Advertisement

Vaginal laser therapy for genitourinary syndrome of menopause – systematic review

  • Eduard Mension
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author
  • Inmaculada Alonso
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author
  • Marta Tortajada
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author
  • Isabel Matas
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author
  • Sílvia Gómez
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author
  • Laura Ribera
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author
  • Sònia Anglès
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author
  • Camil Castelo-Branco
    Correspondence
    Corresponding author at: Camil Castelo-Branco, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain.
    Affiliations
    Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
    Search for articles by this author

      Highlights

      • Genitourinary syndrome of menopause affects between 53.8% and 90% of postmenopausal women.
      • The efficacy and safety of laser therapy have not been yet established and international societies do not endorse its use.
      • Treatment with carbon dioxide laser seems to improve scores on the Visual Analogue Scale, Female Sexual Function Index and Vaginal Health Index in genitourinary syndrome of menopause and its safety appears to be proved.
      • Further well-designed clinical trials with sham-laser control groups and evaluating objective variables are needed to provide the best evidence.

      Abstract

      Background

      Genitourinary syndrome of menopause (GSM) can have a great impact on the quality of life (QOL), and affects between 53.8% and 90% of postmenopausal women. The literature suggests that vaginal laser therapy could be an effective treatment for GSM symptoms, but its efficacy and safety have not been established and international societies do not endorse its use. Despite that, there has been an increase in the use of vaginal laser therapy globally over the last decade.

      Objective

      The objective of this review is to evaluate the literature which assesses the efficacy and safety of the vaginal laser therapy in the treatment of GSM.

      Methods

      A comprehensive literature search was conducted electronically using Embase and PubMed to retrieve studies assessing evidence for the efficacy and safety of vaginal laser therapy for GSM or vulvovaginal atrophy up to June 2021.

      Results

      A total of 64 studies were finally included in the review. There were 10 controlled intervention studies, 7 observational cohort and cross-sectional studies and 47 before-after studies without a control group.

      Conclusion

      Vaginal laser seems to improve scores on the Visual Analogue Scale (VAS), Female Sexual Function Index (FSFI) and Vaginal Health Index (VHI) in GSM over the short term. Safety outcomes are underreported and short-term. Further well-designed clinical trials with sham-laser control groups and evaluating objective variables are needed to provide the best evidence on efficacy.

      Keywords

      Abbreviations:

      GSM (Genitourinary syndrome of menopause), QoL (Quality of life), VVA (Vulvovaginal Atrophy), FSFI (Female Sexual Function Index), VHI (Vaginal Health Index), FDA (Food and Drug Administration), NHLBI (National Heart, Lung and Blood Institute), CIS (Controlled Intervention Studies), VMI (Vaginal Maturation Index / Vaginal Maturation Value), UDIQ (Urogenital Distress Inventory Questionnaire), ICIQ‐UI SF (International Consultation on Incontinence Questionnaire), ICIQ‐OAB (Incontinence Questionnaire Overactive Bladder), SF-12 (Short form Quality Of Life Survey), PFDI-20 (Pelvic Floor Disability Index), SUI (Stress Urinary Incontinence Questionnaire), PGI-I (Patient Global Impression of Improvement), SPEQ (Specific Psychotic Experiences Questionnaire), NSR (Numeric Rating Scale), FLUTS (Female Lower Urinary Tract Symptoms Questionnaire), UDI-6 (Urogenital Distress Inventory), WHOQoL-BREF (World Health Organization Quality of Life), KHQ (Urinary symptoms scale by King's Health Questionnaire)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Maturitas
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Portman DJ
        • Gass ML
        Vulvovaginal atrophy terminology consensus conference P. 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.
        Climacteric. 2014; 17: 557-563
        • Palacios S
        • Nappi RE
        • Bruyniks N
        • Particco M
        • Panay N
        • Investigators ES.
        The European Vulvovaginal Epidemiological Survey (EVES): prevalence, symptoms and impact of vulvovaginal atrophy of menopause.
        Climacteric. 2018; 21: 286-291
        • Zerbinati N
        • Serati M
        • Origoni M
        • Candiani M
        • Iannitti T
        • Salvatore S
        • Marotta F
        • Calligaro A
        Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment.
        Lasers Med. Sci. 2015; 30: 429-436
        • Di Pace R
        • Portuesi R.
        Vaginal health index score and urogenital syndrome of menopause.
        Gazz Med. Ital - Arch Sci. Med. 2018; 177: 741-744
        • Quick AM
        • Dockter T
        • Le-Rademacher J
        • Salani R
        • Hudson C
        • Hundley A
        • Terstriep S
        • Streicher L
        • Faubion S
        • Loprinzi CL
        • Coleman JS
        • Wang KC
        • Lustberg M.
        Pilot study of fractional CO(2) laser therapy for genitourinary syndrome of menopause in gynecologic cancer survivors.
        Maturitas. 2021; 144 (Feb): 37-44
        • Aguiar LB
        • Politano CA
        • Costa-Paiva L
        • Juliato CRT.
        Efficacy of fractional CO2 laser, promestriene, and vaginal lubricant in the treatment of urinary symptoms in postmenopausal women: a randomized clinical trial.
        Lasers Surg. Med. 2020; 52 (Oct): 713-720
        • Eftekhar T
        • Forooghifar T
        • Khalili T
        • Shariat M
        • Haghollahi F.
        The effect of the CO2 fractional laser or premarin vaginal cream on improving sexual function in menopausal women: a randomized controlled trial.
        J. Lasers Med. Sci. 2020; 11 (Summer): 292-298
        • Ruanphoo P
        • Bunyavejchevin S.
        Treatment for vaginal atrophy using microablative fractional CO2 laser: a randomized double-blinded sham-controlled trial.
        Menopause. 2020; 27 (Aug): 858-863
        • Paraiso MFR
        • Ferrando CA
        • Sokol ER
        • Rardin CR
        • Matthews CA
        • Karram MM
        • Iglesia CB.
        A randomized clinical trial comparing vaginal laser therapy to vaginal estrogen therapy in women with genitourinary syndrome of menopause: The VeLVET Trial.
        Menopause. 2020; 27 (Jan): 50-56
        • 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 (Aug): 833-840
        • Cruz VL
        • Steiner ML
        • Pompei LM
        • Strufaldi R
        • Fonseca FLA
        • Santiago LHS
        • Wajsfeld T
        • Fernandes CE.
        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 (Jan): 21-28
        • Di Donato V
        • D'Oria O
        • Scudo M
        • Prata G
        • Fischetti M
        • Lecce F
        • Schiavi MC
        • Giannini A
        • Muzii L
        • Battaglia F
        • Monti M
        • Benedetti Panici P.
        Safety evaluation of fractional CO2 laser treatment in post-menopausal women with vaginal atrophy: A prospective observational study.
        Maturitas. 2020; 135 (May): 34-39
        • Li J
        • Li H
        • Zhou Y
        • Xie M
        • Miao Y
        • Wang L
        • Zhao Y
        • Ying T
        • Hu Y
        • Chen Y
        • Chen Y
        • Sun X
        • Wang J.
        The Fractional CO(2) laser for the treatment of genitourinary syndrome of menopause: a prospective multicenter cohort study.
        Lasers Surg. Med. 2020; (Nov 19)
        • Marin J
        • Lipa G
        • Dunet E.
        The results of new low dose fractional CO2 Laser - a prospective clinical study in France.
        J. Gynecol. Obstet. Hum. Reprod. 2020; 49 (Mar)101614
        • 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 (Sep): 78-88
        • Gaspar A
        • Brandi H
        • Gomez V
        • Luque D.
        Efficacy of Erbium:YAG laser treatment compared to topical estriol treatment for symptoms of genitourinary syndrome of menopause.
        Lasers Surg. Med. 2017; 49 (Feb): 160-168
        • Quick AM
        • Zvinovski F
        • Hudson C
        • Hundley A
        • Evans C
        • Stephens JA
        • Arthur E
        • Ramaswamy B
        • Reinbolt RE
        • Noonan AM
        • VanDeusen JB
        • Wesolowski R
        • Stover DG
        • Williams NO
        • Sardesai SD
        • Faubion SS
        • Loprinzi CL
        • Lustberg MB
        Patient-reported sexual function of breast cancer survivors with genitourinary syndrome of menopause after fractional CO2 laser therapy.
        Menopause. 2021; (Feb 1)
        • Adabi K
        • Golshahi F
        • Niroomansh S
        • Razzaghi Z
        • Ghaemi M.
        Effect of the fractional CO2 laser on the quality of life, general health, and genitourinary symptoms in postmenopausal women with vaginal atrophy: a prospective cohort.
        J. Lasers Med. Sci. 2020; 11 (Winter): 65-69
        • Alexiades MR.
        Fractional Co2 laser treatment of the vulva and vagina and the effect of postmenopausal duration on efficacy.
        Lasers Surg. Med. 2021; 53 (Feb): 185-198
        • Angioli R
        • Stefano S
        • Filippini M
        • Pieralli A
        • Montera R
        • Plotti F
        • Gatti A
        • Bartolone M
        • Luvero D.
        Effectiveness of CO2 laser on urogenital syndrome in women with a previous gynecological neoplasia: a multicentric study.
        Int. J. Gynecol. Cancer. 2020; 30 (May): 590-595
        • Sindou-Faurie T
        • Louis-Vahdat C
        • Oueld Es
        • Cheikh E
        • Canlorbe G
        • Mergui JL
        • Uzan C
        • Azaïs H
        Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms.
        Arch. Gynecol. Obstet. 2021; 303 (Apr): 955-963
        • Gaspar A
        • Silva J
        • Calderon A
        • Di Placido V
        • Vizintin Z.
        Histological findings after non-ablative Er:YAG laser therapy in women with severe vaginal atrophy.
        Climacteric. 2020; 23: S11-S13
        • Gambacciani M
        • Albertin E
        • Torelli MG
        • Bracco GL
        • Casagrande AC
        • Martella L
        • Baiocchi G
        • Alfieri S
        • Russo N
        • Cervigni M
        Italian Vaginal Erbium Laser Academy. Sexual function after vaginal erbium laser: the results of a large, multicentric, prospective study.
        Climacteric. 2020; 23: S24-S27
        • Mezzana P.
        Two wavelengths endovaginal laser system": Clinical evaluation of a new device for mild SUI and vaginal atrophy treatment.
        Dermatol. Ther. 2020; 33 (Nov): e14445
        • Pagano T
        • Travaglino A
        • Raffone A
        • Vallone R
        • Buonfantino C
        • De Rosa P
        • Locci M
        • Guadagno E
        • Insabato L
        • Salvatore S
        • De Placido G.
        Fractional microablative CO2 laser-related histological changes on vulvar tissue in patients with genitourinary syndrome of menopause.
        Lasers Surg. Med. 2020; (Aug 14)
        • Lauterbach R
        • Dabaja H
        • Matanes E
        • Gruenwald I
        • Lowenstein L.
        The Efficacy and Safety of CO2 Laser Treatment for Sexual Function and Vaginal Laxity Improvement in Pre-Menopausal Women.
        Lasers Surg. Med. 2021; 53 (Feb): 199-203
        • Hersant B
        • Werkoff G
        • Sawan D
        • Sidahmed-Mezi M
        • Bosc R
        • La Padula S
        • Kalsoum S
        • Ouidir N
        • Meningaud JP
        • Belkacemi Y
        Carbon dioxide laser treatment for vulvovaginal atrophy in women treated for breast cancer: preliminary results of the feasibility EPIONE trial.
        Ann. Chir. Plast. Esthet. 2020; 65 (Jul): e23-e31
        • Takacs P
        • Sipos AG
        • Kozma B
        • Cunningham TD
        • Larson K
        • Lampé R
        • Poka R.
        The effect of vaginal microablative fractional CO2 laser treatment on vaginal cytology.
        Lasers Surg. Med. 2020; 52 (Oct): 708-712
        • Quick AM
        • Zvinovski F
        • Hudson C
        • Hundley A
        • Evans C
        • Suresh A
        • Stephens JA
        • Arthur E
        • Ramaswamy B
        • Reinbolt RE
        • Noonan AM
        • VanDeusen JB
        • Wesolowski R
        • Stover DG
        • Williams NO
        • Sardesai SD
        • Smith KL
        • Faubion SS
        • Loprinzi CL
        • Lustberg MB
        Fractional CO2 laser therapy for genitourinary syndrome of menopause for breast cancer survivors.
        Support Care Cancer. 2020; 28 (Aug): 3669-3677
        • Filippini M
        • Luvero D
        • Salvatore S
        • Pieralli A
        • Montera R
        • Plotti F
        • Candiani M
        • Angioli R.
        Efficacy of fractional CO2 laser treatment in postmenopausal women with genitourinary syndrome: a multicenter study.
        Menopause. 2020; 27 (Jan): 43-49
        • Arêas F
        • Valadares ALR
        • Conde DM
        • Costa-Paiva L.
        The effect of vaginal erbium laser treatment on sexual function and vaginal health in women with a history of breast cancer and symptoms of the genitourinary syndrome of menopause: a prospective study.
        Menopause. 2019; 26 (Sep): 1052-1058
        • Samuels JB
        • Pezzella A
        • Berenholz J
        • Alinsod R.
        Safety and efficacy of a non-invasive high-intensity focused electromagnetic field (HIFEM) device for treatment of urinary incontinence and enhancement of quality of life.
        Lasers Surg. Med. 2019; 51 (Nov): 760-766
        • Eder SE.
        Long-Term Safety and Efficacy of Fractional CO2 Laser Treatment in Post-Menopausal Women with Vaginal Atrophy.
        Laser Ther. 2019; 28 (Jun 30): 103-109
        • Murina F
        • Felice R
        • Di Francesco S
        • Nelvastellio L
        • Cetin I
        Ospemifene plus fractional CO2 laser: a powerful strategy to treat postmenopausal vulvar pain.
        Gynecol. Endocrinol. 2020; 36 (May): 431-435
        • Pearson A
        • Booker A
        • Tio M
        • Marx G.
        Vaginal CO2 laser for the treatment of vulvovaginal atrophy in women with breast cancer: LAAVA pilot study.
        Breast Cancer Res. Treat. 2019; 178 (Nov): 135-140
        • Tovar-Huamani J
        • Mercado-Olivares F
        • Grandez-Urbina JA
        • Pichardo-Rodriguez R
        • Tovar-Huamani M
        • García-Perdomo H.
        Efficacy of fractional CO2 laser in the treatment of genitourinary syndrome of menopause in Latin-American Population: First Peruvian experience.
        Lasers Surg. Med. 2019; 51 (Aug): 509-515
        • Athanasiou S
        • Pitsouni E
        • Grigoriadis T
        • Zacharakis D
        • Falagas ME
        • Salvatore S
        • Protopapas A
        • Loutradis D.
        Microablative fractional CO2 laser for the genitourinary syndrome of menopause: up to 12-month results.
        Menopause. 2019; 26 (Mar): 248-255
        • Mothes AR
        • Runnebaum M
        • Runnebaum IB.
        An innovative dual-phase protocol for pulsed ablative vaginal Erbium:YAG laser treatment of urogynecological symptoms.
        Eur. J. Obstet. Gynecol. Reprod. Biol. 2018; 229 (Oct): 167-171
        • Gaspar A
        • Maestri S
        • Silva J
        • Brandi H
        • Luque D
        • Koron N
        • Vižintin Z.
        Intraurethral Erbium:YAG laser for the management of urinary symptoms of genitourinary syndrome of menopause: A pilot study.
        Lasers Surg. Med. 2018; 50 (Oct): 802-807
        • Mothes AR
        • Runnebaum M
        • Runnebaum IB.
        Ablative dual-phase Erbium:YAG laser treatment of atrophy-related vaginal symptoms in post-menopausal breast cancer survivors omitting hormonal treatment.
        J. Cancer Res. Clin. Oncol. 2018; 144 (May): 955-960
        • Gambacciani M
        • Levancini M
        • Russo E
        • Vacca L
        • Simoncini T
        • Cervigni M.
        Long-term effects of vaginal erbium laser in the treatment of genitourinary syndrome of menopause.
        Climacteric. 2018; 21 (Apr): 148-152
        • Eder SE.
        Early effect of fractional CO2 laser treatment in Post-menopausal women with vaginal atrophy.
        Laser Ther. 2018; 27 (Mar 31): 41-47
        • Vanaman M
        • Bolton J
        • Placik O
        • Fabi SG.
        Emerging Trends in Nonsurgical Female Genital Rejuvenation.
        Dermatol. Surg. 2016; 42 (Sep): 1019-1029
        • Kamilos MF
        • Borrelli CL.
        New therapeutic option in genitourinary syndrome of menopause: pilot study using microablative fractional radiofrequency.
        Einstein (Sao Paulo). 2017; 15 (Oct-Dec): 445-451
        • Athanasiou S
        • Pitsouni E
        • Falagas ME
        • Salvatore S
        • Grigoriadis T.
        CO2-laser for the genitourinary syndrome of menopause. How many laser sessions?.
        Maturitas. 2017; 104 (Oct): 24-28
        • Arroyo C.
        Fractional CO2 laser treatment for vulvovaginal atrophy symptoms and vaginal rejuvenation in perimenopausal women.
        Int. J. Womens Health. 2017; 9 (Aug 28): 591-595
        • Lang P
        • Dell JR
        • Rosen L
        • Weiss P
        • Karram M.
        Fractional CO2 laser of the vagina for genitourinary syndrome of menopause: Is the out-of-pocket cost worth the outcome of treatment?.
        Lasers Surg. Med. 2017; 49 (Dec): 882-885
        • González Isaza P
        • Jaguszewska K
        • Cardona JL
        • Lukaszuk M
        Long-term effect of thermoablative fractional CO2 laser treatment as a novel approach to urinary incontinence management in women with genitourinary syndrome of menopause.
        Int. Urogynecol. J. 2018; 29 (Feb): 211-215
        • Behnia-Willison F
        • Sarraf S
        • Miller J
        • Mohamadi B
        • Care AS
        • Lam A
        • Willison N
        • Behnia L
        • Salvatore S.
        Safety and long-term efficacy of fractional CO2 laser treatment in women suffering from genitourinary syndrome of menopause.
        Eur. J. Obstet. Gynecol. Reprod. Biol. 2017; 213 (Jun): 39-44
        • 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 (Mar): 316-319
        • Sokol ER
        • Karram MM.
        Use of a novel fractional CO2 laser for the treatment of genitourinary syndrome of menopause: 1-year outcomes.
        Menopause. 2017; 24 (Jul): 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 (Dec): 131-136
        • Athanasiou S
        • Pitsouni E
        • Antonopoulou S
        • Zacharakis D
        • Salvatore S
        • Falagas ME
        • Grigoriadis T.
        The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women.
        Climacteric. 2016; 19 (Oct): 512-518
        • Sokol ER
        • Karram MM.
        An assessment of the safety and efficacy of a fractional CO2 laser system for the treatment of vulvovaginal atrophy.
        Menopause. 2016; 23 (Oct): 1102-1107
        • Gambacciani M
        • Levancini M
        • Cervigni M.
        Vaginal erbium laser: the second-generation thermotherapy for the genitourinary syndrome of menopause.
        Climacteric. 2015; 18 (Oct): 757-763
        • Pagano T
        • De Rosa P
        • Vallone R
        • Schettini F
        • Arpino G
        • Giuliano M
        • Lauria R
        • De Santo I
        • Conforti A
        • Gallo A
        • Nazzaro G
        • De Placido S
        • Locci M
        • De Placido G.
        Fractional microablative CO2 laser in breast cancer survivors affected by iatrogenic vulvovaginal atrophy after failure of nonestrogenic local treatments: a retrospective study.
        Menopause. 2018; 25 (Jun): 657-662
        • Pieralli A
        • Bianchi C
        • Longinotti M
        • Corioni S
        • Auzzi N
        • Becorpi A
        • Fallani MG
        • Cariti G
        • Petraglia F.
        Long-term reliability of fractioned CO2 laser as a treatment for vulvovaginal atrophy (VVA) symptoms.
        Arch. Gynecol. Obstet. 2017; 296 (Nov): 973-978
        • Siliquini GP
        • Tuninetti V
        • Bounous VE
        • Bert F
        • Biglia N.
        Fractional CO2 laser therapy: a new challenge for vulvovaginal atrophy in postmenopausal women.
        Climacteric. 2017; 20 (Aug): 379-384
        • Perino A
        • Calligaro A
        • Forlani F
        • Tiberio C
        • Cucinella G
        • Svelato A
        • Saitta S
        • Calagna G.
        Vulvo-vaginal atrophy: a new treatment modality using thermo-ablative fractional CO2 laser.
        Maturitas. 2015; 80 (Mar): 296-301
        • Pagano T
        • De Rosa P
        • Vallone R
        • Schettini F
        • Arpino G
        • De Placido S
        • Nazzaro G
        • Locci M
        • De Placido G.
        Fractional microablative CO2 laser for vulvovaginal atrophy in women treated with chemotherapy and/or hormonal therapy for breast cancer: a retrospective study.
        Menopause. 2016; 23 (Oct): 1108-1113
        • Pieralli A
        • Fallani MG
        • Becorpi A
        • Bianchi C
        • Corioni S
        • Longinotti M
        • Tredici Z
        • Guaschino S.
        Fractional CO2 laser for vulvovaginal atrophy (VVA) dyspareunia relief in breast cancer survivors.
        Arch. Gynecol. Obstet. 2016; 294 (Oct): 841-846
        • Salvatore S
        • Nappi RE
        • Parma M
        • Chionna R
        • Lagona F
        • Zerbinati N
        • Ferrero S
        • Origoni M
        • Candiani M
        • Leone Roberti Maggiore U.
        Sexual function after fractional microablative CO₂ laser in women with vulvovaginal atrophy.
        Climacteric. 2015; 18 (Apr): 219-225
        • Salvatore S
        • Nappi RE
        • Zerbinati N
        • Calligaro A
        • Ferrero S
        • Origoni M
        • Candiani M
        • Leone Roberti Maggiore U.
        A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study.
        Climacteric. 2014; 17 (Aug): 363-369
        • Strasberg Steven M.
        • Linehan David C.
        • Hawkins William G.
        The accordion severity grading system of surgical complications.
        Ann. Surg. 2009; 250: 177-186
        • Snoeckx LHEH
        • Cornelussen RN
        • Van Neiuwenhoven FA
        • Reneman RS
        • VanderVusse GJ.
        Heat shock proteins and cardiovascular pathophysiology.
        PhysiolRev. 2002; 81: 1461-1497
        • Yamasaki A
        • Tamamura K
        • Sakurai Y
        • Okuyama N
        • Yusa J
        • Ito H.
        Remodelin-gof the rat gingiva induced by CO2laser coagulation mode.
        Lasers Surg. Med. 2008; 40: 695-703
        • Gaspar A
        • Addamo G
        • Brandi H
        Vaginal fractional CO2 laser: a minimally invasive option for vaginal rejuvenation.
        Am. J. Cosm. Surg. 2011; 28: 156-162
        • Photiou L
        • Lin MJ
        • Dubin DP
        • Lenskaya V
        • Khorasani H.
        Review of non-invasive vulvovaginal rejuvenation.
        J. Eur. Acad. Dermatol. Venereol. 2020; 34 (Apr): 716-726
        • Mension E
        • Alonso I
        • Castelo-Branco C.
        Genitourinary syndrome of menopause: current treatment options in breast cancer survivors - systematic review.
        Maturitas. 2021; 143 (Jan): 47-58
        • Mitchell CM.
        How do we measure success in the treatment of genitourinary syndrome of menopause?.
        Menopause. 2020; 27 (Aug): 844-845
      1. US Food and Drug Administration. Estrogen and estrogen/progestin drug products to treat vasomotor symptoms and vulvar and vaginal atrophy symptoms-Recommendations for clinical evaluation. Available at: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/estrogen-and-estrogenprogestin-drug-products-treat-vasomotor-symptoms-and-vulvar-and-vaginal-atrophy.

      2. US Food and Drug Administration. FDA warns against use of energy-based devices to perform vaginal 'rejuvenation' or vaginal cosmetic procedures: FDA safety communication. Available at: https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic.

        • Mackova K
        • Mazzer AM
        • Mori Da Cunha M
        • Hajkova Hympanova L
        • Urbankova I
        • Kastelein AW
        • Vodegel E
        • Vander Linden K
        • Fehervary H
        • Guler Z
        • Roovers JP
        • Krofta L
        • Verhaeghe J
        • Deprest J
        Vaginal Er:YAG laser application in the menopausal ewe model: a randomised estrogen and sham-controlled trial.
        BJOG. 2020; (Oct 5)
        • Hympanova L
        • Rynkevic R
        • Mori Da Cunha MGMC
        • Diedrich CM
        • Blacher S
        • De Landsheere L
        • Mackova K
        • Krofta L
        • Roovers JP
        • Deprest J
        The ewe as an animal model of vaginal atrophy and vaginal Er: YAG laser application.
        Menopause. 2020; (Nov 23)
        • Dutra PFSP
        • Heinke T
        • Pinho SC
        • Focchi GRA
        • Tso FK
        • de Almeida BC
        • Silva I
        • Speck NMG.
        Comparison of topical fractional CO2 laser and vaginal estrogen for the treatment of genitourinary syndrome in postmenopausal women: a randomized controlled trial.
        Menopause. 2021; (May 17)
        • Cruff J
        • Khandwala S.
        A double-blind randomized sham-controlled trial to evaluate the efficacy of fractional carbon dioxide laser therapy on genitourinary syndrome of menopause.
        J. Sex Med. 2021; 18 (Apr): 761-769
        • Salvatore S
        • Pitsouni E
        • Grigoriadis T
        • Zacharakis D
        • Pantaleo G
        • Candiani M
        • Athanasiou S.
        CO2 laser and the genitourinary syndrome of menopause: a randomized sham-controlled trial.
        Climacteric. 2021; 24 (Apr): 187-193
        • Singh Priyanka
        • Chong Christopher Yew Luen
        • Han How Chuan
        J. Gynecol. Surgery. 2019; (Apr): 99-104
        • Bojanini J.
        Treatment of Genitourinary syndrome of menopause with Erbium:YAG laser: a prospective study of efficacy and safety of the treatment for women after menopause of natural origin and therapy-induced menopause in breast cancer survivors.
        J. Laser Health Acad. 2016; 2016 (October 19): 35-40
        • Flint R
        • Cardozo L
        • Grigoriadis T
        • Rantell A
        • Pitsouni E
        • Athanasiou S.
        Rationale and design for fractional microablative CO2 laser versus photothermal non-ablative erbium:YAG laser for the management of genitourinary syndrome of menopause: a non-inferiority, single-blind randomized controlled trial.
        Climacteric. 2019; 22 (Jun): 307-311
        • Kozma B
        • Póka R
        • Sipos A
        • Ács N
        • Takács P.
        A hüvelyi CO2-lézer-kezelés rövid távú hatásai a menopausalis genitourinalis szindróma tüneteire [Short-term efficacy of vaginal CO2 laser therapy as a treatment modality for genitourinary syndrome of menopause].
        Orv. Hetil. 2019; 160 (OctHungarian): 1617-1622
        • Salvatore S
        • Leone Roberti Maggiore U
        • Athanasiou S
        • Origoni M
        • Candiani M
        • Calligaro A
        • Zerbinati N
        Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study.
        Menopause. 2015; 22 (Aug): 845-849
        • Sudol NT
        • Miao Y
        • Li Y
        • Chen JJ
        • Jing JC
        • Zhu J
        • Tadir Y
        • Chen Z
        • Lane F.
        Optical vaginal biopsy using optical coherence tomography.
        Female Pelvic Med. Reconstr. Surg. 2020; 26 (Feb): 155-158
        • Knight C
        • Logan V
        • Fenlon D.
        A systematic review of laser therapy for vulvovaginal atrophy/genitourinary syndrome of menopause in breast cancer survivors.
        Ecancermedicalscience. 2019; 13 (Dec 12): 988
        • Sarmento ACA
        • Lírio JF
        • Medeiros KS
        • Marconi C
        • Costa APF
        • Crispim JC
        • Gonçalves AK.
        Physical methods for the treatment of genitourinary syndrome of menopause: a systematic review.
        Int. J. Gynaecol. Obstet. 2021; 153 (May): 200-219