Clinical Review

Genitourinary syndrome of menopause: Current and emerging therapies

OBG Manag. 2015 August;27(8):e1–e6

References

Portman DJ, Gass ML. 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(10):1–6.
Calleja-Agius J, Brincat MP. Urogenital atrophy. Climacteric. 2009;12(4):279–285.
Mehta A, Bachmann G. Vulvovaginal complaints. Clin Obstet Gynecol. 2008;51(3):549–555.
Pastore LM, Carter RA, Hulka BS, Wells E. Self-reported urogenital symptoms in postmenopausal women: Women’s Health Initiative. Maturitas. 2004;49(4):292–303.
Santoro N, Komi J. Prevalence and impact of vaginal symptoms among postmenopausal women. J Sex Med. 2009;6(8):2133–2142.
Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013;10(7):1790–1799.
Nappi RE, Kokot-Kierepa M. Vaginal Health Insights, Views and Attitudes (VIVA)—results from an international survey. Climacteric. 2012;15(1):36–44.
Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric. 2014;17(1):3–9.
Nappi RE, Kokot-Kierepa M. Women’s voices in menopause: results from an international survey on vaginal atrophy. Maturitas. 2010;67(3):233–238.
Rahn DD, Carberry C, Sanses TV, et al. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol. 2014;124(6):1147–1156.
Suckling J, Lethaby A, Kennedy R. Local estrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006;Oct 18(4):CD001500.
Utian WH. A decade post WHI, menopausal hormone therapy comes full circle—need for independent commission. Climacteric 2012;15(4):320–325.
Bachmann GA, Komi JO. Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study. Ospemifene Study Group. Menopause. 2010;17(3):480–486.
Wurz GT, Kao CT, Degregorio MW. Safety and efficacy of ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy due to menopause. Clin Interv Aging. 2014;9:1939–1950.
Letter to Paolo Peruzzi. US Food and Drug Administration; September 5, 2014. http://www.accessdata.fda.gov/cdrh_docs/pdf13/K133895.pdf. Accessed July 8, 2015.
Krychman ML, Shifren JL, Liu JH, Kingsberg SL, Utian WH. The North American Menopause Society Menopause e-Consult: Laser Treatment Safe for Vulvovaginal Atrophy? The North American Menopause Society (NAMS). 2015;11(3). http://www.medscape.com/viewarticle/846960. Accessed July 8, 2015.
Salvatore S, Nappi RE, Zerbinati N, et al. A 12-week treatment with fractional CO₂ laser for vulvovaginal atrophy: a pilot study. Climacteric. 2014;17(4):363–369.
Salvatore S, Maggiore ULR, Origoni M, et al. Microablative fractional CO₂ laser improves dyspareunia related to vulvovaginal atrophy: a pilot study. J Endometriosis Pelvic Pain Disorders. 2014;6(3):121–162.
Salvatore S, Nappi RE, Parma M, et al. Sexual function after fractional microablative CO₂ laser in women with vulvovaginal atrophy. Climacteric. 2015;18(2):219–225.
Salvatore S, Maggiore LR, 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(8):845–849.
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(1):429–436.
Tierney EP, Hanke CW. Ablative fractionated CO₂, laser resurfacing for the neck: prospective study and review of the literature. J Drugs Dermatol. 2009;8(8):723–731.
Peterson JD, Goldman MP. Rejuvenation of the aging chest: a review and our experience. Dermatol Surg. 2011;37(5):555–571.

Fractional CO₂ laser: A study in progress
Two authors (Mickey Karram, MD, and Eric Sokol, MD) are performing a study of the fractional CO₂ laser for treatment of genitourinary syndrome of menopause (GSM) in the United States. To date, 30 women with GSM have been treated with 3 cycles and followed for 3 months. Preliminary data show significant improvement in all symptoms, with all patients treated in an office setting with no pretreatment or posttreatment analgesia required.

FIGURE 3: Fractional CO2 laser treatmentThe probe is slowly inserted to the top of the vaginal canal and then gradually withdrawn, treating the vaginal epithelium at increments of almost 1 cm.

The laser settings for treatment included a power of 30 W, a dwell time of 1,000 µs, spacing between 2 adjacent treated spots of 1,000 µs, and a stack parameter for pulses from 1 to 3.

Laser energy is delivered through a specially designed scanner and a vaginal probe. The probe is slowly inserted to the top of the vaginal canal and then gradually withdrawn, treating the vaginal epithelium at increments of almost 1 cm (FIGURE 3). The laser beam projects onto a 45° mirror placed at the tip of the probe, which reflects it at 90°, thereby ensuring that only the vaginal wall is treated, and not the uterine cervix.

A treatment cycle included 3 laser treatments at 6-week intervals. Each treatment lasted 3 to 5 minutes. Initial improvement was noted in most patients, including increased lubrication within 1 week after the first treatment, with further improvement after each session. To date, the positive results have persisted, and all women in the trial now have been followed for 3 months—all have noted improvement in symptoms. They will continue periodic assessment, with a final subjective and objective evaluation 1 year after their first treatment.

Bottom line
Although preliminary studies of the fractional CO₂ laser as a treatment for GSM are promising, local estrogen is backed by a large body of reliable data. Ospemifene also has FDA approval for treatment of this disorder.

For women who cannot or will not use a hormone-based therapy, vaginal lubricants and moisturizer may offer at least some relief.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

References

Portman DJ, Gass ML. 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(10):1–6.
Calleja-Agius J, Brincat MP. Urogenital atrophy. Climacteric. 2009;12(4):279–285.
Mehta A, Bachmann G. Vulvovaginal complaints. Clin Obstet Gynecol. 2008;51(3):549–555.
Pastore LM, Carter RA, Hulka BS, Wells E. Self-reported urogenital symptoms in postmenopausal women: Women’s Health Initiative. Maturitas. 2004;49(4):292–303.
Santoro N, Komi J. Prevalence and impact of vaginal symptoms among postmenopausal women. J Sex Med. 2009;6(8):2133–2142.
Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013;10(7):1790–1799.
Nappi RE, Kokot-Kierepa M. Vaginal Health Insights, Views and Attitudes (VIVA)—results from an international survey. Climacteric. 2012;15(1):36–44.
Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric. 2014;17(1):3–9.
Nappi RE, Kokot-Kierepa M. Women’s voices in menopause: results from an international survey on vaginal atrophy. Maturitas. 2010;67(3):233–238.
Rahn DD, Carberry C, Sanses TV, et al. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol. 2014;124(6):1147–1156.
Suckling J, Lethaby A, Kennedy R. Local estrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006;Oct 18(4):CD001500.
Utian WH. A decade post WHI, menopausal hormone therapy comes full circle—need for independent commission. Climacteric 2012;15(4):320–325.
Bachmann GA, Komi JO. Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study. Ospemifene Study Group. Menopause. 2010;17(3):480–486.
Wurz GT, Kao CT, Degregorio MW. Safety and efficacy of ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy due to menopause. Clin Interv Aging. 2014;9:1939–1950.
Letter to Paolo Peruzzi. US Food and Drug Administration; September 5, 2014. http://www.accessdata.fda.gov/cdrh_docs/pdf13/K133895.pdf. Accessed July 8, 2015.
Krychman ML, Shifren JL, Liu JH, Kingsberg SL, Utian WH. The North American Menopause Society Menopause e-Consult: Laser Treatment Safe for Vulvovaginal Atrophy? The North American Menopause Society (NAMS). 2015;11(3). http://www.medscape.com/viewarticle/846960. Accessed July 8, 2015.
Salvatore S, Nappi RE, Zerbinati N, et al. A 12-week treatment with fractional CO₂ laser for vulvovaginal atrophy: a pilot study. Climacteric. 2014;17(4):363–369.
Salvatore S, Maggiore ULR, Origoni M, et al. Microablative fractional CO₂ laser improves dyspareunia related to vulvovaginal atrophy: a pilot study. J Endometriosis Pelvic Pain Disorders. 2014;6(3):121–162.
Salvatore S, Nappi RE, Parma M, et al. Sexual function after fractional microablative CO₂ laser in women with vulvovaginal atrophy. Climacteric. 2015;18(2):219–225.
Salvatore S, Maggiore LR, 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(8):845–849.
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(1):429–436.
Tierney EP, Hanke CW. Ablative fractionated CO₂, laser resurfacing for the neck: prospective study and review of the literature. J Drugs Dermatol. 2009;8(8):723–731.
Peterson JD, Goldman MP. Rejuvenation of the aging chest: a review and our experience. Dermatol Surg. 2011;37(5):555–571.

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Genitourinary syndrome of menopause: Current and emerging therapies

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