Laser devices licensed in Canada to treat genitourinary syndrome of menopause (GSM) are often marketed for vaginal rejuvenation with claims that they will tighten the vagina and improve sexual function, despite lack of evidence, a new commentary reveals.
Vaginal lasers heat the vaginal epithelium and cause thermal necrosis. This intervention induces collagen remodeling and synthesis, neovascularization, and elastin formation and may result in improved vaginal elasticity and restoration of premenopausal epithelial function, according to co-authors Blayne Welk, MD, MSc, an associate professor of urologic surgery at Western University in London, Ontario, and Erin Kelly, MD, a lecturer in obstetrics and gynecology at the University of Alberta in Edmonton.
Their patients' questions and experiences with the laser devices prompted the commentary, they told Medscape Medical News.
"A large part of my practice involves addressing GSM and urinary incontinence," said Kelly. "Many women present to the clinic having heard of vaginal laser procedures, having had vaginal laser procedures, or having been told they need vaginal laser procedures. My impression has been that these procedures are being marketed to women…without rigorous study."
"Many women are reluctant to have mesh slings for stress incontinence due to some of the potential risks," and they are looking for less invasive options, said Welk. Over the past few years, he has had increasing questions from patients about the use of lasers to improve this condition.
The commentary was published online February 6 in the Canadian Medical Association Journal.
The first vaginal energy device was licensed by Health Canada in 2015 to treat GSM. That meant the device was deemed to have met basic safety, effectiveness, and quality criteria. But no controlled studies are required for regulatory approval of such devices, and after licensing, some providers rebranded the device indication from GSM to vaginal rejuvenation, said Kelly and Welk.
Vaginal laser therapies are offered throughout Canada, with at least one provider of vaginal rejuvenation procedures in the 10 most populous cities. Under the current system, the number of patients who pay for these procedures and the amount that they pay cannot be tracked. Nor can the number of vaginal laser systems active in Canada be tracked. Patients can refer themselves for the service, and providers' publicly quoted costs (on websites, for example) are thousands of dollars for treatment.
The rebranding for vaginal rejuvenation "represents a difference between the licensing of a medical device by Health Canada and the way that these devices are used and marketed," according to the commentary. "A procedure with limited high-quality evidence supporting its efficacy and a potential financial conflict of interest for providers may not be serving the best interests of people in Canada, even if the risk of adverse events is low."
Updates to Canada's medical devices action plan, including mandatory reporting of serious incidents and the ability to compel manufacturers to provide information on safety and effectiveness, "represent important progress," according to Kelly and Welk. However, problems persist, including lack of a requirement for peer-reviewed, controlled studies.
Furthermore, women who undergo laser treatment for GSM, urinary incontinence, or vaginal rejuvenation may not receive a proper medical evaluation and standard treatments, the authors noted.
"I would like to see more transparency and public-facing information available on approved medical devices," said Welk. "Health Canada has an online database of approved devices, but no information around the evidence submitted during the approval process is available, nor are the indications for the various devices."
In addition, he said, many devices in the registry are listed by a serial number rather than the name that would be familiar to the public, "making it hard to match up information."
Kelly added the "encouraging" news that the Canadian Society for Pelvic Medicine is working with Health Canada to "improve knowledge translation when it comes to transparency regarding medical devices."
Medicine Before Marketing
"The commentary provides an accurate and evidence-based assessment of the use of vaginal laser treatments," Jason Abbott, B Med (Hons), PhD, professor of gynecology at the University of New South Wales in Sydney, Australia, told Medscape. "The marketing of this device is a case of putting the cart before the horse. It is essential that strong, scientific, and reproducible studies be available on efficacy and safety before there is a direct-to-consumer marketing approach."
Clinicians should advise patients when the treatment effect is likely to be minimal or risky, especially when there is a financial incentive to the clinician, he said. "Governments, regulators, and medical societies have a duty of care to the public to make sure that the medicine comes before the marketing. Otherwise, we are no better than snake oil sellers.
"Given the size of studies to date, the improvement in symptoms following treatment may be less than a few percent," he noted. "That may be acceptable to some women. We don't know."
Abbott's team is conducting research to define what women would want as a minimal level of improvement, the maximum cost, and the maximum risk from the laser procedure.
"In cancer…the benefit of a new treatment may only be a few percent for survival," he said. "That may be completely acceptable for some or even many patients. What we cannot do, however, is extrapolate those same expectations to a treatment for a benign condition where quality of life is compromised."
Echoing Kelly and Welk, Abbott said, "It is important that there be transparency in the clinical communication. Patients should be told that the best scientific studies that are judged based on their quality show there is no benefit to laser treatment for GSM or urinary incontinence."
Although the medical risks may be low, he added, "financial risk also needs to be discussed. Patients should be encouraged to participate in clinical trials where there is no cost to them to gain the information first, before wholesale uptake of the treatment.... Should patients still wish to undergo the procedure once the risks and an honest account of the evidence is given to them, that of course is their choice."
Kelly, Welk, and Abbott had no commercial funding or relevant financial relationships to report.
CMAJ. Published online February 6, 2023. Commentary
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Image 1: Blayne Welk
Image 2: University of Alberta
Image 3: University of New South Wales
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Cite this: Little Evidence to Support Lasers for 'Vaginal Rejuvenation' - Medscape - Feb 07, 2023.