Does Vaginal Rejuvenation Work?

One of the most common types of questions I get in my medical practice and from Hot Flash readers is about vulvovaginal symptoms—itchiness, dryness, and general discomfort. These questions come both from people who are experiencing symptoms of perimenopause now and those who are simply arming themselves with knowledge for the future. It strikes a chord!

Maybe it is the terminology we use to talk about these symptoms: genitourinary syndrome, vaginal dryness, vulvovaginal atrophy. Each one sounds worse than the last. But I don’t think it is just that. The symptoms are often very uncomfortable—one of my patients told me that when she stood up after sitting for a long time, it felt like the walls of her vagina were two pieces of Velcro being ripped apart. Not to mention, by some estimations, more than 80% of women experience vulvovaginal symptoms. Unlike other symptoms, such as brain fog and hot flushes, vulvovaginal symptoms don’t improve once the roller coaster of the perimenopausal transition is over.

Take me to the bottom line

What can be done about vulvovaginal discomfort?

Vaginal estrogen and specially formulated moisturizers and lubricants have been shown to improve symptoms. While vaginal estrogen is safe for most women, for some breast cancer survivors, it may not be recommended. Moisturizers and lubricants are most effective for mild symptoms. Applying messy creams and gels can be a hassle. And the fact that estrogen creams are not used daily makes it hard for patients to get into the habit of using them regularly.

It would be great to have an effective non-hormonal, non-messy alternative for treating vulvovaginal symptoms. Over the past couple of decades, doctors and patients have wondered whether laser ablation or radiofrequency ablation—which are both sometimes referred to as vaginal rejuvenation or energy-based treatments—might fill that gap in treatment options. The names of the devices used to administer these treatments may be familiar to you: MonaLisa Touch, FemiLift, and IntimaLase are a few.

How do laser and radiofrequency ablation work?

Laser and radiofrequency ablation each work a little differently. Lasers burn tiny holes in the tissue that lines the vulva and vagina. This damage to the tissue triggers the body to send in the repair crew to fix the damage. In theory, the repaired tissue is made up of fresher, younger cells that will remain plump and make lubrication to keep the lining of the vulva and vagina moist and supple. Results are expected to last about 18 months.

Radiofrequency ablation works slightly differently. It uses radio waves to generate heat. This stimulates increased collagen production in the tissues that line the vulva and vagina. As with laser treatment, the hope is that this more supple tissue will also generate more lubrication and reduce symptoms like vaginal dryness and pain with sex. Radiofrequency ablation doesn’t last quite as long as laser and needs to be repeated every six months to a year.

Lasers are not specifically approved by the FDA for the treatment of vulvovaginal symptoms associated with perimenopause, but they are approved for a number of skin issues, including reducing the appearance of acne scars, treating hyperpigmentation, and removing skin tags. Using lasers to treat scarring and vulvovaginal atrophy are similar in the sense that the goal is to get the body to generate new tissue that is plumper and more elastic. Similarly, radiofrequency ablation is approved to treat a number of medical problems, including certain pain syndromes, but is not approved specifically to treat vulvovaginal symptoms. Often, energy-based treatments like these are not covered by insurance.

But do these treatments even work? What does the data say?

One of the issues regarding using laser and radiofrequency ablation to treat vulvovaginal symptoms is that most of the clinical trials using these techniques have been small, with fewer than 100 participants included. However, earlier this year Menopause published a review that compiled data from some of the highest-quality randomized controlled trials exploring the efficacy of energy-based techniques for treating vulvovaginal symptoms.

The authors reviewed 32 publications that included both randomized controlled trials and non-controlled trials and compiled data from the 16 randomized controlled trials. There was some variation regarding what the energy-based treatments were compared against. In some cases, the control group was given what’s called a “sham procedure”—one in which they underwent a process identical to the treatment group but no laser or radiofrequency ablation was administered. In other cases, energy-based treatments were compared with vaginal estrogen cream or a vaginal moisturizer.

The authors note that the studies report a variety of different outcomes, including whether or not the participants experienced improvement in symptoms like painful sex, vulvovaginal dryness, vulvovaginal discomfort, painful urination, and overall quality of life. However, in many cases the studies did not use previously validated survey tools and scoring for assessing these different symptoms. Using validated tools in research is important, because they are developed to give reliable results in research studies and have been tested to confirm they will. The studies also used different types of lasers and different treatment protocols. They were all relatively short.

Ultimately, when the authors of the review analyzed the data from the randomized controlled trials collectively, they found that neither laser nor radiofrequency ablation significantly improved any of the symptoms assessed, compared with a sham procedure or vaginal estrogen cream. They also noted that there were no serious side effects associated with energy-based treatments.

There are a couple possible reasons why the authors didn’t find benefits. The first could be that energy-based treatments are not effective at relieving vulvovaginal symptoms associated with perimenopause; maybe they just don’t work. But another possibility is that it’s more of a data problem—even if the treatments do work, the amount of data we have is limited and the quality is poor. Collecting more data using standard protocols and validated survey tools would allow us to know if energy-based treatments are an effective alternative to vaginal estrogen and moisturizers. At this point, we just don’t know.

The authors of this study, the Menopause Society, and the American Urogynecologic Society all agree that we need bigger, better trials to understand whether energy-based treatments are effective for vulvovaginal symptoms during perimenopause.

The bottom line

Vulvovaginal symptoms associated with perimenopause, such as vaginal dryness and discomfort, and pain during sex, may affect more than 80% of women.
Current treatments, including vaginal estrogen and vulvovaginal moisturizers, are often messy and they aren’t applied daily. This results in many women using them infrequently and irregularly.
Energy-based treatments, including laser and radiofrequency ablation, cause minor damage to the tissues that line the vulva and vagina that may stimulate new tissue to form. The data we have right now does not show that these treatments result in an improvement in vulvovaginal symptoms. This may be because the amount of data we have is small and the quality of it is poor.