Wendy Lewis talks to five experts on how the rise of non-surgical, minimally invasive vaginal health options is empowering women to feel good about themselves

Discouraged by the limitations of Kegels, HRT , and Poise®, a record number of women are seeking procedures that address both their functional concerns, and the myriad of changes that accompany childbirth, menopause, and ageing. Women are becoming more empowered to take steps to improve their health, confidence, and sex lives.

While some women opt for surgery because of physical discomfort during sex, yoga, running, and other daily activities, as well as stress urinary incontinence (SUI), there is also a growing segment of patients seeking treatments because they feel self-conscious about their anatomy post-childbirth. Surgery to reshape the labia and other aspects of the vagina has experienced a major boost. Once considered a best-kept secret, women are now openly discussing their concerns with other women, losing their inhibitions about talking zto doctors, and doing research on the options available. And there are many. The desire for vaginal rejuvenation is emerging as a topic of interest with a wide audience. This newfound acceptance of an expanding range of procedures to enhance the appearance and function of an area once considered off limits is translating into huge growth opportunities for practitioners looking to get in on the ground floor of this new frontier in aesthetic medicine.

Vaginal health

The term ‘vaginal health’ has grown to encompass a broad category that covers sexual dysfunction and mild to moderate urinary incontinence, including leakage; urgency on the way to the bathroom, coughing, sneezing, exercising; soaking a pad, or the inability to do certain exercises.

According to Nathan L. Guerette, MD, FPMRS, FACOG; Urogynecologist and Director and President of the Female Pelvic Medicine Institute of Virginia, ‘Two major events in a woman’s life leading to a decline in vaginal and pelvic health are childbirth and the cumulative effects of menopause and ageing.’

‘As every woman knows, vaginal childbirth is traumatic. The tissues recover but for most never return to their predelivery state. The trauma of childbirth damages the vaginal walls, perineum, and surrounding tissues, which can lead to diminished function and aesthetics of the vagina and surrounding organs, such as the bladder as well as the muscles and nerves. This often leads to issues such as urinary incontinence and pain, looseness, or numbness with sexual intercourse as well as other issues that impair quality of life and self esteem,’ he continued.

Vaginal childbirth is not the only life event that can have a dramatic impact on vaginal health for many women. According to Dr. Guerette, ‘Later in life events such as menopause, hysterectomy, or cancer treatment can also contribute to reduced estrogen production and thinning, drying and inflammation of the vagina, which can have a devastating effect on function of the vagina and surrounding tissues. Women, typically, have simply lived with these issues and stopped enjoying or even partaking in physical intimacy, doing activities they enjoy, and adapted their lives to this impairment. It is time to change this thinking. These issues, just like other issues we face after an injury or as we age, can be improved and often cured, usually with simple, safe office-based treatments.’

Dr. Guerette points out Sciton’s diVa system as an example. ‘The diVa and diVa Tyte treatments by Sciton can dramatically improve vaginal and vulvar function and appearance with a quick office procedure that has no preparation and minimal recovery. The Sciton diVa Hybrid Fractional Laser (HFL) technology is an innovativedual wavelength system that is taking the treatment ofvulvar and vaginal tissues to a new level. The sophisticated system allows me to use the lasers separately or as hybridablation and heating, which has turned a 30-minute procedure into a straightforward 5-minute application. The programming also allows a customized approach for my patients, which I have not seen with other systems. Further, diVa is designed to work simply and reputably so ancillary providers may participate in care delivery under supervision,’ said Dr. Guerette.

The scope of vaginal health

Dr. Robert D. Moore of Miklos & Moore Urogynecology in Atlanta, GA ; Beverly Hills, CA; and Dubai offered his perspective on the emergence of this new specialty that has morphed into aesthetics. ‘“Female Pelvic Medicine and Reconstructive Vaginal Surgery” is now the official title from the American Urological Association (AUA .org) and American Congress of Obstetricians and Gynecologists (ACOG.org), a joint sub-specialty of the two groups. The first board certification occurred in 2013. Being within this subspecialty, one of the goals via the AUA basically states to maintain or restore pelvic floor support as well as bladder, bowel, and sexual function.’

He continues, ‘When vaginal rejuvenation and cosmetic vaginal surgery first came to light 15 to 20 years ago, there was very little data and it was basically ignored. It was just like years ago when women had SUI and it wasn’t being treated. As we gained more knowledge and procedures became less invasive, we learned that women don’t have to live with sexual dysfunction and incontinence anymore. Labiaplasty for functional issues and discomfort are accepted, but for cosmetic issues or sexual dysfunction caused by vaginal laxity, many professional societies still don’t recognize procedures, such as vaginal rejuvenation surgery1, even though we now have clinical studies showing their success. But not all women want or need surgery.

‘We have found that if we correct the functional problems, sexual function also improves. We have observed that women are coming to our office daily complaining about these issues as well as cosmetic issues that don’t necessarily want surgery, so we decided to put some clinical data behind it. We started using ThermiVa® after Red Alinsod was investigating RF as an alternative to CO2 energy and more invasive surgery. We got involved with one of the early studies for Thermi Aesthetics and performed the treatment under a study protocol to learn whether it was effective and safe, and the ease of treatment,’ he said.

“Once considered a best-kept secret, women are now openly discussing their concerns with other women, losing their inhibitions about talking to doctors, and doing research on the options available.”

‘We have found that ThermiVa is ideal for patients who aren’t surgical candidates (or want to avoid surgery) for vaginal laxity, decreased vaginal sensation with intercourse, or have cosmetic issues concerning the outside of the vagina, such as sagging labia skin, or a wide vaginal opening secondary to childbirth. Ultimately, it is also helpful for some of the benefits that we didn’t even realize were going to be helped by this technology — SUI, decreased clitoral sensation, vaginal atrophy, vaginal dryness,’ said Dr. Moore.

‘Due to the regenerative medicine benefits of this system, we are seeing that the treatment is laying down new collagen, bringing in new vascularity, and new nerve growth and stimulating new blood supply. This is an added benefit that we don’t see from a surgical approach.

‘We are now also treating some surgical patients after vaginal rejuvenation surgery with ThermiVa. In patients that have more severe damage and end up going down a surgical route, and they don’t get the kind of sensation that they want, then we will add in ThermiVa to get those benefits of the regenerative aspects of the technology,’ he said. ‘We may actually be preventing a lot of this dysfunction from getting worse over time by treating it earlier. Can we treat more significant incontinence and do we need to change the protocols? We don’t know yet but it is definitely something we are looking at for the future,’ continued Dr. Moore.

Target audiences

Who is really pushing this field?

According to Dr. Moore, ‘When men are actually surveyed, it has been found by scientific studies the majority don’t really care about the appearance of the female vulva. When women present with cosmetic vaginal issues, they are the ones not comfortable with the appearance of this area (not their partner), and want to know what they can do about it. Women are now more relaxed about getting these treatments and asking about them. We have finally taken our blinders off. This is a real problem that is important to many women. We want to make procedures less invasive and more effective across the board.’

More mature women tend to have a different focus of concern than their younger counterparts, according to most practitioners, however SUI is an issue for women across the board. There has been much ado about the risks of vaginal mesh slings for SUI2, most notably from the law firms that heavily advertise on television looking for patients to add to their ongoing class action suits. More women are now looking for alternative non-surgical treatments to address this common and potentially embarrassing condition.

According to Marco A. Pelosi, III, MD, FACOG, FACS, FICS, FAACS, Cosmetic Gynecologist in Bayonne, NJ and Founder of International Society of Cosmetogynecology (ISCGyn. com), ‘The primary drivers for nonsurgical vaginal rejuvenation in 2016 are a desire for better sex, a more youthful appearance, and convenience. Better sex means different things for different women. For those in their 30s and 40s, this usually means a tighter vagina especially after childbirth. Most commonly, I see empty nesters, fitness fanatics and women moving on after a divorce in this age group.’

“Better sex means different things for different women. For those in their 30s and 40s, this usually means a tighter vagina especially after childbirth.”

‘When menopause enters the picture, better sex usually means better lubrication and a vagina that can stretch without pain during sex. These women tend to be in longterm relationships and simply want to restore the pleasure by removing the pain. A more youthful appearance is a frequent concern of women in their 30s and 40s who notice wrinkles, sagging or deflated appearance to the visible areas of the vaginal region — the labia majora especially, the labia minora less so in this age group. Parallels to body and facial concerns are obvious,’ he added.

Dr. Pelosi noted that these issues overwhelmingly affect women with low body fat, as well as those who have experienced large or rapid weight loss. ‘When I see a lean and fit woman coming in for a cosmetic gyn consultation, I can almost guarantee that this is going to be an issue that she wants addressed,’ he said.

Convenience is another big consideration among women seeking non-surgical vaginal health treatments.

‘Convenience is the touchstone of the “BOTOX generation”. If you can address their needs with no downtime, no pain, and quick results, they’re all in. They are quick to understand that surgery is a big deal with a big price tag and more risk than non-surgical alternatives, so they are willing to accept the repetitive nature of these treatments to avoid the fear and uncertainty of surgery,’ said Dr. Pelosi. ‘Any physician with an aesthetic practice that meets this patient profile will find it a natural and smooth expansion of their services.’

‘FemiLift is the Swiss Army knife of nonsurgical vaginal rejuvenation. It does everything you would need to do to address aesthetic issues of the vulva (the labia) and vagina non-surgically. I use it for vaginal canal and vulvar resurfacing to address all of the issues I mentioned earlier. Since it’s a fully loaded CO2 laser platform, I switch to the other handpieces whenever I want to do facial resurfacing, tissue incision or excision all over the body. I have performed over 1,000 treatments on over 300 patients. I treat primarily menopausal vaginal dryness and vaginal laxity on the inside, and laxity of the labia majora on the outside. I also use it in carefully selected cases of urinary incontinence and lichen sclerosus, but those are non-cosmetic applications. The results are overwhelmingly positive for all of these applications and dissatisfaction is a rarity,’ continued Dr Pelosi.

Dr. Pelosi cautions that as with all aesthetic treatments, patients need to be thoroughly counseled on what to expect and what not to expect. ‘The standard protocol of three treatments spaced 4–6 weeks apart followed by an annual booster session is sufficient and a great starting point for both physicians and patients. I also combine FemiLift treatments with cosmetic and reconstructive vaginal surgery on a regular basis,’ he said.

PATIENT GROUPS

1. Younger women (late 20s-early 40s of child bearing age) — interested in in improvement in sexual function post childbirth, and are more interested in a nonsurgical approach. Increased sexual satisfaction and aesthetics are also as important
2. Perimenopausal women (late 40s-early 50s) and postmenopausal age ranges — tend to have more interest secondary to sexual dysfunction, painful intercourse, and vaginal dryness. Cosmetic appearance is less of an issue

Starting the conversation

Addressing these intensely personal concerns with women who are feeling vulnerable, especially for practitioners who are not trained in gynecology, can be a sensitive matter at first. Some practitioners may not have the requisite bedside manner or comfort level to speak to patients about the very intimate aspects of vaginal rejuvenation.

The consultation process can be a challenge. ‘Women do have some advantages in this arena. I can speak to female patients from a different perspective,’ says Beverly Hills, CA plastic surgeon Sheila S. Nazarian, MD, MMM who uses the Sciton diVa® system that utilizes the Hybrid Laser Technology developed for Halo™, the world’s first and only Hybrid Fractional Laser, to treat the vaginal tissue.

‘diVa® can help so many women, but it is difficult to know how to position it in the practice. Do you market to SUI? To women looking for more moisture? Chemotherapy patients? Cancer survivors who don’t want to be on HRT ? Those looking for more sexualsatisfaction? The answer is all of the above, but how do you bring up the topic?’ She said. ‘So far, moisture and tightness have been the driving factor in my practice. We can talk openly to patients about their needs and goals coming from a place of credibility on these delicate issues and it helps to put them at ease.’

‘I think more and more, women are looking to have it all: children, a career, a youthful appearance, and a vibrant emotional state. We have known all along that plastic surgery provides confidence and boosts selfesteem in the right patients. Sciton diVa® is just an extension of that,’ said Dr. Nazarian.

NONSURGICAL TREATMENT OVERVIEW

1. Treatment time: ranges from 5 – 40 minutes
2. Protocol: one treatment every 4–6 weeks for a total of three approximately
3. Anesthesia: none ortopical may be used
4. Maintenance: additional treatment(s) recommended at 1–2 years; annual touch-up suggested for best results
5. Side-effects: minimal side-effects, little or no recovery time
6. Costs to patient: $1,000–1,500 per treatment session; some practices bundle internal/external treatments under one global fee

The opportunity

The beauty of these systems from a business model perspective is that the procedures are typically performed in a clinic environment, usually take up to 30 minutes, often without the need for any anesthesia or only topical may be used. There is minimal to no discomfort, side effects, or downtime for the patient. In most cases, it involves a course of several treatment sessions (three is typical), with one or more maintenance sessions a year later, leaving an opportunity to introduce them to other treatments and services in the practice. Vaginal health treatments can also dovetail into other non-surgical cosmetic procedures, including injectables, laser resurfacing, laser hair removal, fat reduction, and other energy-based treatments.

‘Increased consumer awareness of treatments that address the symptoms that are already on the minds of women of all ages is expanding the number of women seeking solutions. It is clear that women are primarily driving the demand,’ said Plastic surgeon David Shafer, MD, FACS in New York City.

One woman tells a friend or a few friends, or reads something on a blog or in a magazine, or views a segment on the nightly news, and her interest is piqued. Her next logical step is to go online to find out more.

To capitalize on this perfect storm, Dr. Nazarian has been effectively using social media, billboards, and TV exposure to drive interest in diVa in her practice. ‘We are also planning an evening with our VIP patients to introduce them to the new concept of a hybrid laser and educate them on the improvements that can be achieved,’ she said.

Dr. Shafer has been regularly performing labiaplasty surgery, so adding the CO2RE Intima Laser from Syneron- Candela for vaginal and labial rejuvenation was well within his comfort zone. ‘Mommy Makeovers often include areas where women have suffered side-effects from childbirth and with new laser technology, our practice can give patients value added with vaginal rejuvenation that causes no discomfort and minimal downtime. Adding the CO2RE Intima laser system into our practice was an easy transition. Working closely with our certified laser technician, we provide a full range of treatments including skin resurfacing, tightening, tattoo removal, capillary reduction, and dyschromia. It is not unusual for a patient to ask me about labia and vaginal rejuvenation options,’ he said.

“One woman tells a friend or a few friends, or reads something on a blog or in a magazine, or views a segment on the nightly news =and her interest is piqued. Her next logical step is to go online to find out more.”

Not all aesthetic practitioners are completely comfortable with the idea of treating female anatomy and take a conservative approach of external treatments only. Contraindications to consider include pregnant or lactating women, active yeast, bacterial or viral infection, urinary tract infection, known collagen disorder,vascular disease, history of bleeding disorder, severe vaginal atrophy, and moderate to severe pelvic organ prolapse.

Dr. Moore has not seen complications from these treatments, but he has seen mistreatment. ‘A surgeon who does not have the training to do the appropriate exam may not know whether it is prolapse or if there are other symptoms, so the treatment may not be appropriate for that patient. Treatments done externally are generally fine, but it’s when we get into internal treatments for sexual dysfunction, you have to be very careful about that approach. We work with a plastic surgeon who refers his patients to us for that reason,’ he said.

According to Dr. Pelosi, ‘A background in gynecology, although helpful, is not mandatory, but it’s always a good idea to encourage patients to visit their gynecologist prior to any internal vaginal treatments.’

References

¹ American Congress of Obstetricians and Gynecologists. Vaginal ‘Rejuvenation’ and Cosmetic Vaginal Procedures. Available at: www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Vaginal-Rejuvenation-and-Cosmetic-Vaginal-Procedures [last accessed 23 August 2016]

² U.S. Food and Drug Administration. Urogynecologic Surgical Mesh Implants. Available at: www.fda.gov/medicaldevices/productsandmedicalprocedures/implantsandprosthetics/urogynsurgicalmesh/ [last accessed 23 August 2016]