Vaginal laser therapy for gynecologic conditions: re-examining the controversy and where do we go from here

Laser technologies are rapidly emerging as a treatment option for numerous vaginal conditions, including vaginal atrophy, dryness, dyspareunia, pelvic pain, urinary urgency, and incontinence. Although vaginal ablative devices have been on the market for years, prospective randomized researches were insufficient to describe their effectiveness and safety. But the newer data confirms that, when appropriately used, ablative lasers are generally safe. 

Lasers have shown promising results in treating genitourinary syndrome of menopause (GSM), yet sufficient data to draw a meaningful conclusion on its long-term safety and efficacy is lacking. Further, there are emerging yet insufficient data for other vaginal conditions (not necessarily associated with menopause) as well, like sexual dysfunction, vulvar pain, pelvic pain, and IC/BPS. 

In their recent study published in The Journal of Comparative effectiveness research, the authors' Zipper R. and Lamvu G. emphasize the need for more research to determine the duration and magnitude of effect and standard dosing to be used in each condition. Until then, they have advised the clinicians to consider ablative devices with caution, following careful patient selection and extensive discussion of risks and benefits (especially long-term outcomes, which are yet unclear). They further mentioned the importance of discussing concerns about vaginal injury, scarring, and pain, especially with patients who do not have a history of vaginal pain. They also mentioned that, interestingly, the risk-benefit considerations for patients undergoing laser therapy for cosmesis or rejuvenation are different than those with conditions significantly impairing quality of life, such as atrophy, dryness, and pain.

The authors have directed Clinicians to understand the difference between ablative and non-ablative devices. TV-PBM delivered at powers below 10 W carries safety concerns associated with ablative lasers. They can target deeper pelvic tissues like the pelvic floor muscles and the bladder. Thus, TV-PBM remains an option only in patients with pelvic pain conditions. However, more research is needed to confirm the efficacy, effect duration, and long-term safety of TV-PBM. 

Since millions of women suffer from conditions curable using ablative and non-ablative lasers (both external and transvaginal), the authors emphasize on exploring their potential impact and not delaying the research on these technologies.

Although there is a lack of sufficient evidence to guide treatment protocols and suggestions to keep vaginal lasers on 'pause', they are widely used by clinicians and requested by patients, a trend that may be difficult to reverse. Thus, along with contributing to research, clinicians must continue to educate their patients about laser technology and conditions for appropriate use. 

A recent recommendation by the American Urogynecologic Society regarding ablative lasers seems prudent at the moment. It says that clinicians may continue to use these technologies with caution and with extensive patient counseling regarding cost and limited knowledge of efficacy and safety.

Zipper R, Lamvu G. Vaginal laser therapy for gynecologic conditions: re-examining the controversy and where do we go from here. JOURNAL OF COMPARATIVE EFFECTIVENESS RESEARCH. 2022;11(11).

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