Tales from the laser clinic

Introduction

In this tale, we would like to consider a potential new treatment option for urogenital atrophy, CO₂ laser therapy. Although this treatment is only available privately at present, it offers an additional non-hormonal intervention for symptomatic women with a history of breast cancer, the commonest cancer affecting women, with a quarter of new diagnoses in pre-menopausal women. Although we review only a handful of cases, around 75% of breast cancer survivors are likely to experience symptoms of urogenital atrophy which is also known as genitourinary syndrome of menopause (GSM).

Clinical cases

This tale focusses on women undergoing CO₂ laser treatment for GSM. All of the women described below presented with a request for treatment with CO₂ laser therapy. All were either using or had used an aromatase inhibitor, and none would have contemplated treatment with any form of hormonal therapy. CO₂ laser therapy (Mona Lisa Touch ® - Deka) potentially offers symptom relief, to this patient group, with no impact on the risk of breast cancer recurrence.

Ms A is a 47-year-old woman, who was diagnosed with estrogen receptor positive breast cancer in 2016. She had a lumpectomy, 5 weeks of radiotherapy and hormone blocking treatment, initially Tamoxifen® (3 years) followed by

Anastrozole®, an aromatase inhibitor (AI), after bilateral oophorectomy in 2019, for a complex ovarian cyst. Exemestane® was prescribed initially, then Anastrozole®, but neither were well tolerated. The patient has now been discharged from oncology and sees a breast surgeon privately twice a year for an annual mammogram and MRI assessment. This was the patient’s choice because of lumpy breasts, which are difficult to self-assess. At presentation, she had been unable to have sex with her husband for 2 years. Treatment has made her more comfortable, and she can now use the toilet without tearing of the vulval mucosa on wiping. However, she has still been unable to have sex, but she thinks this is more likely due to lack of desire related to her diagnosis and necessary treatment. Tearing tends to occur at the entrance to the vagina, in the posterior fourchette, within Hart’s line.

Ms B is a 37-year woman who was diagnosed with breast cancer in 2018, age 30. She was managed with bilateral mastectomy, Zoladex® and Letrozole®, which had a devastating impact on urogenital tissue quality. She presented to an NHS menopause service as a result of being unable to have sex. After undergoing three CO₂ laser treatments, whilst penetrative sex is still not possible, she is now able to horse ride, without significant discomfort. She has been referred for specialist pelvic floor physiotherapy and psychosexual counselling to help with relaxation of her pelvic floor. Treatment with Zoladex® is now complete and a change from Letrozole® to Tamoxifen® has been requested. With the addition of Imvaggis ®, a weak estrogen, in the lowest concentration of any available preparation, we hope that she will experience further improvement in symptom control.

Ms C is a 47-year-old woman, who was diagnosed with breast cancer in May 2020.

She was already using Prostap® and add back Tibolone® for pre-menstrual dysphoric disorder (PMDD), diagnosed in July 2019. Treatment for her breast cancer included a lumpectomy, chemotherapy, radiotherapy, Zoladex® and Letrozole®. A hysterectomy and bilateral salpingo-oophorectomy were performed in 2022, as a definitive treatment for PMDD. She presented for CO₂ laser therapy, due to concerns about changes in urogenital appearance and smell. She is not sexually active at present and was concerned at presentation that she might have delayed seeking treatment too late to benefit from it. However, she reported an improvement in symptoms following the first treatment.

Ms D who is age 56 was diagnosed with breast cancer, age 52. She was treated with lumpectomy, followed by revision surgery to confirm clear margins. The cancer was ER/PR positive, HER 2 negative with lymph node involvement, necessitating 16 rounds of chemotherapy (Paclitaxel/EC). She is currently taking Anastrozole®. She presented for treatment with CO₂ laser therapy as she and her husband are unable to have sex. She has had two treatments with some improvement in symptom control, and has now been able to have sex.

CO₂ laser therapy – practical considerations

Treatments are delivered every 4–6 weeks and take around 5–10 min to perform. A clinical assessment including a speculum examination should be undertaken before each treatment. This is to confirm the diagnosis and exclude other causes for symptoms, including malignancy.

Patients should be consented before the initial procedure, to confirm understanding of basic information relating to the mode of action of the device (see below) and possible limitations (failure to respond) and side effects of the treatment (feeling hot at the treatment site). Contraindications include active infection, anticoagulation and previous mesh surgery.

Each treatment costs around £400 and the recommendation is for 3 treatments at baseline, occasionally 4, followed by an annual top up from the time of the initial treatment. All people present, generally the clinician delivering the treatment, a health care assistant and the patient, should wear protective glasses. The probes are sterilised between procedures and most procedures are undertaken using a 360-degree probe for vaginal administration and a vulvar probe. For the most severely affected women, a 90-degree, narrower probe is available for the vaginal treatment. Local anaesthetic is not required in the majority of cases, but if requested, topical local anaesthetic is sufficient.

How does CO₂ laser work in urogenital atrophy?

CO₂ micro ablative laser has a wavelength of 10,600 nm, which causes heat damage to a minimal amount of tissue, with rapid recovery and an associated coagulative effect that prevents bleeding. Treatments are delivered at gradually increasing levels of penetration, starting with the most superficial level and increasing progressively to deeper levels, depending on the extent of the atrophy and patient tolerance. This is achieved with Mona Lisa Touch ® through the use of a stacking system, built into the machine and accessed through pre-set programs. The mode of action is based on the concept of water absorption, with the laser at this wavelength, attracted to any residual water within the connective tissue. For this reason, any vaginal secretions should be removed prior to delivering treatment and minimal use of lubricant or topical analgesia is recommended. The thermal effect produces oedema in the first few days and collagen producing fibroblasts are stimulated, resulting in neocollagenesis and neovascularisation, using the body’s own repair mechanism. This is associated with urogenital tissue restructuring with an increase in collagen and sub-epithelial papillae and an increase in vaginal lubrication and acidity. The stratified squamous epithelium becomes thickened with an increase in glycogen and lactobacilli.

The vulvar probe uses Dermal Optical Thermolysis (DOT) to apply laser therapy in a non-continuous mode (200 micrometre dots), again with only a very small amount of vulval tissue directly affected, resulting in decreased damage to the deeper or surrounding tissues, reducing pain and promoting rapid recovery following treatment.

Alternative laser treatment options

In addition to CO₂ micro ablative laser therapy, patients have the option of non-ablative photothermal Erbium Yag laser therapy. This has a wavelength of 2940 nm, which results in reduced tissue penetration, longer treatment times (25 min) and there is no associated tissue coagulation.

Discussion

Urogenital atrophy in women taking aromatase inhibitors is challenging to treat. Whilst early intervention with vaginal estrogen is associated with less risk of systemic absorption, it is counterintuitive to give a drug to prevent estrogen production, and then provide treatment with estrogen. Nevertheless, this has to be balanced against the deleterious effect that severe urogenital atrophy can have on quality of life, including the impact on relationships. As highlighted above, where deemed appropriate, vaginally delivered estriol, which is a weaker estrogen than estradiol, is the preferred treatment option, but many affected women are extremely anxious about use of any kind of hormonal preparation.

Outcomes following treatment with CO₂ laser therapy may be similar to those achieved with vaginal estrogen. A Danish study undertaken in women following both natural menopause and induced menopause, as a result of endocrine therapy or oophorectomy for breast cancer, found that all women experienced an improvement in symptoms, relating to sexual and urinary function. ¹ Another study undertaken in women with a history of breast cancer found no serious adverse effects. ²

Whilst this is reassuring, the number of women in the study was small and before CO₂ laser therapy can be made available to NHS patients, a UK-based randomised controlled trial, comparing active laser with sham laser is needed, as suggested by the National Institute for Health and Care Excellence. A UK feasibility study is planned, the outcomes of which will inform the need for a larger multicentre clinical trial, with long-term follow-up. It is important that future research is guided by what affected women want and they should be involved in the design and choice of outcome, including use of a patient-reported outcome measure. A JAMA editorial, Time for a ‘Pause’ on the Use of Vaginal Laser, would have been better titled, Time for a ‘Pause’ on the use of vaginal laser, while a good quality, adequately powered randomised controlled trial is carried out.^3,4

Conclusion

The impact of a diagnosis of breast cancer on general wellbeing cannot be underestimated. However, there is a significant unmet need in women with urogenital atrophy resulting from or exacerbated by breast cancer treatment. Whilst the most important concern at the time of the initial diagnosis is containment of the cancer, for many affected women, the impact on sexual function in not proactively managed, despite recent publications supporting safety and efficacy of CO₂ laser treatment. A systematic review and meta-analysis of vaginal laser treatment for urogenital atrophy in breast cancer survivors demonstrated an improvement in vaginal dryness and dyspareunia with minimal side effects.^5,6