Letter to the Editor

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To the Editor:
It is with great eagerness that many of us awaited the publication of randomized studies on the long-term outcomes on fractional CO2 laser (FCL) for genitourinary syndrome of menopause (GSM). Treatment failure for GSM using standard modalities is not uncommon and FCL may offer a viable option for the appropriately selected woman. FCL is being heavily marketed to practitioners (eg, gynecologists, dermatologists, nurse practitioners) and patients with little knowledge about its long-term effects. Unfortunately, patients pay out of pocket for this procedure, do not know the experience (or success) of their clinician, and may be unaware of the limited long-term studies.
The study by Drs. Sokol and Karram in the July 2017 issue of Menopause1 presents convincing data that FCL is successful with little risk in a well-screened woman. I am reporting three cases of severe adverse side effects to FCL seen in the past 4 months during initial therapy. All are now responding well to more traditional modalities such as vaginal estrogen and long-acting, over-the-counter lubricants. Whether these were appropriate candidates for FCL is unknown as FCL was performed in other locations by three different gynecologists.
Case 1: A 53-year-old P3 woman was treated for aggressive breast cancer (ER negative, HER2 positive) at 45. She opted for bilateral mastectomies, chemotherapy, and trastuzumab. She immediately went into menopause and developed dyspareunia. This was treated with small doses of estradiol vaginal cream locally and over-the-counter long-acting lubricants. When her interstitial cystitis flared, her urologist recommended increased estradiol cream. She decided to undergo Mona Lisa™ laser treatment under the recommendation of her gynecologist so she could stop the long-term estradiol. After the second treatment, she developed intense pruritis that was debilitating. Her gynecologist did many cultures and diagnosed her with a Beta strep infection. This was treated with oral amoxicillin, amoxicillin/clavulanic acid, and Culturelle. In addition, she received vaginal boric acid, estradiol, and long-acting lubricants. There is continued pruritis and discomfort with intercourse.
On physical examination, the vulva and vagina appear moderately atrophic. The pH was elevated. Beta strep was still positive and other infectious tests were negative. She has responded to a continued oral probiotic combined with vaginal antibiotic (compounded), vaginal estradiol cream and pelvic physical therapy.
Case 2: A 58-year-old P2 woman presented complaining of vaginal itching, dryness, and painful intercourse. She completed the Mona Lisa™ treatments 3 months before visit. Dyspareunia had subsequently worsened since the treatment. She had used numerous over-the-counter and Internet-ordered lubricants during menopause. She has been afraid to use vaginal estrogen due to an inherited coagulapathy discovered during a work-up for her migraine headaches. She has not had any thrombotic events.
On physical examination the vulva was mildly atrophic. There was scarring at the perineum and small punctations seen around the entire inner labia minora. The left Skenes gland was intensely tender. The vagina was very erythematous and without discharge. The patient has responded well to vaginal estradiol cream.
Case 3: A 57-year-old P2 woman presented to discuss severe pain with intercourse. She went through menopause 5 years ago and previously had a “healthy, active sex life” before the onset of menopause. She received no hormone therapy. Mona Lisa™ laser treatment was completed about 1 year ago and “worked” for a few months then penile penetration and thrusting resumed being very painful. She had not used any vaginal lubricants or estrogen.
On physical examination the patient had lichen sclerosis involving the labia. She also has severe atrophy of the vagina. She has started on vaginal estrogen and topical steroid creams.
These cases are presented for a number of reasons.

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