Contribution of innovative medical treatments for female genital rejuvenation.

Dr Fabienne MARCHAND-LAMIRAUD

Gynecological Surgeon and Cosmetic Gynecologist. 

Elsan Santé - Centre de médecine Esthétique de l'Atlantique. Avenue Claude Bernard Porte D, level 1. 44800 Nantes- Saint Herblain. drmarchand@polyclinique-atlantique.fr

Summary

Vulvovaginal rejuvenation is booming thanks to innovative medical techniques:

  • Hyaluronic acid (HA) specific to the intimate sphere for the treatment of dryness and vulvo-vaginal atrophy and for vulvar aesthetics.

  • The laser for the treatment of vaginal dryness,

  • Radiofrequency also improves vulvovaginal tone and peri-clitoral vascularization,

  • THE HIFU for the treatment of vaginal laxity and early to moderate urogenital prolapse,

  • The LED for the treatment of genital irritation and pain.

Feeling good about your body and your private parts is not a luxury, as it contributes to your self-esteem and allows you to have a fulfilling sex life.

Keywords: Dryness and vulvovaginal atrophy, vulvar hollowness, dyspareunia, genital restoration, fulfilled sexual life.

Introduction 

Genital rejuvenation is a growing demand as women seek intimate comfort and improved sexuality. Nevertheless, the subject is still taboo and few practitioners are responding to the demand.

Why is there a demand for genital rejuvenation?

The genitals, like the rest of the body, undergo natural aging and have been subjected to changes related to pregnancy and childbirth.

Photo 1. 

Example of relaxation of the perineum with vulvar and vaginal gap.

The hormonal fall modifies the vaginal mucous membrane and this at any age of life:

  1. In young women, because the pills are now minidosed, so the estrogen level is lower than the natural level, during anti-hormonal treatments, especially in endometriosis, to block menstruation.

  2. At menopause, when the ovaries no longer produce estrogen.

  3. During breast cancer treatments: chemotherapy and hormone therapy.

Any aggressive local treatment is responsible for a premature alteration of the genitals:

  1.  Pelvic radiotherapy for cervical, rectal and anal cancer,

  2. Vaginal brachytherapy in cervical cancer.

  3. Obstetrical trauma in particular

  4. During excess weight gain during pregnancy,

  5. Or related to a long and difficult delivery (large babies, large episiotomy...)

Consequences of aging of the genitals: aging of the genitals is responsible for:

  1. Dryness and vulvovaginal atrophy

  2. Loosening of the perineum with vulval hollowness

  3. Then a prolapse of the bladder, uterus, rectum isolated or combined more or less important.

These disorders are responsible for sexual dysfunction and dyspareunia.

Indications: genital rejuvenation: for whom?

  1. Any young woman who wishes to improve her genital aesthetics and/or sexuality.

  2. Any woman in pain in the postpartum period.

  3. Any post-menopausal woman, after cancer treatment or after gynecological or bariatric surgery with significant and rapid weight loss. A preliminary: a gynecological consultation before any genital rejuvenation procedure is essential

A gynecological consultation is essential:

  • Screening cervical smears should be normal,

  • Absence of active gynecological infection, including herpes.Methods.

 A/ Medical treatments for genital rejuvenation

Recently, several innovative techniques of aesthetic medicine have appeared to obtain a rejuvenation of the intimate genital sphere:

  1. Hyaluronic acid specific to the intimate sphere: Désirial®.

  2. lipofilling by reinjection of autologous fat.

  3. PRP by injection of platelet-rich plasma.

 

1. Vulvo-vaginal hyaluronic acid: Desirial®.

1.A. Desirial®: This is a hyaluronic acid dedicated exclusively to the genital area, which has a high hydrating power.

It was developed by the French laboratory, VIVACY, which obtained the European authorization of use in the genital sphere. It has an important hygroscopicity since it can capture up to 1000 times its molecular weight. 

It is a combination of HA and mannitol, which is an antioxidant whose effect potentiates the action of HA [10].

The injection is done at the doctor's office. With a 27 or 30G needle, 1ml of product is injected under local anesthesia, at the level of the perineal fork and the vestibule. 

The injection is done using the retro-trace or fan technique or in multiple points. The massage correctly distributes the injected product.

This is THE treatment for intromission dyspareunia due to dryness and atrophy. A reinjection is recommended at 6 months and then every year.

1.B. Desirial Plus®: has a moisturizing and volumizing effect.

  • It is therefore indicated in the aesthetics of the vulva in order to shape and plump up the atrophied labia majora to regain the youthful appearance of the vulva. More developed labia majora mask slightly hypertrophied labia minora. This volumizing effect also has a protective effect against vaginal infections.

  • The injection is done with the cannula in a linear trajectory. 2 ml are injected into each large lip.

  • It can also be used on the anterior wall of the vagina to highlight the G-spot to enhance pleasure and vaginal orgasm. 

  • AH Desirial® Its use is simple, provided that rigorous training is given and basic rules of asepsis are followed. It is a valuable innovation in the field of vulvovaginal rehydration.

Technical:  Injection of hyaluronic acid in vulvo-vaginal with Desirial Plus ®

 2. The repairing and volumizing effect can be achieved by lipofilling associated or not with PRP (Platelet Rich Plasma) and growth factors.

The injection is done :

  • In the vaginal walls in submucosal,

  • In the vulvar region in particular-to treat pain during penetration, -to fill in episiotomy retraction scars, -or cracks in the perineal fork during sexual intercourse.

  • This technique requires a neuro-analgesia and a hospitalization of a few hours.

 B/ Physical treatments for genital rejuvenation

Physical treatments use the thermal effect to stimulate blood circulation and fibroblasts that produce collagen, elastin and hyaluronic acid.  

The treated tissue regains thickness, suppleness and hydration. Physical treatments restore the mucosa and normalize the pH and the vaginal flora. By creating neocollagenesis, tissue retraction is obtained.

Several techniques can be used to achieve this result:

  1. The vaginal laser

  2. Vulvovaginal radiofrequency

  3.  HIFU (high intensity focused ultrasound)

  4. LED-BPM (with photo-bio-modulation). These techniques use vaginal probes.

1/ The vaginal laser is a CO2 or Erbium laser.

The delivered temperature is 80°C for CO2 and 60°C for Erbium. 

  • This high heat causes micro-abrasions of the tissue (fractional emission) with an ablative action on the mucosa.

  • It is tissue repair that will bring the desired result.

2/ The vulvovaginal radio frequency:  

Emits electromagnetic waves that deliver controlled heat at around 45°C and always < 50°C.  

  • It has no ablative action.

  • It stimulates the vaginal mucosa and the muscles of the perineum, which leads to regeneration and rejuvenation of the tissues.

  • Vulvovaginal radio frequency is a recent technique in Europe, introduced in late 2017.

  • It allows to obtain the vaginal restoration but also of the vulva and the clitoris (specific handpiece for the vulva).

 3/ Vaginal HIFU:

It uses high frequency focused ultrasound. The heat emitted at depth is 60°C maximum. Depending on the probe used, the depth of action is different: 1.5mm - 3mm - 4.5mm.

  • By using the 4.5mm probe, the deep muscular layer of the mucosa is reached, which allows to obtain a "tensor" effect used for the treatment of vulvar hollowness and beginning prolapse.

  • HIFU is not yet well developed in France. The Food and Drug Administration (FDA) classifies the focused ultrasound stimulator system for cosmetic use as a class II device (special controls).

  • The special controls that will apply to the device are the Class II Special Controls Guidance Document: "Focused Ultrasound Stimulator System for Aesthetic Use".

  • The Agency classifies the device as Class II (special controls) to provide reasonable assurance of the safety and effectiveness of the device.

  • System using the latest advances in ultrasound study, the energy released is precise on the required depth. The emission is circular at 360 degrees in the form of thermal energy in the vaginal mucosa and muscle, stimulating the appropriate blade and muscle fibers in cell regeneration.

.

4/ LED-BPM (photo-bio-modulation):

 It generates a biological reaction by light whose effect varies according to the wavelength. The principle is based on the stimulation of intra-cellular mitochondria which release energy to promote cell renewal.

Light stimulates the cytochrome C-oxidase in the millions of mitochondria in our cells. This results in the production of ATP (cellular energy).

LEDs are cold light sources that act through non-thermal effects called "photobiomodulation" at the level of the cells.

They deliver narrow bands of light from the "visible" and infrared spectrum of the sun: blue, violet, green, yellow, orange, red or infrared depending on the wavelength.

Each color has an effect on certain types of cells and the dose used is also important.

  • Red light (630nm) or infrared light (830nm) has an anti-inflammatory and restorative cellular stimulation action.

  • Blue light (475nm) has an anti-infectious or antimycotic action.

  • The effects of different colors can overlap and complement each other, hence the interest of color combinations.

The mode of action is very different from that of lasers which generally act by thermal action to destroy a target. Depending on the protocols and parameters used (wavelengths, combinations of wavelengths, power, duration of irradiation, pulsed or non-pulsed mode, duration of interpulses), preventive or therapeutic results can be obtained. The skin, due to its surface position, is one of the most accessible organs for these treatments. The penetration into the tissues varies according to the wavelength used. Currently only a few light bands are used in medicine, red (625-645 nm), blue (455-475 nm), and near infrared (815-835 nm).

  • Yellow is sometimes used, but other colors have not (yet) been the subject of validated scientific studies.

There are never any side effects after a photobiomodulation session but only repercussions in the functioning of the target cells, generally dermal (skin) and/or hypodermal (fatty tissue) depending on the wavelength used. Vaginal probes and panels positioned in front of the vulva are used.

The use of LED in gynecology is under development and is very promising, because the soothing and healing effect is felt quickly and LEDs potentiate the effects of thermal treatments such as laser and radiofrequency.

The results

More than 50 % of women will eventually be affected by genital discomfort.

The "EVES" Study of >1000 postmenopausal women shows that:

  • 66 % have severe vaginal symptoms

  • 30 % have severe vulvar symptoms

  • 11 % have severe urinary symptoms

Most often these symptoms are associated with each other. Thanks to the new treatments, a clear improvement in clinical signs and sexuality is obtained from the first month and continues for up to 6 months. An annual maintenance treatment is recommended.

https://surgerycongress.conferenceseries.com/ocm/2019/red-m-alinsod-the-alinsod-institute-of-aesthetic-vulvovaginal-surgery-usa

1/ The effectiveness of HA treatment

According to P. Sebban-Sarfati, the results of the first injection are significant.     

15 % of women were lost to follow-up at six months.

At one month, 90 % of patients were globally satisfied, 75 % very satisfied, 15 % moderately satisfied.

However, this satisfaction rate decreased significantly at six months (45 % of unsatisfied).

The very low failure rate is probably multifactorial and more complex than a simple organic disorder.

The six-month efficacy period coincides perfectly with the half-life of the molecule.

This important finding may prompt̀ a recommendation to repeat the injection as early as this time, even before the disorders reappear.

No complications occurred and only one session had to be interrupted due to excessive pain experienced by the patient.

The sensation of well-being and local comfort associated with̀ a disappearance of burning and dryness is mostly expressed very quickly. Finally, an improvement in sexual health and the disappearance of dyspareunia allow the progressive restoration of sexual life. The testimonies are enthusiastic. This treatment is innovative because it is simple and safe, provided that the recommendations are respected.

Of the 25 women registered:

    • 19 (76 %) reported an average reduction in time to orgasm of at least 50 %

    • 23 (92 %) reported an average reduction in time to orgasm of at least 33 %.

All patients also noted significant vaginal tightening effects, increased vaginal moisture and improved vulvar and clitoral sensitivity.

    • All anorgasmic patients (n = 10) reported regaining their ability to achieve orgasm.

    • 2 patients reported a minimal response.

Questionnaire results:

    • 23 of 25 subjects (92 %) reported achieving orgasm after TTCRF treatment;

    • 16 reported no change in orgasm intensity,

    • While 9 subjects reported having more intense orgasms.

    • The time required to reach orgasm was reduced by half or more in 19 of the 25 subjects.

    • All subjects reported a tightening of the vaginal canal.

    • An improvement in vaginal moisture was noted in 20 of 25 patients.

    • All 25 patients reported being satisfied with the treatment and would recommend it to family and friends. The complete results are presented in the table below:

https://surgerycongress.conferenceseries.com/ocm/2019/red-m-alinsod-the-alinsod-institute-of-aesthetic-vulvovaginal-surgery-usa

http://www.centrelaserclipp.com/laser-thermiva-rajeunissement-vagin-clipp-paris-large-trop-radiofrequence.html#thermiva

3/ Results of laser treatment for genitourinary menopausal syndrome.

A systematic review and meta-analysis. (9)

The purpose of this study was to identify and then synthesize all available data regarding the efficacy of laser therapy for postmenopausal women with genitourinary menopausal syndrome (GMS) with or without urinary incontinence (UI). PubMed, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched in October 2016. 

The keywords were: "laser genitourinary syndrome of menopause", "laser vulvovaginal atrophy", "laser vaginal atrophy" and "laser women incontinence".

The reporting quality and risk of bias of the included studies were assessed according to the STROBE and MINORs checklists, respectively. 

The quality of the body of evidence was assessed using the GRADE approach. Fourteen studies involving 542 participants were included in this systematic review and meta-analysis.                                              

Dryness/dyspareunia/itching/burning/dysuria/urgency/frequency: all symptoms of GSM and UI were significantly and consistently reduced in all available publications. 

The pooled mean differences for the different symptoms were as follows:

  • Drought: - 5.5 (95% CI: - 6.7, - 4.4; 7 studies; I2: 0%)

  • Dyspareunia - 5.6 (95% CI: - 6.8, - 4.5; 7 studies; I2: 0%),

  • Itching: - 4 (95% CI: - 5. 7, - 2.2; 6 studies; I2: 79%)

  • Burns: - 3.9 (95% CI: - 5.9, - 2; 6 studies; I2: 87%)

  • Dysuria: - 2.9 (95% CI: - 5.1, - 0.7; 4 studies; I2: 90%)

  • IU: - 4.9 (95% CI: - 6.4, - 3 .4; 2 studies; I2: 0%).

Because urgency/frequency were assessed by different methodologies, the data could not be meta-analyzed. In addition, KHQ, UDI-6, MCS12/PCS12, FSFI, overall sexual satisfaction, and measures of the effect of laser therapy on local pathophysiology were significantly improved.

In conclusion, laser therapy for postmenopausal women with GSM appears promising. It may reduce the severity of symptoms, improve the quality of life of postmenopausal women, and restore the vaginal mucosa to premenopausal status. However, the overall quality of the evidence is "low" or "very low" and, therefore, no change in current clinical practice can be suggested based on the evidence.

 

In (9) Pitsouni E1Grigoriadis T1Tsiveleka A2Zacharakis D1Salvatore S3Athanasiou S4. Microablative fractional CO2-laser therapy and the genitourinary syndrome of menopause: An observational study. Maturitas. 2016 Dec;94:131-136. doi: 10.1016/j.maturitas.2016.09.012. Epub 2016 Sep 16.

 SYMPTOMS IMPROVEMENT (%) AFTER 3 TREATMENTS. MONALISA TOUCH®.

  • BURN: 84%

  • ITCHING: 85%

  • DROUGHT: 76%

  • DYSPAREUNIA: 72%

  • LAXITY: 90%

Dr. Stefano Salvatore - Hospital of San Raffaele, Milan (Italy)

Conclusion

Medical treatments for female genital rejuvenation using innovative physical methods are a recent development.

They have completely changed the therapeutic approach to very frequent genital disorders due to aging such as dryness with vulvovaginal atrophy and vulvar hollowness. 

They allow to obtain a real vulvo-vaginal rejuvenation. They transform the lives of women who suffer from them.

By regaining feminine comfort and a youthful appearance of her genitals, the woman regains the self-esteem and self-confidence necessary to achieve a fulfilling sexuality and harmony in the couple. 

It is urgent that health professionals inform their patients of the existence of these recent techniques and refer them to centers that perform them safely.  "The silence around this innovative treatment is due to its relative youth associated with̀ bibliographic povertý and media silence" (P. Sebban-Sarfati).

Hope will come from the studies that will be launched:

  • In particular, the randomized double-blind study that is starting up, conducted by the Vivacy laboratory, entitled "Treatment of vulvovaginal symptomatology suggestive of estrogen deficiency by injection of HA into the vaginal mucosa",

  • As well as the study announced in the framework of the DUMEG, by Dr Barbara Hersant, within the service of Pr Jean-Paul Meningaud, on "Comparative studies of different innovative treatments, lasers, HA and local treatments of side effects of hormone therapy after breast cancer". 

  • If these studies scientifically demonstrate actual effectiveness, which is likely, then a media "buzz" will be triggered́.

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