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About Vulvovaginal Atrophy (Genitourinary Symptoms of Menopause)

An active older woman.

When a woman goes through menopause, a drop in estrogen levels can affect the vulvar and vaginal areas in multiple ways. The tissues can become thinned out, and the thinning in turn can cause pain, burning, dryness and an abnormal discharge. Some women may also get urinary symptoms such as frequency and pain. It may also increase the chances of getting certain inflammatory skin problems such as lichen sclerosus, which can cause itching and pain. Although these changes probably happen in most women, it is estimated that only 30% develop symptomatic vulvovaginal atrophy. In an effort to capture the relatively wide range of symptoms that can occur, the term "genitourinary symptoms of menopause" has been proposed to replace the older term "vulvovaginal atrophy."

How is vulvovaginal atrophy diagnosed?

Vulvovaginal atrophy is diagnosed with a combination of history, physical examination, and laboratory testing. On examination, there may be some flattening of some of the external structures of the vulva and tightness at the opening to the vagina. The area at the opening of the vagina and the vagina itself may appear pale. There may be bleeding when the vagina is swabbed. There can be no discharge or sometimes discharge can be heavier, yellow, blood-tinged or watery. Office testing with a high vaginal pH and of the vaginal secretions helps to confirm the diagnosis. It's worth mentioning that the physical and laboratory changes do not always match with symptoms. For example, some women with mild changes can be severely symptomatic, and vice versa.

How is vulvovaginal atrophy treated?

Nonhormonal vaginal lubricants and moisturizers, as well as continued sexual activity, are recommended as initial therapy for women with vulvovaginal atrophy. However, in our experience, they have minimal impact in helping patients feel better. By the time patients see us, they usually require more aggressive treatment.

Traditionally, patients have been treated with estrogen (with or without progesterone) given orally or transdermally. However, these treatments may not be fully effective in restoring vaginal health. Other products, such as ospemifene, can be considered but may have similar risks to estrogen use, particularly when it comes to blood clots.

Vaginal estrogen tends to be the approach we use the most in our practice. With vaginal estrogen, there are lower levels of estrogen and more estrogen locally where the tissues need it. It can be used either as vaginal rings (Estring), tablets (Vagifem), or creams (Premarin or Estrace). It is important to emphasize that it takes time for these medications to work, so patients should use them for a minimum of a month (optimally two) before deciding whether it helps. The main side effects are burning and irritation which usually resolve with time. Side effects such as headache and breast tenderness are much less common.

For patients with a prior history of breast cancer or blood clots, there is no published data that answers the question of whether vaginal estrogen can be used safely. We tailor therapy in such patients, in conjunction with the opinion of the patient's other doctors. The decision often comes down to a quality of life issue. Also, depending on a patient's insurance coverage, the cost of vaginal estrogen can be either quite low or very expensive.

A new, nonhormonal option is the MonaLisa Touch laser. This laser is FDA cleared for vaporization and coagulation of body soft tissues, including the vulva and vagina. In the initial studies performed in Italy and in the United States, the changes induced by the laser energy lead to increased blood flow (which leads to increased feelings of moisture), thickening of the tissues, and production of the right types of connective tissue. A series of three five-minute procedures, done in the office and generally well tolerated, are required as initial treatment. As of now, there are no published studies comparing the MonaLisa Touch laser to vaginal estrogen therapy.

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About MonaLisa Touch Laser Therapy at Drexel Medicine

Menopause can affect a woman's quality of life in unexpected ways. In the vaginal area, a drop in estrogen levels can cause thinning of the vaginal tissues, which in turn can cause pain, burning, dryness and an abnormal discharge. It may also increase the chances of getting certain inflammatory skin problems such as lichen sclerosus.

Although vaginal estrogen therapy is very effective at reversing many of these changes, there are certain issues which may limit its use. In women with certain medical conditions, for example a history of breast cancer, their doctors may be reluctant to have them use even vaginal estrogen. Some women may get local burning and irritation from vaginal estrogen products; more rarely, side effects such as headache or breast tenderness may limit its use. Depending on the prescription plan, some patients describe large co-pays for vaginal estrogen preparations. Finally, some women don't like the concepts of using estrogen in any form or of being on long-term therapy with vaginal treatments to keep symptoms under control.

What is the MonaLisa Touch?

The MonaLisa Touch is a gentle laser therapy that delivers controlled energy to the vaginal wall tissue. It restores vaginal health by generating new collagen, elastin and vascularization. It can also be used to treat the vulvar area for women with vulvar conditions. The MonaLisa Touch was first available outside the U.S.; thousands of patients have been treated worldwide. The procedure requires no anesthesia apart from local numbing medicines such as EMLA or lidocaine. Some patients may experience some discomfort the first time the probe is inserted, but the actual treatment is not painful. Many patients report that it feels like a gentle vibration.

How does it work?

The MonaLisa Touch uses laser energy that is delivered via a side-firing probe inserted into the vaginal canal. A two-part pulse targets surface (epithelial) tissue and deep (lamina propria) tissue to promote vaginal mucosal revitalization. A separate probe can also be used to treat the vulva and vestibule (the area at the opening to the vagina).

What clinical trials have been conducted on the MonaLisa Touch?

In the United States, a multisite study was conducted by Dr. Eric Sokol, associate professor of obstetrics and gynecology at the Stanford University Medical Center, and Dr. Mickey Karram, director of Fellowship Program on Female Pelvic Medicine & Reconstructive Surgery at The Christ Hospital, Cincinnati, Ohio. The trial assessed the use of CO2 fractional laser therapy on 30 women with vaginal health issues due to natural or induced menopause. All of the patients in the trial were treated with the MonaLisa Touch laser therapy. They found that 96% of patients were either satisfied or extremely satisfied at follow-up. All measurements of symptoms and findings were improved. This U.S. study confirmed the original Italian study of 42 women by Dr. Stefano Salvatore, where 84% showed significant improvement in their physical and mental quality of life scores over baseline and were satisfied with the treatment. Other published studies have had similar findings to these two papers.

The MonaLisa Touch has also been studied as a treatment for lichen sclerosus. Dr. Michael Baggish, affiliated with the University of California - San Francisco published a study that included 27 women with lichen sclerosus; 24 of them described significant improvement in itching and pain.

Finally, Dr. Filippo Murino published an Italian study of 37 women with vestibulodynia (also known as vulvar vestibulitis or localized provoked vulvodynia). After the series of laser treatments, 67% felt that their symptoms were either improved or very improved.

These trials support the concept that the MonaLisa Touch laser may be helpful in the treatment not just of vulvovaginal atrophy, but also other conditions such as lichen sclerosus and vulvodynia.

Where can I have this done?

The MonaLisa Touch is an in-office procedure performed in our Feinstein office. Patients receive three treatments, spaced six weeks apart, with each one taking about five minutes to perform. For patients who require external treatments, four to five treatments may be required initially.

When will I see results?

Most patients feel improvement after the very first treatment, although the procedure calls for three treatments that are generally spaced over an18-week period. Even if there is initial improvement, all three treatments are recommended as initial therapy.

What are the main possible side effects?

Possible side effects are primarily local and include spotting, mild vaginal bleeding, pink or brown vaginal discharge, mild to profuse watery vaginal discharge, redness, swelling, inflammation, tenderness, itching, irritation, burning upon urination, pinpoint bleeding and discomfort. Most of the time, these will resolve after three to four days.

How long does the improvement last?

In women being treated for vulvovaginal atrophy, patients should expect to come back annually for a maintenance treatment.

What are my limitations after the procedure is done?

Patients should refrain from sexual activity for two to three days. Depending on a variety of factors, we will determine a post-procedure regimen that is right for you.

For which patients is this treatment appropriate?

The MonaLisa Touch may be appropriate for any female suffering from vaginal issues from a decline in estrogen, as well as those who are experiencing vaginal symptoms as a result of a hysterectomy or breast cancer treatments. For other conditions for which there is less information, such as lichen sclerosus or vulvodynia, it may be a useful tool to add to other treatments.

Is this procedure safe for women with breast cancer?

Yes, the MonaLisa Touch therapy is particularly well-suited for patients who cannot or prefer not to receive estrogen therapy.

Will the procedure be covered by insurance?

No processing code has been established, so this will not be covered by any insurance. For the same reason, we don't expect that patients can get reimbursed with medical flexible spending accounts. The device is FDA approved.

How much does it cost? What are acceptable payment methods? Will refunds be available?

Please contact the Drexel Vaginitis Center for more information.

Sections courtesy of Cynosure.

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

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