the end of the treatment, using the subjective visual analog scale (VAS) for superficial dyspareunia. All the participants (n = 30) of the both groups showed a rapid and significant improvement of superficial dyspareunia over time independently of age and years since menopause. The VEL + Nd:YAG group showed a greater improvement of superficial dyspareunia; this difference was evident since the first treatment and remained stable over time. Authors conclude that this pilot study demonstrates that the addition of Nd:YAG to VEL may induce greater improvement in superficial dyspareunia in PMW with GSM.

Commentary

GSM is a newly coined term that refers to a series of concerning symptoms related to estrogen deficiency, involving changes not only in the genital area but also the urinary tract. This term was first proposed in 2014 by the North American Menopause Society (NAMS) and the International Society for the Study of Women’s Sexual Health (ISSWSH) to provide a more accurate representation of vulvovaginal atrophy (VVA) in menopause [2].  GSM is chronic and is likely to worsen over time, affecting up to 50% of postmenopausal women. The symptoms related to GSM include genital symptoms of dryness, burning, irritation, but also sexual symptoms including lack of lubrication, discomfort or pain, and impaired sexual function, as well as urinary symptoms of urgency, dysuria and recurrent urinary tract infections. All these symptoms may interfere with sexual function and quality of life [3]. Dyspareunia is the most bothersome symptom in sexually active women suffering of GSM [4]. However, these symptoms can be overcome by understanding the various treatment options and finding optimized options for each patient. The gold standard as conservative treatment of GSM are systemic and local hormone therapy, vaginal dehydroepiandrosterone and oral selective estrogen receptor modulators.

Although it is known that hormone therapy is a safe and a useful option for selected populations, many postmenopausal women still refuse its use. Moreover, these therapies present several contraindications. GMS is often underdiagnosed and undertreated [5]. Non-pharmacological therapies include non-hormonal local preparations, acupuncture, laser therapies and pelvic floor muscle training, lubricants, moisturizers and hyaluronic acid based preparations all which may be useful to relieve symptoms of GSM. There is even some evidence that laser therapies can restore the vaginal epithelium to that of the premenopausal state; however, these studies lack of randomization [6].

Laser treatments, including fractional CO2 laser therapy, erbium laser therapy (Er:YAG) [7], and other energy based devices, such as radiofrequency treatments are being used to treatment symptoms of GSM [8]. A meta-analysis of vaginal laser treatments [CO2 laser (n = 10 papers) and Er: YAG (n = 4 papers)] concluded that laser therapy appears to reduce symptoms of GSM and improve quality of life [9]. Similar to vaginal estrogen treatment, vaginal laser treatment has been shown to increase the thickness of vaginal epithelium and improve the quality of the vaginal mucosa. However, there is still limited prospective data with long-term follow-up and there are some studies which failed to show an improvement with laser treatment [10].

In the present commented study, Gambacciani et al. [1], have shown that the addition of Nd:YAG to VEL may induce greater improvement in superficial dyspareunia in PMW with GSM.  This is the first study that evaluates the efficacy of the combination of VEL + Nd:YAG laser on superficial dyspareunia in PMW. The results of this pilot, prospective longitudinal study indicate that the proposed association induces a more rapid, greater and sustained improvement of superficial dyspareunia than VEL treatment alone. The study suggests that the combined laser treatment is effective as a new non-ablative photothermal therapy for the treatment of superficial dyspareunia. Despite this, further larger, long-term and well-controlled studies are required to explore the use of the two complementary laser wavelengths (VEL + Nd:YAG) as compared to VEL alone and/or different therapeutic options, in order to offer a safe and effective option to treat superficial dyspareunia in women with GSM.

Mónica L. Ñañez, MD, PhD
National University of Cordoba, Cordoba, Argentina
President of Argentine Association of Menopause and Andropause

References

  1. Gambacciani M, Fidecicchi T. Short-term effects of an erbium/neodymium laser combination in superficial dyspareunia: a pilot study. Climacteric. 2022;25(2):208-211.
    https://pubmed.ncbi.nlm.nih.gov/35006008/
  2. Portman DJ, Gass ML. Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Maturitas. 2014;79(3):349-354.
    https://pubmed.ncbi.nlm.nih.gov/25179577/
  3. Ñañez M. Síndrome genitourinario (GSM). Diagnóstico. Prevención. Tratamiento hormonal local. Climaterio: lo que hay que saber. pp: 213-223. 1era edición para el profesional, Ciudad Autónoma de Buenos Aires: Ascune, 2019.
  4. Phillips NA, Bachmann GA. The genitourinary syndrome of menopause. Menopause. 2021;28(5):579-588.
    https://pubmed.ncbi.nlm.nih.gov/33534428/
  5. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992.
    https://pubmed.ncbi.nlm.nih.gov/32852449/
  6. Athanasiou S, Pitsouni E, Grigoriadis T, et al. Microablative fractional CO2 laser for the genitourinary syndrome of menopause: up to 12-month results. Menopause. 2019;26(3):248-255.
    https://pubmed.ncbi.nlm.nih.gov/30252804/
  7. Gambacciani M, Levancini M. Vaginal erbium laser as second-generation thermotherapy for the genitourinary syndrome of menopause: a pilot study in breast cancer survivors. Menopause. 2017;24(3):316-319.
    https://pubmed.ncbi.nlm.nih.gov/28231079/
  8. 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.
    https://pubmed.ncbi.nlm.nih.gov/33089713/
  9. Pitsouni E, Grigoriadis T, Falagas ME, Salvatore S, Athanasiou S. Laser therapy for the genitourinary syndrome of menopause. A systematic review and meta-analysis. Maturitas. 2017;103:78-88.
    https://pubmed.ncbi.nlm.nih.gov/28778337/
  10. Dutra PFSP, Heinke T, Pinho SC, et al. Comparison of topical fractional CO2 laser and vaginal estrogen for the treatment of genitourinary syndrome in postmenopausal women: a randomized controlled trial. Menopause. 2021;28(7):756-763.
    https://pubmed.ncbi.nlm.nih.gov/34010934/

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