Rethinking the Techno Vagina: A Case Series of Patient Complications Following Vaginal Laser Treatment for Atrophy

Catherine Gordon, MD; Savanah Gonzales; Michael L. Krychman, MD


Menopause. 2019;26(4):423-427. 

In This Article

Case Studies

Case 1

Case 1 is a 65-year-old postmenopausal patient who had a left mastectomy for breast ductal carcinoma in situ and presented to the tertiary center with complaints of severe vaginal dryness and moderate vaginal stenosis. Previously, she reported mild headache, when treated with intravaginal estradiol cream by an outside health care professional. She self-discontinued local therapy due to these mild headaches and her health care professional offered a series of laser treatments for her vaginal dryness. She underwent three consecutive CO2 vaginal laser treatments, which she reports were uncomplicated. After her last laser treatment, the health care professional informed her that intercourse was permitted. She was not given any adjunctive information concerning minimally absorbed local therapy, vaginal moisturizers, or sexual lubricants. A few weeks after her last treatment, she engaged in intercourse, and reported heavy vaginal bleeding immediately following. The following morning, she was seen in her provider's office, and described heavy bleeding with clots and reported changing her pad every 20 minutes. She was sent to the emergency department and her hemoglobin and hematocrit were determined to be 12.7/36.5 respectively; however, active bleeding was present on pelvic examination. In the operating room she underwent an examination under anesthesia and two vaginal wall lacerations were noted and repaired (a 2 cm laceration left lateral to the cervix and a 1 cm laceration right lateral to the cervix). There were areas of adhesive agglutination noted in the vaginal canal. She recovered from this procedure. However, several months later she presented to the tertiary sexual medicine center with complaints of severe vaginal pain, dryness, and inability to engage in penetrative intercourse. She was distraught since she was under the impression that the laser was her last and only resort for resolution of her distressing problem. On examination, she currently continues to have a foreshortened vaginal canal of approximately 2.5 cm in length. Vaginal canal length was measured by digital examination, and then an external tape measure was used to document measured length. In addition, the tissue was visually examined and fibrotic tissue was noted at the apex and within the canal of the vagina. She is currently being treated with intravaginal dehydroepiandrosterone, genitopelvic physical therapy and an aggressive vaginal dilator program. She was counseled on alternative sexual positions, as well as using the come-close ring. At her 3-month follow up, she is able to engage in intercourse using alternative sexual positions, copious amounts of silicone-based lubricant and use of dilators before coitus.

Case 2

Case 2 is a 61-year-old woman who presented to the tertiary sexual medicine center with complaints of persistent painful intercourse following her three courses of CO2 laser treatment which occurred 10 months before her visit. Medical history is consistent with hypertension. She reported mild painful intercourse before her laser procedure; however, following the laser treatments, she continued to report persistent and progressively painful intercourse. Although the pain was mild in intensity before the procedure, she reported that immediately after her laser procedures her coital pain increased, especially during coital thrusting. Surveillance was encouraged as her only follow-up. After completion of the third laser treatment, she had a brief trial of vaginal estrogen cream and a history of two to three genitopelvic floor therapy sessions with no reduction in her symptomatology. The patient reported progressive decline (over the previous 10 months since her laser series) in her sexual life with impact on her libido, arousal, and orgasmic ability and intensity. Her overall sexual satisfaction was noted to be reduced and problematic. She was frustrated and despondent when she sought a second opinion for her worsening sexual function. On clinical examination, the patient was noted to have moderate vaginal dryness with a vaginal pH of 6.5; she had a positive Q-tip test with vestibular inflammation and pelvic floor hypertonus with spasm of both levator and vaginal muscles. She is currently undergoing aggressive vaginal rehabilitation with topical hormones to the vestibule, intravaginal valium, and intravaginal sex steroid for moderate to severe dyspareunia, a symptom of GSM. She is using lidocaine ointment for coital bridging. She has been referred for counseling with her partner.

Case 3

Case 3 is a 68-year-old woman complaining of persistent and worsening painful intercourse after completing three consecutive and reportedly uncomplicated CO2 laser treatments. Her medical history is uncomplicated, and she did not report prior use of systemic or local hormones. She has no chronic medical diseases, is on no medications, and is in a long-lasting marriage. She is a nonsmoker and exercises two to three times a week. She denied use of vaginal moisturizers or sexual lubricants. The patient reported that sexual intercourse became increasingly unbearable since the last laser treatment. She returned to her health care professional following the laser and was told that she was a "treatment failure" and that there were no other safe and effective treatment options available. Upon presentation to the sexual medicine center, the patient reports severe vaginal dryness, with burning and itchiness and associated coital pain. She reported that coitus had become unbearable and she had some concerns about the impact on her relationship. On genital pelvic digital examination, there was a crescent shaped fibrous band mid vagina, which impinged on the diameter of the vaginal canal, creating a partial obstruction and vaginal canal stricture. She was noted to have a vaginal pH of 6.5 with decreased rugae, pale, frail, and inelastic tissues. The patient was extensively counseled on minimally absorbed local vaginal hormone treatment for GSM including the sex steroid, prasterone. She is currently undergoing aggressive vaginal rehabilitation with nightly intravaginal local prasterone coupled with vaginal moisturizers. She was instructed on a home vaginal dilator program. She was seen for a 1-month follow-up and reports and improvement in vaginal dryness; however, she is still concerned about resumption of intercourse. Further counseling and dilator instruction is anticipated.

Case 4

Case 4 is a 55-year-old woman who complained of persistent and progressively worsening painful intercourse after three consecutive and reportedly uncomplicated CO2 laser treatments. She had a history of a hysterectomy with a bladder sling, mesh erosion surgery with removal and fascial sling placement, and a third surgery for loosening the sling due to overtightening. Before the laser procedure, she reported vaginal dryness and mild to moderate dyspareunia. Upon further questioning, the patient reported that her health care professional told her that the laser treatments would decrease her vaginal dryness and painful intercourse. Following the laser treatments, she presented to the specialty clinic and described that sexual intercourse was now severely painful, with increased pain on penile insertion. She reported discomfort and pelvic pain, down the lateral aspect of her vaginal canal and deep in the canal. On physical and pelvic floor assessment, she was noted to have a moderate amount of pelvic floor hypertonus, and a moderate amount of levator ani spasms with minimal anterior and lateral wall scaring. Her treatment consisted of vaginal moisturizer and nightly off-label use of intravaginal valium. She was instructed on self-dilation exercises. She was given information on silicone-based lubricants and instructed to use them during intercourse. She has recently had her 6-week follow up appointment and continues to notice improvement. She uses the dilators before coitus, with copious amount of lubricant. Intercourse is now feasible and mildly pleasurable.