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JOGC

No. 358-Intravaginal Laser for Genitourinary Syndrome of Menopause and Stress Urinary Incontinence

      Abstract

      Objective

      This technical bulletin reviews the evidence relating to risks and benefits of using intravaginal laser technology in the management of genitourinary syndrome of menopause and stress urinary incontinence.

      Intended Users

      Gynaecologists, urogynaecologists, urologists, and other health care professionals who assess, counsel, and provide care for women with genitourinary syndrome of menopause and stress urinary incontinence.

      Target Population

      Adult women with genitourinary syndrome of menopause and stress urinary incontinence seeking complementary or alternative treatment options to topical estrogen, non-hormonal vaginal moisturizers, physiotherapy, intravaginal devices, and surgery.

      Options

      The discussion relates to intravaginal laser treatments for genitourinary syndrome of menopause compared with topical estrogen and that for stress urinary incontinence.

      Outcomes

      The outcomes of interest are objective and subjective rates of response to treatment, histologic outcomes, and procedural complications.

      Evidence

      PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words “genitourinary syndrome of menopause,” “vaginal laser,” “topical estrogen,” and “urogenital atrophy.” Results were restricted to English and human research. Articles were included until the end of September 2016. Clinical practice guidelines and guidelines of specialty societies were reviewed. Included studies were observational or prospective cohort when available. Only publications with study groups larger than or equal to 20 individuals were included, and non–peer-reviewed papers were excluded.

      Validation Methods

      The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.

      Benefits, Harms, and/or Costs

      It is expected that this technical bulletin will benefit patients with genitourinary syndrome of menopause by ensuring treating physicians are aware of all treatment options including the potential benefit and associated risk with intravaginal laser therapy. This should guide patient informed consent before such procedures are undertaken. There are no direct harms or costs identified with the implementation of this guideline.

      Sponsors

      The SOGC.

      Summary Statements

      • 1.
        Histologic evaluation has shown a similar short-term improvement in vaginal epithelial maturation in post-procedural vaginal wall biopsies with the use of intravaginal laser as that seen with local estrogen (Moderate).
      • 2.
        Short-term observational studies of small patient number with the use of intravaginal laser have demonstrated reductions in symptoms (including dryness, burning, itching, dysuria, and dyspareunia) and improvements in sexual satisfaction indices (Low).
      • 3.
        Short-term observational studies of small patient number with the use of intravaginal laser have demonstrated improvements in symptoms of stress urinary incontinence (Low).

      Recommendations

      • 1.
        In patients declining or with apparent contraindication to local estrogen, intravaginal laser therapy may be considered for short-term relief of symptoms associated with genitourinary syndrome of menopause (Conditional, Low).
      • 2.
        There is insufficient evidence to offer intravaginal laser therapy as an equivalent modality to local estrogen for the treatment of genitourinary syndrome of menopause (including vulvovaginal atrophy, lower urinary tract symptoms, and sexual dysfunction) (Strong, Very Low).
      • 3.
        There is insufficient evidence to offer intravaginal laser therapy as an effective modality for the treatment of stress urinary incontinence over alternate managements such as pelvic floor physiotherapy, incontinence pessaries, or surgery (strong, very low).
      • 4.
        Long-term use of intravaginal laser therapy for the management of genitourinary syndrome of menopause or stress urinary incontinence remains experimental and should remain within the protocols of well-executed clinical trials in attempts to establish its safety and efficacy (Strong, Very Low).
      • 5.
        Intravaginal laser therapy should not be offered to patients to prevent recurrent urinary tract infections as no literature exists to support such use (Strong, Very Low).

      Key Words

      Abbreviations:

      GUSM (genitourinary syndrome of menopause), ICIQ (International Consultation on Incontinence Questionnaire), MUI (mixed urinary incontinence), RCT (randomized controlled trial), SUI (stress urinary incontinence), UTI (urinary tract infection), VVA (vulvovaginal atrophy)
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      References

        • Portman D.J.
        • Gass M.L.
        • Vulvovaginal Atrophy Terminology Consensus Conference Panel
        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.
        Menopause. 2014; 21: 1063-1068
        • Frank S.M.
        • Ziegler C.
        • Kokot-Kierepa M.
        • et al.
        Vaginal Health: Insights, Views & Attitudes (VIVA) survey - Canadian cohort.
        Menopause Int. 2013; 19: 20-27
        • Johnston S.L.
        The recognition and management of atrophic vaginitis.
        Geriatr Aging. 2002; 5: 9-15
        • The North American Menopause Society
        The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society.
        Menopause. 2007; 14: 357-369
        • Nappi R.E.
        • Kokot-Kierepa M.
        Women's voices in the menopause: results from an international survey on vaginal atrophy.
        Maturitas. 2010; 67: 233-238
        • Labrie F.
        • Archer D.
        • Bouchard C.
        • et al.
        Intravaginal dehydroepiandrosterone (Prasterone), a physiological and highly efficient treatment of vaginal atrophy.
        Menopause. 2009; 16: 907-922
        • Brown J.S.
        • Seeley D.G.
        • Fong J.
        • et al.
        Urinary incontinence in older women: who is at risk? Study of Osteoporotic Fractures Research Group.
        Obstet Gynecol. 1996; 87: 715-721
        • Nappi R.E.
        • Kokot-Kierepa M.
        Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey.
        Climacteric. 2012; 15: 36-44
        • Minassian V.A.
        • Stewart W.F.
        • Wood G.C.
        Urinary incontinence in women: variation in prevalence estimates and risk factors.
        Obstet Gynecol. 2008; 111: 324-331
        • Dennerstein L.
        • Dudley E.C.
        • Hopper J.L.
        • et al.
        A prospective population-based study of menopausal symptoms.
        Obstet Gynecol. 2000; 96: 351-358
        • Kelleher C.J.
        • Cardozo L.D.
        • Toozs-Hobson P.M.
        Quality of life and urinary incontinence.
        Curr Opin Obstet Gynecol. 1995; 7: 404-408
        • van der Vaart C.H.
        • de Leeuw J.R.
        • Roovers J.P.
        • et al.
        Measuring health-related quality of life in women with urogenital dysfunction: the urogenital distress inventory and incontinence impact questionnaire revisited.
        Neurourol Urodyn. 2003; 22: 97-104
        • Bachmann G.A.
        Influence of menopause on sexuality.
        Int J Fertil Menopausal Stud. 1995; 40: 16-22
        • Simon J.
        • Nachtigall L.
        • Gut R.
        • et al.
        Effective treatment of vaginal atrophy with an ultra-low-dose estradiol vaginal tablet.
        Obstet Gynecol. 2008; 112: 1053-1060
        • Raz R.
        • Stamm W.E.
        A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections.
        N Engl J Med. 1993; 329: 753-756
        • Eriksen B.
        A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women.
        Am J Obstet Gynecol. 1999; 180: 1072-1079
        • Rahn D.D.
        • Carberry C.
        • Sanses T.V.
        • et al.
        Society of Gynecologic Surgeons Systematic Review Group. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review.
        Obstet Gynecol. 2014; 124: 1147-1156
        • Suckling J.
        • Lethaby A.
        • Kennedy R.
        Local oestrogen for vaginal atrophy in postmenopausal women.
        Cochrane Database Syst Rev. 2006; (CD001500)
        • Cardozo L.D.
        • Wise B.G.
        • Benness C.J.
        Vaginal oestradiol for the treatment of lower urinary tract symptoms in postmenopausal women–a double-blind placebo-controlled study.
        J Obstet Gynaecol. 2001; 21: 383-385
        • Smith P.
        • Heimer G.
        • Lindskog M.
        • et al.
        Oestradiol-releasing vaginal ring for treatment of postmenopausal urogenital atrophy.
        Maturitas. 1993; 16: 145-154
        • Schünemann H.
        • Brożek J.
        • Guyatt G.
        • Oxman A.
        • GRADE Working Group
        The GRADE handbook 2013.
        2013 (Available at)
        • Salvatore S.
        • Leone Roberti Maggiore U.
        • Athanasiou S.
        • 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
        • Frega A.
        • Verrone A.
        • Schimberni M.
        • et al.
        Feasibility of office CO2 laser surgery in patients affected by benign pathologies and congenital malformations of female lower genital tract.
        Eur Rev Med Pharmacol Sci. 2015; 19: 2528-2536
        • Ogrinc U.B.
        • Senčar S.
        • Lenasi H.
        Novel minimally invasive laser treatment of urinary incontinence in women.
        Lasers Surg Med. 2015; 47: 689-697
        • Zerbinati N.
        • Serati M.
        • Origoni M.
        • et al.
        Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment.
        Lasers Med Sci. 2015; 30: 429-436
      1. Scientific Committee communication with Dr Mary Senterman, Professor, Departments of Pathology and Laboratory Medicine and Obstetrics and Gynecology.
        (University of Ottawa, August)2017
        • Salvatore S.
        • Nappi R.E.
        • Zerbinati N.
        • et al.
        A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study.
        Climacteric. 2014; 17: 363-369
        • Perino A.
        • Calligaro A.
        • Forlani F.
        • et al.
        Vulvo-vaginal atrophy: a new treatment modality using thermo-ablative fractional CO2 laser.
        Maturitas. 2015; 80: 296-301
        • Sokol E.R.
        • Karram M.M.
        An assessment of the safety and efficacy of a fractional CO2 laser system for the treatment of vulvovaginal atrophy.
        Menopause. 2016; 23: 1102-1107
        • Salvatore S.
        • Nappi R.E.
        • Parma M.
        • et al.
        Sexual function after fractional microablative CO2 laser in women with vulvovaginal atrophy.
        Climacteric. 2015; 18: 219-225
        • Gambacciani M.
        • Levancini M.
        • Cervigni M.
        Vaginal erbium laser: the second-generation thermotherapy for the genitourinary syndrome of menopause.
        Climacteric. 2015; 18: 757-763
        • Fistonić N.
        • Fistonić I.
        • Lukanovič A.
        • et al.
        First assessment of short-term efficacy of Er:YAG laser treatment on stress urinary incontinence in women: prospective cohort study.
        Climacteric. 2015; 18: 37-42
        • Fistonić N.
        • Fistonić I.
        • Guštek Š.F.
        • et al.
        Minimally invasive, non-ablative Er:YAG laser treatment of stress urinary incontinence in women–a pilot study.
        Lasers Med Sci. 2016; 31: 635-643
        • Arunkalaivanan A.
        • Kaur H.
        • Onuma O.
        Laser therapy as a treatment modality for genitourinary syndrome of menopause: a critical appraisal of evidence.
        Int Urogynecol J. 2017; 28: 681-685
        • Digesu G.
        • Swift S.
        Laser treatment in urogynaecology and the myth of the scientific evidence.
        Int Urogynecol J. 2017; 28: 1443-1444
        • Krychman M.L.
        • Shifren J.L.
        • Liu J.H.
        • et al.
        Laser treatment safe for vulvovaginal atrophy?.
        The North American Menopause Society (NAMS), 2015: 11