Summary

Due to the increase in female life expectancy (around 80 years) observed in the different continents and with an average age at menopause onset of 48.6 years, it is becoming very important to seek new strategies to maintain an adequate quality of life in the different aspects of mid-life women's health. In this regard, it has been observed that the Genitourinary Syndrome of Menopause (GSM) can affect up to 75% of postmenopausal women, seriously altering different aspects of their lives. The most frequently reported symptoms include vaginal dryness, pruritus, burning, dyspareunia, altered urination frequency, urgency, dysuria and different degrees of stress urinary incontinence. Sexuality is one of the most affected aspects. In July of this year, Salvatore et al. [1], as part of the working group of the European Urogynecology Association (EUGA), published a review on a still controversial topic comparing the 2 types of lasers most frequently used in gynecology to manage the GSM. In this regard, it clarifies that the current indication for its use is mainly the treatment of symptoms of vulvovaginal atrophy and/or the GSM, and not in the area of gynecological cosmetology where it has been widely used with very different results.

Commentary

The objective of the review was to evaluate the safety and effectiveness of the two main types of vaginal lasers used to treat symptoms of vulvovaginal atrophy and/or GSM: micro-ablative fractional CO2 laser and the non-ablative photothermal Er:YAG laser. Salvatore's review includes mostly non-randomized prospective studies and prospective observational studies with very heterogeneous protocols, which makes their comparison very complex. The selected population, in the vast majority of the studies, corresponded to postmenopausal women as an alternative to local hormonal therapies (estrogens) when the effectiveness is not as expected or when they do not want or cannot use hormonal therapy, such as breast cancer survivors [2]. The effectiveness of both types of lasers at improving vaginal health was mainly evaluated through the vaginal health index (VHI) and the vaginal maturation index (VMI). In studies where sexual function was evaluated, studies used the Female Sexual Function index (FSFI).
 
In this review, with the use of the mentioned indexes both lasers demonstrated similar results in reducing symptoms of vulvovaginal atrophy and/or the GSM, this way improving the quality of life of women during this menopausal stage. However, despite the multiple publications on the matter, to date there are no Randomized Controlled Trials with an adequate control group or clear inclusion criteria with homogeneous protocols and long-term follow-up to validate its effectiveness and safety. Hence, there is still a need for adequate RCTs to further provide clear conclusions.
 
Margot Acuña-San Martín, MD
President of the Chilean Menopause Society
Director of the Department of Obstetrics and Gynecology
Universidad de la Frontera, Temuco, Chile
 

References

1. Salvatore S, Ruffolo AF, Phillips C, Athanasiou S, Cardozo L, Serati M; EUGA Working Group. Vaginal laser therapy for GSM/VVA: where we stand now - a review by the EUGA Working Group on Laser. Climacteric. 2023;26(4):336-352.
   https://pubmed.ncbi.nlm.nih.gov/37395104/
2. “The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
   https://pubmed.ncbi.nlm.nih.gov/35797481/