Menopause is a significant milestone in a woman’s life, and with it comes significant hormonal changes—specifically the loss of estrogen – that results for many women in bothersome symptoms of hot flashes and night sweats. The good news is, for most women, these menopause symptoms improve with time. In fact, the vast majority of women (85%) will resolve their hot flashes within 5 years of their last menstrual period. Unfortunately, the one menopause-associated symptom that get worse with time is vulvovaginal atrophy (VVA). In fact, more than 50% of women (estimated 32 million US women) will develop vulvovaginal atrophy after menopause. Unfortunately, studies show that only 7% of women will receive treatment despite the availability of many safe and effective treatment options.
WHAT IS GENITOURINARY SYNDROME OF MENOPAUSE (GSM) OR VULVAR VAGINAL ATROPHY (VVA)?
Vulvovaginal atrophy (VVA), now renamed Genitourinary Syndrome of Menopause (GSM), is a medical condition that develops after menopause. The decrease in estrogen associated with menopause leads to thinning of the vulvovaginal tissue, including the urethra and bladder, changes in vaginal pH, changes in the vaginal microbiome, and loss of ability to lubricate, that result in the symptoms of GSM. GSM negatively impacts sexual health and quality of life and is associated with recurrent urinary tract infections.
Fifty-percent or more of post-menopausal women, (higher in women who did not have any vaginal births, or who have a history of breast cancer and are on anti-hormonal therapy) develop GSM. The incidence increases with time from menopause. Ongoing, regular sexual activity can help delay or prevent the development of GSM.
All women with vulvovaginal complaints should have a physical exam, including a vulvovaginal exam and a pelvic exam. There are other conditions and other pathology that can mimic GSM, and a thorough evaluation by a women’s health clinician is important before therapy is offered. In our practice, we commonly show women (using a hand-held mirror), the changes in their vulvovaginal tissue and document their vaginal pH as a way to help them understand their symptoms.
The good news is there are many options available to treat GSM that are safe and effective. First-line therapies include over the counter, non-hormonal, vaginal moisturizers and lubricants. Moisturizers, when used regularly, effectively treat dryness, while lubricants are used specifically for and during sexual activity. For some women, especially with mild symptoms, moisturizers and lubricants may be adequate. Within our practice we offer, and also make recommendations for, specific over-the-counter products.
For many women, however, moisturizers and lubricants are not adequate, and additional therapy is indicated. The good news for women is there are a number of safe and effective options! Low-dose vaginal estrogen is considered the gold standard for treating GSM, and for most women, it is safe. There are many vaginal estrogen products available. These include FDA-approved bioidentical estradiol formulated as creams, tablets, a vaginal ring, and most recently, a soft gel capsule. Any of these products, when used regularly, are highly effective and lead to improvement in symptoms, improved sexual health, and decreased urinary tract infections. Ospemifene, a daily oral medication, and Intrarosa (intravaginal DHEA) a daily vaginal insert, are also FDA-approved, and highly effective.
Although vaginal estrogen has a long history of safety and effectiveness, many women are unwilling to use vaginal estrogen products because of persistent concerns about estrogen risk—such as an increase in breast cancer—despite no data to support this claim with local vaginal estrogen. Other women find the local treatment bothersome or messy and time consuming.
For some women, energy-based laser devices, such as the MonaLisa Touch ™ might be an appropriate therapy for GSM. (Read more about MonaLisa Touch ™ here.)
WHAT ABOUT GSM IN BREAST CANCER SURVIVORS?
GSM is more common and more severe in breast cancer survivors than in the general population, as a result of cancer treatments. It is commonly undiagnosed and untreated, and has a profound impact on survivors’ quality of life. Over the counter therapies are often ineffective in these women. The use of vaginal estrogen and vaginal DHEA in breast cancer survivors remains controversial because of the paucity of data, although NAMS and ACOG support the use of local vaginal estrogen, and vaginal DHEA in women following a discussion of risk and benefit. Recently a NAMS/ISSWSH Consensus recommendation on the management of GSM in women at high risk for breast cancer was published in Menopause (Menopause Vol 25, No6, 2018.) It provides a comprehensive review of the available data and suggests an approach to management of these women for clinicians. (Dr. Larkin participated in the development of this consensus paper and is the second author.)
WHAT IS VAGINAL REJUVENATION? IS IT THE SAME AS GSM?
“Vaginal rejuvenation” is not a medical term nor does it address a medical condition. It is a marketing term being touted to make women more self-conscious about the appearance of their labia and to promote laser-based procedures to address appearance or other claims, such as improving bladder control, sexual function and laxity – all with no data to support these claims. Vaginal rejuvenation is NOT the same as GSM, which IS a documented medical condition.
Women who receive chemotherapy for breast cancer treatment experience menopause (often called “medical” menopause because it is induced by chemotherapy,) which leads to GSM. Additionally, drugs used to prevent recurrence of breast cancer (aromatase inhibitors, or AIs) also decrease estrogen levels, leading to GSM. In fact, women on AIs often have the most severe cases of GSM. Breast cancer is a contraindication to the use of estrogen. Even low dose, local vaginal estrogen has been shown to raise estrogen levels transiently in women on AIs, and this is a concern for some women. Thus, women on AIs who are unable to use vaginal estrogen need alternative therapies, and the MonaLisa Touch™ is an excellent option for these women.
WHY IS MONALISA TOUCH™ LASER THERAPY AN OPTION FOR BREAST CANCER SURVIVORS WITH GSM?
WHAT IS THE MONALISA TOUCH™ LASER AND WHAT CONDITIONS DOES IT TREAT?
The MonaLisa Touch™ is a CO2 laser used to treat symptoms of GSM, including vaginal dryness, burning, and irritation; lack of lubrication, discomfort or pain during sex; and urinary symptoms of urgency, pain or burning during urination (dysuria) and recurrent urinary tract infections. It is a non-hormonal, FDA-approved therapy, proven safe and effective through numerous clinical trials.
Decrease in estrogen leads to thinning of the vaginal tissue, changes in vaginal pH, loss of ability to lubricate, and changes in the vaginal micro biome that are associated with symptoms of GSM. The MonaLisa Touch™ laser treatment provides fractionated beams of light that penetrate small areas of tissue, triggering a healing response by inducing the body’s own “repair mechanism,” prompting increased levels of collagen, elastin and improved blood vessel supply, and enhanced moisture of the vaginal canal. Each treatment lasts about 5 minutes, and is completely painless. Patients require no down-time, and most patients experience some relief from the very first treatment. A complete treatment course consists of three treatments, scheduled 6 weeks apart.
The MonaLisa Touch™ laser is a non-hormonal, FDA-approved therapy, proven safe and effective through numerous clinical trials. This in-office procedure requires no anesthesia, no down-time, and has been used to treat thousands of women since entering the market as an effective treatment several years ago. It is particularly well suited for breast cancer patients or women who cannot or do not wish to receive estrogen therapy.
DO I HAVE TO BE A MEMBER OF THE PRACTICE TO RECEIVE MONALISA TOUCH™ THERAPY?
No, you do not have to be a member of our concierge medicine or direct primary care practice in order to receive laser therapy treatments. You may be referred to our practice by your primary care physician or OB/GYN, or you may simply schedule a consultation with one of our providers prior to scheduling treatment in our office.
HOW MUCH DOES A COURSE OF TREATMENT COST?
Please call our office to discuss pricing and plans. Need more information? Please call our office (513.760.5511) and request a private consultation with one of our providers, or click here for additional information.