A New Approach to Managing Atrophic Vaginitis. Decrease in Oestrogen after menopause Up to 40% of...

Fariba WillisonEndogynaecology

Flinders UniversityAshford Hospital

PLATELET RICH PLASMA AND

V2LR LASER THERAPY A New Approach to Managing Atrophic Vaginitis

Atrophic Vaginitis

Decrease in Oestrogen after menopause

Up to 40% of postmenopausal women suffer from Atrophic Vaginitis1

Decreased quality of life and direct impact on women’s sex life

- Vaginal dryness, painful sex, low libido, sluggish orgasm, urinary problems, vaginal infection

Atrophic Vaginitis

Decrease in oestrogen levels › Less Connective Tissue› Less capacity to retain water› Increased risk of fissuring &ulceration3

Decrease in glycogen in vagina tissue› Change in vaginal flora› Change in vagina pH› Increased risk of UTI& thrush

Atrophic Vaginitis

Normal Pap Smear• Abundant

Cytoplasm• Low Nuclear

Cytoplasmic Ratio

Atrophic Vaginitis Pap Smear• Enlarged Nuclei• Inflammatory Exudate• Amorphous

Basophillic Structurs (Blue Bulbs)

• Loss of Gylcogen in the Squamous Cells

Vaginal Wall 2-3 mm

1)Tunica mucosa(lining of the vagina) Epithelium regeneration 30 days, no glands Lamina Propria: vessels &elastic fiber

transudate

2)Tunica muscularis vaginal distention- Sex to birth. 3)Tunica adventitia

Low Magnification Vaginal Mucosa Medium Magnification Vaginal Mucosa

Vaginal MucosaTunica mucosa – epithelium & lamina

propria› Rich in collagen, Fibroblasts, & elastic

fibers› Proteoglycans retain large amount of

water

› The surgical stand point for vaginal repair(endopelvic facia)

Low Magnification Vaginal Mucosa Medium Magnification Vaginal Mucosa

Current Management

Oestrogen Replacement4

› Systemic or Local› Can reverse or prevent symptoms

Moisturizers and Lubricants› Can be independently or with oestrogen

replacement therapy Sexual Activity- 3 times per week

Current Management Drawbacks

Oestrogen Replacement› 10-25% of women do not respond5

› Some women will never fully respond› Small increase risk of endometrial ca› ? Oestrogen therapy in ER+ Breast cancer

Moisturizers and Lubricants› Short term benefit

Sexual Activity› No firm understanding of mechanism

Non-Surgical, Non-Hormonal Options

Platelet Rich Plasma Therapy - 27 gage needle and vaginal gel V2 LR Laser Therapy - using a vaginal probe

Platelet Rich Plasma

High concentration of platelets› Increased release of growth factors from

platelets› Promotes regeneration of connective tissue › Suggested applications in Dentistry,

Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery 6, 7, 8

What is a Laser?

LASER - Light Amplification by Stimulated Emission of Radiation› An intense beam of light› Highly directional› A single wavelength or colour

How does it work?

Pump some energy into it – electrically or with light› The material naturally emits light (of a characteristic colour)› Feedback (between the mirrors) build the intensity› Light ‘leaks’ out a partially reflecting mirror

Laser materialMirrorMirror

Energy in

excited

Light Laser beam

Interaction with the body

Pulsed lasers deliver a lot of energy in a very short time

Choice of laser determines the type of interaction

The CO2 Laser is ideal for skin resurfacing › Ablates away surface epidermal layers› Controlled dermal heating stimulates collagen tightening› Structured pulse pattern optimizes treatment efficacy

CO2 Laser Therapy

Can be done in a clinic setting Works to restore vaginal mucosa to

pre-menopausal structure› Increases fibroblast activity› Promotes of Collagen synthesis› Increases H2O content resulting in

rehydration

Our pilot Study

Limited studies in Gynaecology to assess potential applications

Pilot study

› Women with painful intercourse due to severe atrophic vaginitis, recurrent thrush and scarring of the perineum 18 PRP 20 Laser 4 both PRP and Laser

Our Pilot study

Response to therapy based on:

› Symptom response of patients QOL and PISQ 12 questionnaires

› Colposcopic Changes/Biopsie Pre and Post treatment of vaginal mucosa

Our Pilot study

Patients underwent 2-3 therapy sessions every 4 -6 weeks

Follow up with questionnaires at 1- 3 months( 85% improvement in PRP, 93% in Laser group and 100% in PRP and Laser

(4 women only) Post Therapy biopsy at 12 month follow

up will be performed Limitation of pilot study and need for

RCT

FBW RCT study

Inclusion Criteria› Women with Atrophic Vaginitis

and breast Ca unable to use local HRT not responding to local HRT

› Women with recurrent thrush+ vaginismus› Women with vaginal dryness & irritation› Women with perineal scarring post delivery› Vaginal laxity

Exclusion Criteria› Acute bacterial Infections, active cancer, blood

disorders, anti-platelet medication, systematic auto-immune disorder

References1. Greendale  GA, Judd  HL.  The menopause: health implications and clinical management.  J Am Geriatr Soc.  1993;41:426–362. Pandit  L, Ouslander  JG.  Postmenopausal vaginal atrophy and atrophic vaginitis.  Am J Med Sci.  1997;314:228–31.3. Rigg  LA.  Estrogen replacement therapy for atrophic vaginitis.  Int J Fertil.  1986;31:29–34.4. Handa  VL, Bachus  KE, Johnston  WW, Robboy  SJ, Hammond  CB.  Vaginal administration of low-dose conjugated estrogens: systemic absorption and effects on the endometrium.  Obstet Gynecol.  1994;84:215–8.5. Smith  RN, Studd  JW.  Recent advances in hormone replacement therapy.  Br J Hosp Med.  1993;49:799–808.6. Robert E Marx, DDS, a, Eric R Carlson, DMDb, Ralph M Eichstaedt, DDSc, Steven R Schimmele, DDSd, James E Strauss, DMDe, Karen R Georgefff (RN) Platelet-rich plasma: Growth factor enhancement for bone grafts, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology Vol 85, Issue 6, June 1998, 638-6467. Eppley, Barry L. M.D., D.M.D.; Pietrzak, William S. Ph.D.; Blanton, Matthew M.D., Platelet-Rich Plasma: A Review of Biology and Applications in Plastic Surgery, Plastic and Reconstructive Surgery. Nov 2006 Vol 118 Issue 6 147-159 8. Timothy E. Foster, MD†*, Brian L. Puskas, MD†, Bert R. Mandelbaum, MD‡, Michael B. Gerhardt, MD‡ and Scott A. Rodeo, MD

Platelet-Rich Plasma From Basic Science to Clinical Applications, The American Journal of

Sports Medicine Nov 2009 Vol 37 no 11 2259-2272