Carbon Dioxide Laser Vulvovaginal Rejuvenation: A Systematic Review

Abstract

Genitourinary syndrome of menopause (GSM) causes significant symptomatic aggravation that affects the quality of life (QoL). Vulvovaginal atrophy (VVA), the hallmark of GSM, is managed with topical non-hormonal therapy, including moisturizers and lubricants, and topical estrogen application. Patients not responding/being unsatisfied with previous local estrogen therapies are candidates for a noninvasive modality. Carbon dioxide (CO2) laser therapy, especially the fractionated type (FrCO2), has drawn considerable attention over the past two decades as a non-invasive treatment for GSM. This systematic review describes the accumulated evidence from 40 FrCO2 laser studies (3466 participants) in GSM/VVA. MEDLINE, Scopus and Cochrane databases were searched through April 2021. We analyze the effects of FrCO2 laser therapy on symptoms, sexual function, and QoL of patients with GSM/VVA. As shown in this review, FrCO2 laser therapy for GSM shows good efficacy and safety. This modality has the potential to advance female sexual wellness. Patient satisfaction was high in the studies included in this systematic review. However, there is a lack of level I evidence, and more randomized sham-controlled trials are required. Furthermore, several clinical questions, such as the number of sessions required that determine cost-effectiveness, should be addressed. Also, whether FrCO2 laser therapy may exert a synergistic effect with systemic and/or local hormonal/non-hormonal treatments, energy-based devices, and other modalities to treat GMS requires further investigation. Lastly, studies are required to compare FrCO2 laser therapy with other energy-based devices such as erbium:YAG laser and radiofrequency.

Physical energies for the management of genitourinary syndrome of menopause: An overview of a systematic review and network meta‐analysis

“…Vaginal laser treatment was associated with improvement in atrophy symptom scores, as assessed by the VAS, principally for dryness and dyspareunia. 11,12,[20][21][22][23][24][25][26] Additionally, we observed improvements in objective tissue findings: VHIS, [20][21][22]26 VMV, 12,20,21,24 and urinary symptoms. of meta-analysis, lack of assessment of the risk of bias, and assessment of the quality of evidence observed in the systematic reviews are also reflections of this fragility.…”

“…Confidence in review findings was low in six reviews 11,12,[20][21][22]25 and critically low in three reviews 23,24,26 due to one or more critical…”

“…Of the systematic reviews included in this overview, nine addressed CO 2 laser, 11,12,[20][21][22][23][24][25][26] four addressed YAG laser, 12,[24][25][26] and only two addressed radiofrequency. 12,26 The interventions compared were vaginal estriol, 12,20,[24][25][26] vaginal estrogen, 21,23 lubricant, 20,23,24,26 promestriene, 12,24 conjugated estrogen, 12 promestriene, 24 sham, 11,20,24,26 and placebo. 26 The general characteristics of the included studies are presented in Table 2.…”

“…21,23 However, concerns regarding vaginal estrogen therapy include adverse effects, safety of long-term use, and cancer risk. 3 Nine systematic reviews met the eligibility criteria for this overview, 11,12,[20][21][22][23][24][25][26] This overview suggests that CO 2 laser is efficient in GSM symptoms, with few adverse events and the benefit of being hormonefree. 11,12,[20][21][22][23][24][25][26] However, there is little evidence to support the hypothesis that YAG laser 12,[24][25][26] and radiofrequency therapy 12,26 are safe and effective for GSM.…”

“…were included in this study. Finally, nine systematic reviews met the eligibility criteria and were included in this overview, 11,12,[20][21][22][23][24][25][26] and four randomized controlled trials met the inclusion criteria in our component NMA 5,13,27,28 (Figure 1).…”