HORMONAL FLUCTUATIONS IN PERI- AND MENOPAUSE CAN LEAD TO DRY VAGINAS!
What is Menopause?
Menopause, also known as 'The Change' or climacteric, is defined as the lack of menstrual bleeding for 12 months as a result of ovarian failure or due to surgical removal of the ovaries. Normally, it is a slow process and can start as early as the late thirties and forties when it is referred to as perimenopause.
Menopause is an entirely normal process unless it occurs before 35 years of age. Many women are completely asymptomatic or have minimal symptoms from the lack of estrogen. However, some women have severe symptoms and benefit from medications. Hormonal supplements can be prescribed to prevent or treat these symptoms, but not all women need them or benefit from them. There are hundreds of studies that analyzed the issue of hormone supplementation, and the consensus is that each case must be individualized, but the benefit appears to be higher if it is started earlier in menopause rather than many years later.
There are situations, diseases, or habits that can affect when menopause will occur, although it is mainly genetic. A woman tends to go through 'the change' about the same time as her mother did. Smoking, chemotherapy, previous ovarian surgery, and ethnicity affect the timing of menopause. Hispanic and African-American women experience it a little earlier while Chinese and Japanese experience it a little later than whites, whose average age is 51.5.
How or Why Does Menopause Occur?
As we age, the estrogen production from the ovary decreases, which increases the production of a hormone called FSH from the pituitary, which is a gland in the brain near the hypothalamus. Thus, an elevated FSH is a useful blood test to determine whether the woman has good (fertile) or poor (subfertile) ovarian function. FSH is low during fertile times and high closer to menopause. Eventually, the estrogen level is too low even to produce a lining that can shed each month. Voila, menopause!
What are the Signs and Symptoms of Menopause?
So, what are the other signs of menopause besides no bleeding each month? One of the first signs is the well-known and dreaded 'hot flash' which is a rush of heat to the face, head, neck, and other body parts. The face flushes pinkish, and a racing heart rate may occur. Hot flashes can impair sleep when they happen at night, which seems to be common.
The lack of estrogen can have effects on other body systems such as the bladder, vagina, bones, brain, and breasts. Estrogen is essential for collagen formation, and this loss results in a thinning of the vaginal tissue, known as vaginal atrophy. Atrophy means the vagina is drier, the walls thinner, and can burn during sex. These symptoms can also occur in perimenopause!
Other symptoms of low estrogen are:
Osteoporosis-bone thinning or weakening
Achy joints,
Brain fogginess
Gastrointestinal problems
Hair loss
Abnormal hair gain growth on the face
Fatigue
Headaches
What Can Be Done About Dry, Irritated Vaginas?
Dry, irritated, and thin vaginas cause much distress and can mess up your sex life just when the fear of becoming pregnant disappears. How ironic is that? Vulvovaginal atrophy (VVA) is the official medical term for the condition. VVA symptoms include dryness, burning, pain, less lubrication, and pain with sex, called dyspareunia.
Standard therapies include estrogen both topically and orally. With longstanding vaginal atrophy, it may take three or more months of topical estrogen to see any relief. The sooner a woman takes action to protect her vagina from the lack of estrogen, the better her result will be. The reason that estrogen is important for vaginal health is because it maintains the collagen, elastin, and blood supply. As collagen and elastin break down and are no longer replenished, the walls get thinner and lose support. The vagina starts to shrink in length and caliber. The diminished blood supply only adds to the problem since a good blood supply is essential for carrying nutrients, oxygen, and for healing.
Minimally absorbed local vaginal estrogen via creams or vaginal suppositories, or selective estrogen agonist and estrogen antagonist medications, remain the endorsed treatment of choice for genitourinary syndrome of menopause (GSM), by both the North American Menopause Society (NAMS)1 and The American College of Obstetricians and Gynecologists (ACOG),2 However, CO2 Laser therapies have come to the forefront based on their successful use in improving facial tone and wrinkles, both of which are due to less collagen and elastin in older skin and women with low estrogen.
Let's Learn About Lasers
The word LASER is an acronym for "light amplification by stimulated emission of radiation." Lasers generate light energy in the form of a beam of photons (light units) released from the medium contained in the laser device. This generally gives the laser its name such as CO2 or erbium and defines its specific wavelength. Current medical lasers emit wavelengths from the ultraviolet to the mid-infrared spectrum. The medium is activated with some form of energy, which is usually light or electricity. Lasers are designed to focus their rays on very small areas or points.
The main biological targets of lasers are blood (hemoglobin)-varicose veins, melanin (age spots), and water. These absorb the energy of light very differently and have optimal absorption spectra depending on the wavelength of the incident photon energy. Laser treatment has been used safely and effectively in many areas, such as dermatology, dentistry, ophthalmology, and cosmetic-aesthetic medicine. In recent years, several innovative publications on the use of lasers in gynecology have emerged, mirroring the benefits observed in other medical specialties.
The three physical characteristics that have made it possible to use lasers in the vulvovaginal areas are:
they are not ablative or destructive but have thermal effects;
are absorbed by water effectively-the vagina is 90%
they are fractional, which means that the surrounding healthy tissue recovers and regenerates quickly and without discomfort [17].
In gynecology, there are three basic indications where lasers are effective.
Vulvovaginal atrophy (VVA)/genitourinary syndrome of menopause (and PERImenopause, too),
Vaginal hyperlaxity syndrome,
Stress urinary incontinence (SUI) [18].
There are also studies in other diseases such as genital prolapse and vulvar lichen, but more evidence is needed.
How Do Lasers Work?
The possible mechanisms by which laser treatment may improve SUI are its stimulant and photothermal effects. Laser biostimulation restores vaginal functions such as secretion, absorption, elasticity, lubrication, and thickness of the vaginal epithelium [19]. The photothermal effect is the result of the laser penetrating the vagina to a depth of 0.5 mm, resulting in a 30% reduction in tissue volume. The mechanical traction on the surrounding tissues contributes to the production of new elastin and collagen. This, in turn, increases the thickness of the vaginal lining, elasticity, and firmness of the vaginal wall, all of which help with stress urinary incontinence (SUI) [20].
Atrophy of the pelvic floor muscles and the reduction of collagen content are important factors in the increased prevalence of both SUI and urge urinary incontinence (UUI). Laser-induced neocollagenesis (new collagen growth)changes the composition of the pelvic support tissues and thus increases the pressure throughout the length of the urethra. This increase in urethral pressure can relieve overactive bladder (OAB) symptoms.
There are controversies and doubts regarding the efficacy and safety of the CO2 laser in urinary incontinence (UI). A recent study by Palacios and Ramirez attempts to clarify the available data on the use of the CO2 laser in the different types of UI (21).
How is Vaginal Laser Therapy Performed?
The procedure is virtually painless, well-tolerated, and easily performed by clinicians. Usually, there are three procedures performed, separated by intervals of between 4 and 6 weeks. The energy will depend on the device and the protocols established for each. However, treatment must be personalized, depending on the disorder to be treated, and the patient's age and sensitivity to the laser. 80% of women at the end of treatment are very satisfied/satisfied. Regarding tolerability, only 1 in 201 patients considered the procedure unacceptable, while tolerability was reported as excellent, good, or acceptable in 90% of treated women. Less than 10% of patients referred to the procedure as a bad experience [18].
Lasers Like FemTouch Improve Vaginal Atrophy Symptoms [13]
Improvement of vulvovaginal symptoms after fractional CO2 laser, like Femtouch, has been demonstrated in multiple case series [3,4,6,8 ]. A study by Cruz et al. was conducted to evaluate the effects of fractional CO2 laser in comparison to estriol topical therapy, considered the gold-standard treatment for local VVA symptoms [6].
The results showed that either fractional CO2 laser alone, estriol alone, or the combination of both treatments resulted in improved vaginal health and VVA symptoms. These results were reinforced with an analysis of the vaginal cell specimens.
The LE, E, and L groups showed statistically significant improvement in the vaginal health index (VHI) at week 8, suggesting that both fractional CO2 laser and estrogen therapies promote a fast and significant improvement in the vaginal mucosa. Similar results were reported in studies evaluating the efficacy of fractional CO2 laser[8,11].
Incremental improvement of VHI was found in the combined use of laser and estrogen after 8 weeks. Sokol and Karram evaluated the efficiency and safety of fractional CO2 laser for VVA in a 1-year follow-up and demonstrated that the positive effects on VVA symptoms (burning, dryness, and dyspareunia) and VHI persisted for at least 1 year after three sessions of fractional CO2 laser[10]
The fractional CO2 laser effects on the vaginal mucosa persisted for at least 16 more weeks after the last session but that if topical estrogen applications had been stopped, the positive results of this treatment would not have been maintained [5,12].
Fractional CO2 laser alone and the combined therapy improved reported VVA symptoms of burning, dryness, and dyspareunia throughout the study.
Salvatore et al. used the same laser system and parameters used in this study, but three laser sessions (weeks 0, 4, and 8) were performed instead and showed significant improvement at week 12 [3].
Salvatore et al. reported similar effects in vaginal mucosa histology after fractional CO2 laser therapy, suggesting that fractional CO2 laser promotes morphological changes and mucosal restoration [9].
This is the first study to compare fractional CO2 laser performance to the use of local estrogen for vulvovaginal symptoms. The vaginal health benefits resulting from fractional CO2 laser treatment persisted for at least 16 weeks. The fractional CO2 laser is a convenient alternative to local estriol, in which contraindications, low compliance due to vaginal discharge, and daily self-application can be of concern[13].
Lasers for Vaginal Elasticity, Moisture, and pH
Another study by Samels and Garcia [14] in 2019 showed that for forty postmenopausal women, three monthly fractional CO2 laser treatments significantly improved and maintained vaginal health indices of elasticity, fluid volume, pH level, epithelial integrity, and moisture. Self-reported symptoms of vaginal atrophy were also measured. Biopsy samples were collected. Vaginal biopsy findings showed increased collagen and elastin as well as a thicker epithelium with an increased number of cell layers that had a favorable level of maturation.
Lasers for Sexual Satisfaction
Politano et al. evaluated 72 postmenopausal women who were randomly put in three different treatment groups; CO2 Laser, promestriene cream, and vaginal lubricant. Vaginal maturation, Vaginal Health Index (VHI) score, and Female Sexual Function Index (FSFI) were evaluated at baseline and after 14 weeks of therapy. The results showed an improvement in the vaginal elasticity, volume, moisture, and pH in the CO2 laser and promestriene groups. Regarding vaginal maturation, immature cells were decreased, and mature cells increased, all indicating improved tissue thickness (15).
Perino et al. studied 48 women with VVA. Data indicated a significant improvement in VVA symptoms (vaginal dryness, burning, itching, and dyspareunia) in patients who had undergone 3 sessions of vaginal fractional CO2 laser treatment. Overall, 91.7% of patients were satisfied or very satisfied with the procedure and experienced considerable improvement in the quality of life (QoL). No adverse events due to fractional CO2 laser treatment occurred (16).
It's Time to Get Your Vagina Back in Shape!
The Gynecology Institute offers one of the best fractional CO2 laser treatments in the form of Femtouch. Femtouch is made by the leader in laser technology, Lumenis. As you can see, studies show that laser rejuvenation can increase lubrication, reduce pain with intercourse, and fight dryness. It can be combined with vaginal estrogen for an even better result. However, some women cannot tolerate or take estrogen, even vaginally. So, Femtouch is the perfect solution for all peri- and postmenopausal women with vaginal dryness and painful sex, especially those women. We're offering special discounts on our signature procedure, so call us today!
Yours in Happy Vaginas,
Dr. Nicole E. Williams, MD, FACOG, FACS
Video on Menopause and Sexual Health
Bioidentical Hormones
References
The NAMS 2017 Hormone Therapy Position Statement Advisory Panel.
The 2017 hormone therapy position statement of The North American Menopause Society . Menopause. 2017;24(7):728-753
ACOG Practice Bulletin No. 141: management of menopausal symptoms Obstet Gynecol 2014;123(1):202-216
Salvatore S, Nappi RE, Parma M, et al. Sexual function after fractional microablative CO2 laser in women with vulvovaginal atrophy. Climacteric , 2015; 18:219–225.
Stefano S, Stavros A, Massimo C. The use of pulsed CO2 lasers for the treatment of vulvovaginal atrophy. Curr Opin Obstet Gynecol 2015; 27:504–508.
Tzur T, Yohai D, Weintraub AY. The role of local estrogen therapy in the management of pelvic floor disorders. Climacteric 2016; 19:162–171.
Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev 2016; 8:CD001500.
Gaspar A, Addamo G, Brandi H. Vaginal fractional CO2 laser: a minimally invasive option for vaginal rejuvenation. Am J Cosmetic Surg 2011; 28:156–162.
Salvatore S, Nappi RE, Zerbinati N, et al. A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study. Climacteric 2014; 17:363–369.
Salvatore S, Leone R, Maggiore U, et al. Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study. Menopause 2015; 22:845–849.
Skol ER, Karram MM. Use of a novel fractional CO2 laser for the treatment of genitourinary syndrome of menopause: 1-year outcomes. Menopause 2017; 24:810–814.
Pitsouni E, Grigoriadis T, Tsiveleka A, Zacharakis D, Salvatore S, Athanasiou S. Microablative fractional CO2 laser therapy and the genitourinary syndrome of menopause: an observational study. Maturitas 2016; 94:131–136.
Goldstein I, Dicks B, Kim NN, Hartzell R. Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sex Med 2013; 1:44–53.
Cruz VL, Steiner ML, Pompei LM, et al. Randomized, double-blind, placebo-controlled clinical trial for evaluating the efficacy of fractional CO2 laser compared with topical estriol in the treatment of vaginal atrophy in postmenopausal women. Menopause. 2018;25(1):21-28. doi:10.1097/GME.0000000000000955
Samuels JB, Garcia MA. Treatment to External Labia and Vaginal Canal With CO2 Laser for Symptoms of Vulvovaginal Atrophy in Postmenopausal Women. Aesthet Surg J. 2019;39(1):83-93. doi:10.1093/asj/sjy087
Politano CA, Costa-Paiva L, Aguiar LB, Machado HC, Baccaro LF. Fractional CO2 laser versus promestriene and lubricant in genitourinary syndrome of menopause: a randomized clinical trial. Menopause. 2019;26(8):833-840. doi:10.1097/GME.0000000000001333
Perino A, Calligaro A, Forlani F, et al. Vulvo-vaginal atrophy: a new treatment modality using thermo-ablative fractional CO2 laser. Maturitas. 2015;80(3):296-301. doi:10.1016/j.maturitas.2014.12.006
Palacio S, Combalia J, Emsellem C, Gaslain Y, Khorsandi D. Therapies for the management of genitourinary syndrome of menopause. Post Reprod Health. 2020;26:32-42.
Gambacciani M, Palacios S. Laser therapy for the restoration of vaginal function. Maturitas. 2017;99:10-5.
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;26:248-55.
Arroyo C. Fractional CO2 laser treatment for vulvovaginal atrophy symptoms and vaginal rejuvenation in perimenopausal women. Int J Womens Health. 2017;9:591-5.
Santiago Palacios, Marieta Ramírez, CO2 Laser Therapy in Stress and Urge Urinary Incontinence, Gynecoloic and Reproductive Endocrinology and Metabolism, June 27, 2020, pp. 076-079
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