Feminine Rejuvenation: The Controversy, The Science, The Results

March 14, 2019

There’s a love-hate relationship with the concept of feminine rejuvenation for dermatologist. It’s impossible to ignore but there starts to be a conversation, it becomes frustrating because the research is still questionable; the promotion makes many promises, than we are left with questions that can’t be answered. So, what is the truth in feminine rejuvenation? Let’s dig in and find out.

There is Data Out There with Dr. Amy Taub

Dr. Taub presents some big questions about vaginal rejuvenation: What questions should be asked? Should dermatologist treat vaginal tissue? Is it worth adding it to your armamentarium? Is there compelling data? What devices should be used?

Dr. Taub says there is compelling data out there to support vaginal rejuvenation.

The symptoms: commonly experienced by postmenopausal and postpartum women are vaginal dryness, “widened” vaginal canal, dyspareunia (pain with sex), stress urinary incontinence (SUI) and decreased sexual pleasure/sensation. Studies show that one in every two women who have undergone menopause has SUI and treating the symptoms costs patients more than 10 billion USD annually.

The three energy sources for non-surgical “vaginal rejuvenation” being utilized in the field are:

  • Fractional Erbium Yag Laser
  • Fractional CO2 laser
  • RF

Dr. Taub has seen good results for CO2 Fractional and RF treatments, but she also presents a collection of studies conducted in Europe on the Erbium lasers.

AT: In the United States, we often think if the study wasn’t done in the US, there’s really no literature, and if it is not in the dermatology literature, then it doesn’t exist. I am here to tell you that the literature does exist.

  1. Post-menopausal treatment with Erbium YAG laser
    – 65 Post-menopausal women were treated with Vaginal Erbium YAG laser with one treatment a month for three months. The result was a decrease in dryness and dyspareunia and there was an increase in vaginal health score (ICIQ).
  2. Erbium Laser Versus. Topical Estrogen
  • Forty-five women had three treatments of Vaginal Erbium Laser and 19 women had topical estrogen. Vaginal dryness and dyspareunia improved in both groups. After 12 weeks, the topical group discontinued estrogen. At 24 weeks, only the vaginal laser group had seen improvement and the topical estrogen group had fall-off of improvements. The laser treatments last longer than estrogen gel.
  1. Long-term treatment with Erbium Laser
  • 205 postmenopausal women had three monthly treatments. After following up at 12 months and 24 months, all women showed statistically significant improvement in dyspareunia and dryness. Their treatment results lasted 18 months and fully diminished at 24 months.
  1. ER: YAG laser for incontinence and vaginal mucosal changes: Biopsy study
    – Results from the biopsy show Neocollagenogenesis, Elastogenesis and Neoangiogenesis, reduction of epithelial degeneration and atrophy, increase fibroblast population, volume density of blood capillaries increased by 61.1%, and thickness of the epithelial layer increased 64.5%

AT: I’ve talked to many of my colleagues and it seems all these treatments appear to work. From an anecdotal point they all work, but there is a lot of controversy. I can applaud the FDA on one hand, because there are people that don’t know what they’re doing, or won’t take the time to study to learn how to do it properly. Much like treating pigmented skin, less is more when it comes to vaginal rejuvenation. So maybe the FDA warning wasn’t bad because after all, none of these companies have clearance for vaginal rejuvenation and only some have clearance for vaginal treatment.”


Vaginal Rejuvenation to Vaginal Restoration with Dr. Doris Day

There is a controversy as to whether or not dermatologist should be doing vaginal rejuvenation. Dermatologists have treated STDs for a very long time and Dr. Day’s theory is that if physicians are able to treat the problem, they should treat the pleasure too. In her practice, she tells her patients sex is really good for the skin and having an orgasm on a regular basis is important for women. She stresses that when physicians talk about aesthetics for women, they need to be comfortable with this conversation.

There are a lot of ways to address the issues that more than 50% of women face, whether it’s urinary incontinence, pain when they’re having sex, or dryness. As with many treatments, combination therapies often provide the best results.

DD: This market is growing. We know the mechanisms of actions in many of these devices. We know where we are delivering energy and what those results are. The key is using them in combination for the best treatment.

As a speaker and user of Lumenis’ devices, Dr. Day reports that the FemTouch treatment takes 5-7 minutes and is completely pain-free with minimal downtime. The treatment is controlled by energy settings. She cautions you’ll want to be careful about the energy levels you choose. The treatment is controlled by energy settings and impacts only the mucosa (which heals quickly) and not the deeper connective tissue. Dr. Day still cautions that one should be careful about the settings you select.

Using a monopolar RF device provides deeper effects. It’s a positive pole built into the treatment tip or hand piece and the only path completing the electrical circuit is the one that passes through the tissue layers. This treatment takes Dr. Day about 30-45 minutes. The current density of the treatment is high, so it’s important to use cooling with this in order to protect vaginal mucosa.

DD: I think we need to change the name from vaginal rejuvenation to vaginal restoration. Rejuvenation implies something that is more elective and appearance related, when restoration is more function related. Hopefully that will catch on as a new way to refer to it.  

Vaginal restoration is a treatment that will build slowly. It’s important to let women know that treatment is available and that they’re not alone if they’re experiencing or have experienced these issues.


ThermiVA: Monopolar RF Study with Dr. Sabrina Fabi

Aging happens in the vaginal tissue like aging happens in the skin. The effects of vaginal aging result in symptoms such as stress urinary incontinence (SUI). Dr. Fabi was curious as to how patients were getting improvements with SUI with superficial treatments? She questioned, what is changing in the body that makes women orgasm more quickly?

Dr. Fabi was a part of a clinical trial using a monopolar RF device called ThermiVA.

In this study, ten women between ages of 23-60 with mild to moderate vulvovaginal laxity were treated. The study protocol was three, thirty minute treatments one month apart at a target temperature of 42-45 ⁰C. After each treatment, biopsies of the tissue were taken in order to understand the affect of the treatment on the tissue.

The study followed patients for 60 days after last treatment to determine the longevity of the ThermiVA. Patients saw a significant improvement in vulvovaginal as early as a single treatment. They noted improvement continued 2 months after their last treatment.

Immediately after the last treatment, patients experienced the most sexual satisfaction. This did, however, started to trend downward at two months after the last treatment.

Atrophic vaginitis symptoms also continued to improve two months after the last treatment.

SF: We asked the patients a number of questions: how would they rate their level or degree of sexual desire or interest? How did they rate their level of sexual arousal during sexual activity or intercourse? How quickly did they reach an orgasm? How satisfied were they in their ability to reach orgasm during sexual activity or intercourse?  Patients showed significant improvement in all of these categories as early as the first treatment.

We also noted there was improvement in discomfort and pain during intercouse as early as the first treatment, although, there was a rebound two months after the last treatment. Even given the rebound of effect, patients reported being extremely satisfied in their overall improvement in their sex lives.

Dr. Fabi said the biological findings were astonishing. The biopsies showed:

  • 3 of 5 subjects had increased small nerve fiber density in vaginal canal.
  • All subjects showed improved epidermal maturation, thickening of mucosa and neocollagensis.
  • Four out of five subjects’ biopsies showed increased elastic fibers in vaginal canal.
  • One subject had Lichen sclerosus on pre-treatment biopsy, but showed no evidence of it on post-treatment biopsy.

Overall, patients significantly improved vulvovaginal laxity as early as 10 days after the first treatment. Sexual satisfaction and atrophic vaginitis was improved as well as orgasmic dysfunction and SUI was also steadily improved.

Reference: Histologic and Clinical Changes in Vulvovaginal Tissue After Treatment with a Transcutaneous Temperature-Controlled Radiofrequency Device, Dermatologic Surgery, May 2018.


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