Subjects still taboo
Female Genital Rejuvenation:
Contribution of Innovative Medical Treatments.
Dr. Fabienne MARCHAND-LAMIRAUD
Gynecological Surgeon and Aesthetic Gynecologist.
Elsan Santé – Atlantic Centre for Aesthetic Medicine. Avenue Claude Bernard Porte D, level 1. 44800 NANTES – SAINT HERBLAIN.
Vulvo-vaginal rejuvenation is booming thanks to the recent innovative medical techniques which enrich the surgical methods of repair, generally reserved for the most advanced cases of alteration of the female genito-urinary system:
– Hyaluronic acid (HA) specific to the intimate sphere for the treatment of vulvovaginal dryness and atrophy and for vulvar aesthetics,
– Radiofrequency also improves the vulvo-vaginal tonicity and peri-clitoral vascularisation,
– HIFU (High Intensity Focused Ultrasound) for the treatment of vaginal laxity and urogenital prolapse beginning to moderate,
– LEDs (Light-Emitting Diode) for the treatment of genital irritations and pain.
Feeling good about one’s body and intimate parts is not a luxury, as it contributes to à̀ self-esteem and enables à̀ a fulfilled sex life.
Key words : Vulvovaginal dryness and atrophy, vulvar gap, dyspareunia, genital restoration, fulfilled sex life.
Genital rejuvenation is a growing demand as women want to experience intimate comfort and improve their sexuality.
Nevertheless, the subject is still taboo and few practitioners are responding to the demand.
Why such a demand for genital rejuvenation?
Genitals, like the rest of the body, undergo natural ageing and have been subjected to the changes associated with pregnancy and childbirth.
The hormonal fall modifies the vaginal mucous membrane and this at any age of life :
– In young women, because the pills are now mini-dosed, so the level of estrogens is lower than the natural level,
– During anti-hormonal treatments, particularly in endometriosis for menstrual blockage,
– The menopause, when the ovaries no longer produce estrogen,
– During breast cancer treatment: by chemotherapy and hormone therapy.
Any aggressive local treatment is responsible for a premature alteration of the genitals:
– Pelvic radiotherapy for cancer of the uterus, rectum and anus,
– Vaginal brachytherapy in cervical cancer.
Obstetric traumas, in particular:
– If you put on too much weight during pregnancy,
– Or related to a long and difficult childbirth (large babies, forceps, large episiotomy…)
Consequences of the ageing of the female genitals.
The ageing of the genitals is responsible for:
– Dryness and vulvo-vaginal atrophy,
– Slackening of the perineum with a vulval gap (Photo 1 and 2),
– Then a prolapse of the bladder, uterus, rectum, isolated or combined to a greater or lesser extent, which are generally the result of reconstructive surgery.
These disorders are responsible for sexual dysfunction and dyspareunia of varying degrees of severity.
Indications for medical treatments for genital rejuvenation: for whom?
– Any young woman who wishes to improve her genital aesthetics and/or sexuality.
– Any woman with pain in the postpartum period.
– Any postmenopausal woman, in the aftermath of anti-cancer treatment or in the aftermath of gynecological or bariatric surgery with significant and rapid weight loss.
A preliminary: a gynecological consultation before any genital rejuvenation operation is essential to check:
– That the screening cervical smears are normal,
– The absence of active gynecological infection, especially herpes.
Medical therapeutic methods of genital rejuvenation
A/ Medical treatments for genital rejuvenation
Recently, several innovative techniques of aesthetic medicine have appeared to help achieve a rejuvenation of the intimate genital sphere:
– Hyaluronic acid specific to the intimate sphere: Desirial®
– Lipofilling by reinjection of autologous fat.
– PRP by injection of platelet-rich plasma.
1. Vulvo-vaginal hyaluronic acid: Desirial® hyaluronic acid
1a / Desirial®
A hyaluronic acid dedicated exclusively to the genital sphere, which has a high hydrating power. 1ml is injected under local anaesthesia at the perineal fourchette, vestibule and lower 1/3 of the vagina. This is the treatment of intromission dyspareunia due to dryness and atrophy. A reinjection is advised at 6 months and then every year.
1b/ Desirial® Plus :
Has a moisturizing but also volumizing effect.
It will therefore be indicated in the aesthetics of the vulva in order to shape and plump up the atrophied labia majora in order to regain the youthful appearance of the vulva. More developed labia majora mask slightly enlarged labia minora.
This volumizing effect also has a protective effect against vaginal infections.
The injection is done with a cannula by back-tracing on a linear trajectory. 2ml is injected into each large lip.
It can also be used on the anterior wall of the vagina to highlight the G-spot to improve vaginal pleasure and orgasm.
Photo 1&2 :Before and after Desirial® hyaluronic acid vulvo-vaginal injection Plus.
Photo 3: Desirial® hyaluronic acid injection in the vulva’s large lip.
2/ The repairing and volumizing effect can be done by lipo-filling associated or not with PRP (Platelet Rich Plasma) and growth factors.
The injection is done:
In the vaginal submucosal walls,
In the vulvar region in particular:
To treat pain during penetration,
Filling retractile episiotomy scars,
Or cracks in the perineal fork during sexual intercourse.
B/ Physical treatments for genital rejuvenation
The physical treatments use the thermal effect which stimulates blood circulation and the fibroblasts which produce collagen, elastin and hyaluronic acid. The treated tissue regains thickness, suppleness and hydration. The physical treatments restore the mucous membrane and normalize the pH and vaginal flora. By creating a neocollagenesis we obtain a retraction of the tissues.
Pre-treatment: Epithelium with low cut layers poor maturation. Post-treatment ThermiVa® .Epithelium with increased cellularity maturation and the epithelium growing toward the surface, with more basal cells and increase the thickness of the epithelium.
Several techniques can be used to achieve this result
– The vaginal laser,
– Vulvovaginal radiofrequency,
– HIFU (High Intensity Focused Ultrasound).
– LED-BPM (with photo-bio-modulation).
These techniques use vaginal probes.
1/ The vaginal laser is CO2 laser or Erbium.
The temperature delivered 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 mucous membrane. It is the tissue repair which will bring the expected result. Action of Laser fractional is highly effective, painless. It is generally free of side effects but there may be burns. The CO2 laser acts on the walls of the vaginal mucosa using a special scanner, causing imperceptible micro lesions to trigger a process of neocollagenesis to reorganize and rebalance the components of the vaginal mucosa. As a result, the action of the laser reactivates and re-establishes, in a safe and painless way, the correct functionality of the structures involved at the urogenital level, thus improving the symptoms associated with urinary dysfunction (mild stress incontinence). A tissue regeneration process is triggered over a period of several weeks; however, stimulation is immediate and clear improvements are seen after the first treatment.
MonaLisa Touch® is a technique that requires no anaesthetic. The procedure is painless. The patient only feels a slight vibration. The treatment requires three twenty-minute sessions at one-month intervals.
Video of the MonaLisa Touch® Laser technique.
2/ The vulvo-vaginal Radiofrequency (VVRF)
VVRF emits electromagnetic waves that deliver controlled heat at around 45°C and always < 50°C. Vulvo-vaginal radio frequency is a recent technique in Europe, introduced at the end of 2017. RF heats less than laser and gives the same or even better results. ThermiVa® is the first model of RF device that has been tested in the field of vaginal rejuvenation. See the ThermiVa® technique in video.
RF has no ablative action. RF causes a stimulation of the vaginal mucosa and perineal muscles, which leads to regeneration and rejuvenation of the tissue.
It allows restoration of the vagina as well as the vulva and clitoris (with specific handpieces for the vulva).
The more recent RF Intima® devices are the ones used by the author of this article.
3/ Vaginal HIFU uses high frequency focused ultrasounds.
The heat emitted in 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 mucous membrane is reached, thus obtaining a « tensing » effect used for the treatment of vulvar gap and beginning prolapse. HIFU is not yet highly developed in France because the Ministry of Health has not yet approved its use.
The Food and Drug Administration (FDA) classifies the focused ultrasound stimulator system for aesthetic use in class II (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) in order to provide reasonable assurance of the safety and effectiveness of the device.
A system using the latest advances in ultrasound research, precise energy to the required depth, a 360-degree circular emission in the form of thermal energy in the vaginal mucosa, muscle, stimulates the appropriate blade and muscle fibres in cell regeneration. And while the freezing point as the centre begins to radiate the rebirth of collagen, double elasticity strengthens the treatment site.
A non-invasive way to treat, improve the vaginal wall, a complete solution to the problem of vaginal relaxation. While activating the restructuring and regeneration of the collagen layer, the problem of vaginal elasticity changes effectively. And no injury, no recovery, no need for multiple treatments to improve the confidentiality of the compact programme.
Comparison with the fractional CO2 laser
4/ LED-BPM (photo-bio-modulation)
LEDs cause a biological reaction by light, the effect of which varies according to wavelength. LEDs are cold light sources that act through non-thermal effects known as « photobiomodulation » at the cell level.
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 colour has an effect on certain types of cells, the dose used is also important. The effects of the different colours sometimes overlap and sometimes complement each other, hence the interest of colour associations.
The mode of action is very different from that of lasers, which generally act by thermal action to destroy a target. LEDs act via membrane photoreceptors on intracellular targets such as mitochondria which are the cell’s energy source.
Depending on the protocols and parameters used (wavelengths, combinations of wavelengths, power, irradiation duration, pulsed or non-pulsed mode, interpulse duration), preventive or therapeutic results can be obtained in many areas of medical or aesthetic dermatology.
The skin, due to its surface position, is in fact one of the most accessible organs for these treatments. The principle is based on a stimulation of the mitochondria, which release energy and provoke cellular stimulation.
Light stimulates the cytochrome C-oxidase in the millions of mitochondria we have in our cells. This results in the production of ATP (cellular energy). And an improved functioning of the skin cells, or other organs.
Penetration into the tissue 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 also sometimes used, but the other colors have not (yet) been the subject of validated scientific studies. Red light or infrared light has an anti-inflammatory and restorative cellular stimulation action. Blue light has an anti-infectious or anti-mycotic action. There is never an apparent or violent reaction after a photobiomodulation session but repercussions in the functioning of the target cells, generally dermal (skin) and/or hypodermal (fat tissue) depending on the wavelength used.
Analysis of the literature on the results
of physical treatments for female genital rejuvenation.
Thanks to the new medical treatments dedicated to female genital rejuvenation, a very clear improvement on clinical signs and sexuality is obtained from the first month and which evolves up to 6 months. An annual maintenance treatment is recommended.
1/ Results of temperature-controlled
transcutaneous radiofrequency for orgasmic dysfunction:
In Red M. Alinsod, MD, FACOG, FACS, ACGE 1 Transcutaneous temperature-controlled radiofrequency for orgasmic dysfunction. Lasers Surg Med. 2016 Sep; 48(7): 641–645. Published online 2016 May 19. doi: 10.1002/lsm.22537
At follow-up, patients were given a questionnaire with eight questions about their treatment experience and perceived outcomes. All subjects completed the study; none were lost to follow-up and no side effects were reported in any of them.
Action of Radiofrequency on the vulva
50 years old, vaginal and vulvar relaxation. Result after 3 sessions of RF.
36 years old, after 2 pregnancies, vaginal relaxation and incontinence. Result after RF.
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 reported significant vaginal tightening effects, increased vaginal moisture and improved vulvar and clitoral sensitivity.
– All anorgasmic patients (n = 10) reported regaining their ability to reach orgasm.
– 2 patients reported minimal response.
The results of the questionnaire:
– 23 of 25 subjects (92%) reported achieving orgasm after treatment with TTCRF;
– 16 reported no change in the intensity of orgasm,
– While 9 subjects reported having more intense orgasms.
– The time it took 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 were satisfied with the treatment and would recommend it to family and friends.
The complete results are shown in the table below :
2/ Results of laser treatment
For genito-urinary menopause syndrome.
A systematic review and meta-analysis. (9)
The aim of this study was to identify and then synthesized all available data concerning the efficacy of laser therapy for postmenopausal women with genitourinary menopausal syndrome (GUMS) with or without urinary incontinence (UI). PubMed, Scopus, Web of Science, Cochrane Library and ClinicalTrials.gov were consulted in October 2016.The key words were: « laser genitourinary syndrome of menopause », « laser vulvovaginal atrophy », « laser vaginal atrophy » and « laser women incontinence ». The quality of the reports and the risk of bias of the included studies were assessed according to the STROBE and MINORs checklists, respectively. The quality of the totality of evidence was assessed according to the GRADE approach.
Fourteen studies involving 542 participants were included in this systematic review and meta-analysis. Drought/dyspareunia/itching/burns/dysuria/urgency/frequency: all symptoms of GUMS and UI were significantly and consistently reduced in all available publications. The average differences pooled 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%)
– UI: – 4.9 (95% CI: – 6.4, – 3 ,4; 2 studies; I2: 0%).
As urgency/frequency were assessed using different methodologies, the data could not be meta-analysed. In addition, the studies KHQ, UDI-6, MCS12/PCS12, FSFI, overall sexual satisfaction and measures of the effect of laser therapy on local pathophysiology, improved significantly.
In conclusion, laser therapy for postmenopausal women with mobile phones seems promising.
It could reduce the severity of symptoms, improve the quality of life of post-menopausal women and restore the vaginal mucosa to pre-menopausal status.
However, the quality of the body of evidence is « poor » or « very poor » and therefore no change in current clinical practice can be suggested on the basis of the evidence.
In (9) Pitsouni E1, Grigoriadis T1, Tsiveleka A2, Zacharakis D1, Salvatore S3, Athanasiou 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® Dr Stefano Salvatore – San Raffaele Hospital, Milan (Italy)
Medical treatments for female genital rejuvenation using innovative physical methods have only recently appeared.
They have completely changed the therapeutic approach to genital disorders due to ageing, such as dryness with vulvovaginal atrophy and vulvar gap.
They make it possible to obtain 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, women regain the self-esteem and self-confidence necessary to achieve a fulfilled 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 the centres that practice them safely.
Güneş A1, Alinsod RM2. A mini-review of aesthetic gynecology and leading gynecology associations’ approaches to this issue. Turk J Obstet Gynecol. 2018 Jun;15(2):105-111. doi: 10.4274/tjod.33407. Epub 2018 Jun 21.
Paul M1, Barwijuk M2, Jurkiewicz A3, Kolczewski P4, Gabriel I5. Invasive aesthetic gynecology trends in Poland between 2010 and 2016: A multicenter experience.J Plast Reconstr Aesthet Surg. 2018 Sep;71(9):1362-1380. doi: 10.1016/j.bjps.2018.05.039. Epub 2018 Jun 8.
Likes WM1, Sideri M, Haefner H, Cunningham P, Albani F. Aesthetic practice of labial reduction. J Low Genit Tract Dis. 2008 Jul;12(3):210-6. doi: 10.1097/LGT.0b013e318161f9ac. 1University of Tennessee Health Science Center, Memphis, TN, USA. firstname.lastname@example.org
Preti, M; Vieira-Baptista, P; Digesu, GA. The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document. Journal of Lower Genital Tract Disease. 23(2):151-160, April 2019.
Marchitelli, Claudia E.; Sluga, Maria Celeste; Perrotta, Myriam; More.Initial Experience in a Vulvovaginal Aesthetic Surgery Unit Within a General Gynecology Department. Journal of Lower Genital Tract Disease. 14(4):295-300, October 2010.
6.Vieira-Baptista, P; Almeida, G; Bogliatto, F; More. International Society for the Study of Vulvovaginal Disease Recommendations Regarding Female Cosmetic Genital Surgery. Journal of Lower Genital Tract Disease. 22(4):415-434, October 2018.
Lykkebo, AW; Drue, HC; Lam, JUH; More. The Size of Labia Minora and Perception of Genital Appearance: A Cross-Sectional Study.Journal of Lower Genital Tract Disease. 21(3):198-203, July 2017.
Red M. Alinsod, MD, FACOG, FACS, ACGE1.Transcutaneous temperature-controlled radiofrequency for orgasmic dysfunction. Lasers Surg Med. 2016 Sep; 48(7): 641–645. Published online 2016 May 19. doi: 10.1002/lsm.22537
Pitsouni E1, Grigoriadis T1, Tsiveleka A2, Zacharakis D1, Salvatore S3, Athanasiou 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.
Pitsouni E1,2, Grigoriadis T1, Falagas M2,3,4, Tsiveleka A5, Salvatore S6, Athanasiou S7. Microablative fractional CO2 laser for the genitourinary syndrome of menopause: power of 30 or 40 W? Lasers Med Sci. 2017 Nov;32(8):1865-1872. doi: 10.1007/s10103-017-2293-8. Epub 2017 Aug 2.
Gold M1,2,3,4, Andriessen A5,6, Bader A7, Alinsod R8, French ES9, Guerette N10, Kolodchenko Y11, Krychman M12, Murrmann S13, Samuels J14. Review and clinical experience exploring evidence, clinical efficacy, and safety regarding nonsurgical treatment of feminine rejuvenation. J Cosmet Dermatol. 2018 Jun;17(3):289-297. doi: 10.1111/jocd.12524. Epub 2018 Mar 10.
Food and Drug Administration, HHS. Medical devices; general and plastic surgery devices; classification of the focused ultrasound stimulator system for aesthetic use. Final rule. Fed Regist. 2011 Jul 20;76(139):43119-21.
Hao Chen, SID Student Member, Juan He, SID Student Member, Raymond Lanzafame, Istvan Stadler, Hamid El Hamidi, Hui Liu, Jonathan Celli, Michael R. Hamblin, Yingying Huang, Emily Oakley, Gal Shafirstein, Ho-Kyoon Chung, SID Fellow, Shin-Tson Wu, SID Fellow, and Yajie Dong, SID Member .Quantum dot light emitting devices for photomedical applications. J Soc Inf Disp. 2017 Mar; 25(3): 177–184. Published online 2017 Apr 10. doi: 10.1002/jsid.543
15. Jewell ML1, Solish NJ, Desilets CS. Noninvasive body sculpting technologies with an emphasis on high-intensity focused ultrasound. Aesthetic Plast Surg. 2011 Oct;35(5):901-12. doi: 10.1007/s00266-011-9700-5. Epub 2011 Apr 1.