Presented by: Eric Sokol, MD
Associate Professor, Obstetrics and Gynecology
October 19, 2016
When production levels of the female sex hormone estrogen drop, many women experience vaginal atrophy—a condition in which the vaginal tissues become thinner, drier, less elastic, and more fragile. Hormonal changes stem from menopause but also can be caused by childbirth and breastfeeding, cancer treatment, surgery, and certain medications. Symptoms range from dryness, burning, and itching to bleeding or pain during sex (dyspareunia).
“The problem is not just sexual,” said Eric Sokol, MD, an associate professor of obstetrics and gynecology, who spoke at a presentation sponsored by the Stanford Health Library. “Vaginal thinning after menopause is inevitable but pain is not. It’s really about making the vagina more comfortable.”
Effects of Reduced Estrogen
During menopause, the connective tissue and epithelium of the vaginal mucosa become compressed because the tissue is unable to produce sufficient amounts of collagen, glycogen, and molecules that help to slough off cells from the epithelial layer. Dehydrated mucosa is prone to infection because the diminished blood vessels are less able to deliver nutrients and lymphocytes to the tissue, causing changes in the organ’s pH balance.
Because the vaginal and urinary systems are closely connected, vaginal atrophy not only can make intercourse painful but also can lead to urinary symptoms for many women, such as urinary urgency or painful urination (dysuria). Together the cluster of vulvovaginal symptoms caused by a drop in estrogen is referred to as genitourinary syndrome of menopause (GSM). It’s estimated that nearly half of postmenopausal women experience the thinning, drying, and inflammation of the vaginal walls, though few seek medical treatment.
There are therapeutic options for women, from non-medicated lubricants and moisturizers to prescription-only topical forms of estrogen therapy. Prescription and over-the-counter vaginal moisturizers and lubricants can restore moisture to the vaginal area and reduce discomfort during intercourse. Ospemifene, a selective estrogen receptor modulator, acts on the body’s estrogen receptors and appears to improve menopause-related vulvar and vaginal symptoms. Hormone replacement therapy (HRT) appears to help alleviate symptoms but is associated with unhealthy side effects, so should be used only for the short term.
The standard of care remains vaginal estrogen, in products such as Vagifem, Estrace, and Premarin. These prescription-only creams and tablets deliver estrogen directly to the vagina and restore tissue thickness and flexibility.
A New Option
Dr. Sokol is assessing and refining a brand new direction in addressing the symptoms of GSM called a fractional CO2 laser. While CO2 lasers are used for cosmetic resurfacing to regenerate skin and connective tissue, this is the first application designed specifically for treating vaginal tissue. Stanford is the first medical center in the country to test the MonaLisa Touch Laser in clinical trials.
A thin probe is inserted into the vagina to create micro-lesions—a series of minute pinholes that stimulates a healing response by activating cytokines and growth factors. The laser triggers the production of collagen, new blood vessels (angiogenesis), endothelial cells, and fibroblasts. The resulting tissue regeneration builds up the vaginal walls in a process that appears to last as long as a year, according to Dr. Sokol.
Treatment involves three clinic visits six weeks apart. There is no pain and no anesthesia, and treatment lasts only a few minutes. Only 6 percent of the mucosa is treated, which appears to be sufficient to induce the healing process. And because no hormones are involved, women undergoing chemotherapy or who cannot be exposed to additional estrogen are candidates for treatment.
Histologic studies suggest that the laser increases collagen, which improves mechanical support; increases acidic mucopolysaccharides to boost hydration; and increases glycogen content to maintain its balance of lactobaccili and reduce the risk of infection.
Dr. Sokol recently completed a study of this novel laser for GSM. His study—the first trial of CO2 laser treatment outcomes for vaginal atrophy in the U.S.—followed 30 menopausal women at two centers for one year. The women reported significant improvement in symptoms of burning, itching, and dryness, and diminished sexual discomfort. Ninety-two percent said they were very satisfied or satisfied with the treatment. His findings were published in the summer 2016 issue of Menopause.
“In my experience with studies of new technology, this showed a very high rate of satisfaction,” Dr. Sokol said. “And it remained safe and effective after one year.”
More studies are under way to determine whether CO2 laser treatment works better than estrogen cream. Stanford is involved in a five-center randomized controlled trial called VeLVET that will track more than 200 GSM patients for six months. Dr. Sokol is also enrolling patients in a study that will assess the changes that occur at the cellular level after laser treatment of the vagina for GSM. In both of these trials, treatments are offered free of charge as part of study participation.
Other clinical applications are also being assessed, including using CO2 laser for external vulvar atrophy (the genital area), lichen sclerosis (a skin condition near the genitals), vestibulodynia (pain in the vaginal opening), and urinary incontinence.
About the Speaker
Eric Sokol, MD, is an associate professor of obstetrics and gynecology, and, by courtesy, of urology, with a special interest in developing and testing novel, minimally invasive surgical and clinical devices. He received his medical degree from Wayne State University School of Medicine in Detroit, Michigan, and did a residency and internship at Northwestern University Feinberg School of Medicine in Chicago. He completed a three-year fellowship in female pelvic medicine and pelvic reconstructive surgery at Warren Alpert Medical School at Brown University in Rhode Island. He joined the Stanford faculty in 2005 and serves as co-chief of Urogynecology and Pelvic Reconstructive Surgery.
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