A Preliminary Qualitative Analysis of women's Experiences With Vaginal Fractional CO2 Laser Treatments

Participants were 14 postmenopausal women aged 36 to 68 years ( M = 52.2, standard deviation [SD] = 9.7 years). Menopause was reached either through the natural aging process or was medically induced earlier in life through treatment for cancer. Participants were eligible to participate in the study if they were a cisgender postmenopausal female who had undergone at least 1 fractional CO 2 laser treatment session in the last 4 years and were proficient in the English language. Four years was chosen to increase the diversity in potential outcomes and add to the richness of the qualitative data collected. The study was approved by the Monash University Human Research Ethics Committee and was part of a wider study described elsewhere. 14 , 15 Participants were recruited from 2 private plastic surgery clinics employing the same treatment protocol (see Samuels et al 17 and Athanasiou et al 18 for specific details). Recruitment of this sample has been reported previously. 14 , 15 Briefly, clinic reception staff contacted and provided study information (through email, mail, and phone) to potential participants who had undergone CO 2 laser therapy in the last 4 years. The treating clinicians, authors C.H. and J.O., were not involved in the contact of any participants. Interested participants were directed to contact the study lead G.S. to organize a suitable time to conduct a telephone interview. Informed consent was obtained in written form before the interview and verbally at the start of the interview. Interviews were conducted between January and April 2019. All interviews were conducted by author G.S. The interviewing author was not involved in any aspect of the treatment of the participant. Semistructured qualitative interviews were conducted through telephone and lasted between 12 and 55 min ( M = 28.1; SD = 12.5). Interview questions were developed by the research team which included researchers, psychologists, and aesthetic surgeons and are provided as an Appendix . The questions were designed to conduct an in-depth exploration of the participants’ motivations to undergo fractional CO 2 laser therapy as well as experiences, emotions, and perspectives of the treatment outcomes. All interviews were audio recorded and transcribed verbatim. Interviews were conducted until author A.N.F., in discussion with co-authors, detected saturation. This point was identified when no new themes, codes, or insights were identified in the data indicating that additional interviews would not yield further themes. 19 , 20 This study provided a moderate-to-large sample size for qualitative research. 19 , 20 Our analysis approach involved a hybrid deductive and inductive thematic analysis methodology, as described by Braun and Clarke. 21 In concordance with this approach, the primary analyst A.N.F. initially familiarized herself with the transcripts, and deductively coded the transcripts according to the semistructured interview questions. This was followed by an inductive approach, developing codes as they emerged through the data. The primary analyst A.N.F. examined all transcripts and discussed initial coding with a secondary analyst G.S. Together the primary and secondary analysts generated themes and subthemes that were relevant to the aims of this project.

Fourteen postmenopausal women aged 36 to 68 years ( M = 52.2, SD = 9.7 years) were interviewed to explore motivations and experiences after undergoing fractional CO 2 laser therapy. The women were between 2 and 48 months postfractional CO 2 laser therapy ( M = 32.1, SD = 14.9 months). The number of fractional CO 2 laser treatments varied with participants receiving 1 treatment ( n = 1, 7.1%), 2 treatments ( n = 1, 7.1%), 3 treatments ( n = 7, 50.0%), 4 treatments ( n = 4, 28.6%), or 6 treatments ( n = 1. 7.1%). None of the participants explicitly reported any complications. The major themes and subthemes from the interviews are described below. Participant demographic characteristics are outlined in Table 1 . Participant Demographics Characteristics ( n = 14) SD, standard deviation. There were a variety of reasons reported by participants for pursuing fractional CO 2 laser therapy. Most of the reasons were related to addressing symptoms of GSM ( n = 12, 85.7%), such as physical discomfort during sexual intercourse ( n = 6, 42.9%), incontinence ( n = 5, 35.7%), dryness ( n = 4, 28.6%), and frequent urinary tract infections ( n = 1, 7.1%). “Having gone through menopause, you’re aware that you get drier and I was worried about the stress incontinence that was getting worse so I was looking for options to address these symptoms.” (Participant 4, aged 65 years, 4 treatments, 48 months post final treatment) “Having gone through menopause, you’re aware that you get drier and I was worried about the stress incontinence that was getting worse so I was looking for options to address these symptoms.” (Participant 4, aged 65 years, 4 treatments, 48 months post final treatment) Participants also expressed frustration at the lack of treatment options to address symptoms of GSM. “It's just more frustrating, ‘why isn’t there more things out there for women?’… because we all go through it [menopause]! And there are a lot of women who are just embarrassed, won’t talk about it and they just don’t have sex anymore and I think it's just so wrong! It's just not right!” (Participant 9, aged 57 years, 6 treatments, 40 months postfinal treatment) “It's just more frustrating, ‘why isn’t there more things out there for women?’… because we all go through it [menopause]! And there are a lot of women who are just embarrassed, won’t talk about it and they just don’t have sex anymore and I think it's just so wrong! It's just not right!” (Participant 9, aged 57 years, 6 treatments, 40 months postfinal treatment) In navigating menopausal symptoms, some participants ( n = 4, 28.6%) discussed pursuing alternative treatments to hormonal therapies expressing reluctance to use “unnatural” hormonal products. “I tried a non-hormonal, medicated vaginal cream, then they gave me this hormone cream and it's not really helping much and then I was worried about the hormones and I thought well why don’t I try to fix it rather than put a band-aid on it.” (Participant 5, aged 62 years, 3 treatments, 12 months postfinal treatment) “I tried a non-hormonal, medicated vaginal cream, then they gave me this hormone cream and it's not really helping much and then I was worried about the hormones and I thought well why don’t I try to fix it rather than put a band-aid on it.” (Participant 5, aged 62 years, 3 treatments, 12 months postfinal treatment) The minimally invasive nature of the procedure as well as the absence of recovery time seemed to resonate with the participants ( n = 3, 21.4%), emerging as a viable and convenient option to pursue ( n = 3, 21.4%). “It's non-invasive, minimal down-time, that's a selling point—hugely.” (Participant 1, aged 41 years, 3 treatments, 2 months postfinal treatment) “It's non-invasive, minimal down-time, that's a selling point—hugely.” (Participant 1, aged 41 years, 3 treatments, 2 months postfinal treatment) However, participants ( n = 3, 21.4%) encountered varying reactions from health professionals (mostly gynecologists). Some were unaware of the procedure, whereas some expressed varying opinions about the procedure. “I said to the gynecologist, ‘…I’ve had the [fractional CO 2 laser therapy] and I thought he did a bit of an eye-roll…’ some doctors you can go and say, ‘…I’m having acupuncture’ and they’ll go, ‘…that's really good’ or they’ll go, ‘…you’re wasting your money.’” (Participant 8, aged 51 years, 3 treatments, 48 months postfinal treatment) “I said to the gynecologist, ‘…I’ve had the [fractional CO 2 laser therapy] and I thought he did a bit of an eye-roll…’ some doctors you can go and say, ‘…I’m having acupuncture’ and they’ll go, ‘…that's really good’ or they’ll go, ‘…you’re wasting your money.’” (Participant 8, aged 51 years, 3 treatments, 48 months postfinal treatment) Despite these encounters, a proportion of participants ( n = 2, 14.3%) believed that more health professionals should be aware of this procedure and its potential impacts on women navigating menopausal symptoms. “He [primary care professional] may be able to suggest this when there aren’t any other avenues for women.” (Participant 9, 57 years of age, 6 treatments, 40 months postfinal treatment) “He [primary care professional] may be able to suggest this when there aren’t any other avenues for women.” (Participant 9, 57 years of age, 6 treatments, 40 months postfinal treatment) Almost half of participants ( n = 6, 42.9%) reported improvements in their sexual experiences post treatment. They specifically noted the absence of pain and an increase in pleasurable sensations. Additionally, some participants ( n = 3, 21.4%) attributed these enhanced sexual experiences to improvements in confidence during sexual encounters. Improved lubrication during intercourse because of being able to enjoy the experience posttreatment was also reported by a proportion of these participants ( n = 2, 14.3%). One participant highlighted the change in sexual activity with her partner and the effect on their relationship. “We were able to have longer sex. My husband didn’t want to have sex because he was worried it was hurting me. I said, ‘I’m okay, I’m okay.’ It helped the relationship that way as well. As I say, it's just feeling better within myself that I was able to have sex again and put his mind at ease that it didn’t hurt anymore.” (Participant 9, aged 57 years, 6 treatments, 40 months postfinal treatment) “We were able to have longer sex. My husband didn’t want to have sex because he was worried it was hurting me. I said, ‘I’m okay, I’m okay.’ It helped the relationship that way as well. As I say, it's just feeling better within myself that I was able to have sex again and put his mind at ease that it didn’t hurt anymore.” (Participant 9, aged 57 years, 6 treatments, 40 months postfinal treatment) Moreover, a few participants ( n = 2, 14.3%) indicated interest in pursuing additional treatments because of perceived short-term results in sexual function. “Yes, you feel a little bit better for a while, but I will say that after repetitive…sexual intercourse and months going by, you go back to where you were.” (Participant 6, aged 68, 3 treatments, 36 months postfinal treatment) “Yes, you feel a little bit better for a while, but I will say that after repetitive…sexual intercourse and months going by, you go back to where you were.” (Participant 6, aged 68, 3 treatments, 36 months postfinal treatment) Participants noted improvements to incontinence concerns ( n = 3, 21.4%). Two participants reported that by addressing incontinence concerns, the procedure had facilitated continued engagement in physical activity (eg, running) which was reported to improve their quality of life. “I didn’t originally go in there from a cosmetic look or for a sexual interest issue. It was more like I said, to take care- increase my quality of my running and try to take care of that issue. And it has helped.” (Participant 3, aged 55 years, 3 treatments, 21 months postfinal treatment) “I didn’t originally go in there from a cosmetic look or for a sexual interest issue. It was more like I said, to take care- increase my quality of my running and try to take care of that issue. And it has helped.” (Participant 3, aged 55 years, 3 treatments, 21 months postfinal treatment) Additionally, participants ( n = 6, 42.9%) reported improvements to psychological well-being following the procedure, specifically improving confidence and self-esteem. “You do definitely have a difference in your psychological wellbeing. I think you do feel a lot more confident and comfortable… you feel a lot better about yourself.” (Participant 11, aged 60 years, 4 treatments, 42 months postfinal treatment) “You do definitely have a difference in your psychological wellbeing. I think you do feel a lot more confident and comfortable… you feel a lot better about yourself.” (Participant 11, aged 60 years, 4 treatments, 42 months postfinal treatment) Some participants reported that the procedure did not meet specific expectations with a proportion of participants ( n = 3, 21.4%), reporting no major changes after treatment. “I had three [treatments] I think. Because I remember after the second [treatment] I still wasn’t happy and it was like nothing! I think they gave me three and there was nothing.” (Participant 7, aged 40, 3 treatments, 36 months postfinal treatment) “I had three [treatments] I think. Because I remember after the second [treatment] I still wasn’t happy and it was like nothing! I think they gave me three and there was nothing.” (Participant 7, aged 40, 3 treatments, 36 months postfinal treatment) There were some reports however ( n = 2, 14.3%) of observing changes only after multiple sessions suggesting that 1 treatment may not suffice. “After the procedure I was hoping that it would be more of a better—I guess a better experience sexually after the first treatment, I guess. I really didn’t notice a whole difference. It was really the second and third, I really started to feel different.” (Participant 2, aged 36 years, 3 treatments, 24 months postfinal treatment) “After the procedure I was hoping that it would be more of a better—I guess a better experience sexually after the first treatment, I guess. I really didn’t notice a whole difference. It was really the second and third, I really started to feel different.” (Participant 2, aged 36 years, 3 treatments, 24 months postfinal treatment) Interestingly, a minority remained unaffected by changes in specifically sexual pleasure posttreatment. “But as far as the tightening and that kind of stuff or the other thing is I noticed that one of the things women talk about is it's easier for them to climax after they get this done. I didn’t notice the difference.” (Participant 2, aged 36 years, 3 treatments, 24 months postfinal treatment) “But as far as the tightening and that kind of stuff or the other thing is I noticed that one of the things women talk about is it's easier for them to climax after they get this done. I didn’t notice the difference.” (Participant 2, aged 36 years, 3 treatments, 24 months postfinal treatment)

To the authors’ knowledge, this study represents the first preliminary qualitative exploration of motivations and outcomes associated with vaginal fractional CO 2 laser therapy. Although a range of quantitative studies have suggested moderate–to-high patient satisfaction rates, 6 , 11 our qualitative approach allowed for an in-depth analysis of women's experiences, including reasons underlying these simpler quantitative results. Our study highlighted that most women pursued this treatment to address the onset of symptoms linked to GSM, but also as a nonhormonal alternative. Additionally, our findings demonstrated the diverse range of experiences among women who underwent the procedure, with some reporting positive impacts across multiple facets of their life (ie, physical, psychological sexual), whereas others noted no discernible effects. Many participants sought fractional CO 2 laser therapy to manage menopausal symptoms (spontaneous or as a result of cancer and its treatment) associated with GSM. There was a proportion of women who were very opposed to any form of hormonal treatment for GSM because of concerns about the use of what they perceived to be “unnatural” hormones. 22 Despite the potential benefits, fractional CO 2 laser therapy has not received official approval for addressing menopausal symptoms. 7 , 8 Yet, despite this lack of endorsement and varying perceptions and skepticism among healthcare professionals, women are pursuing fractional CO 2 laser therapy. This may reflect a sense of frustration towards the lack of available and effective options to manage GSM symptoms (expressed in our sample) as well as desperation and urgency to address such symptoms in a way that existing hormonal treatments have not been able to. The lack of consensus among health professionals about fractional CO 2 laser therapy may also reflect their uncertainty in effectively managing menopausal symptoms, despite their knowledge of menopause. 23 Some women noted the procedure's noninvasive nature and the minimal recovery time required and believed that the procedure should be offered by health professionals to women who have exhausted other treatments. These factors combined with the reduced treatment frequency demands of fractional CO 2 laser therapy compared with the frequent dosing of estrogen therapies, potentially served as appealing factors when considering pursuing the procedure. Close to half of the women reported marked improvements in their sexual experiences following fractional CO 2 laser therapy reflecting the diverse findings reported in previous clinical trial research. 6 The women in our sample noted the need for continued treatment, owing to the return of symptoms such as vaginal laxity, dryness, and discomfort during sexual experiences after treatment. Improvements in sexual function after undergoing fractional CO 2 laser therapy as measured by validated, quantitative measures, have been reported to persist for up to 18 months. 24 However, there is limited research on outcomes, including sexual function outcomes beyond this period. Within our sample, there were reports of limited long-term benefits to sexual function from participants at 12 and 36 months postprocedure. Although we did not determine when effects began to diminish, this finding along with the mixed reports from the literature highlight the potential variation in individual experiences and the importance of perception. 13 When exploring improvements to sexual experiences, several women reported enhancements in confidence during intimate encounters. It is possible that this improvement in confidence relates to the reported enhancements in psychological well-being by nearly half of the women. By alleviating the physical discomfort that women faced during sexual intercourse and improving lubrication, it is likely that they were able to feel more comfortable and confident in sexual encounters, contributing to more fulfilling experiences. Furthermore, improvements may also be linked to improved lubrication or changes to vaginal laxity and reduction in pain as reported by the women in our study and in existing literature. 17 , 25 Interestingly, our study found limited outcomes with just 1 fractional CO 2 laser therapy session, whereas existing research has reported the efficacy of fractional CO 2 laser therapy for the management of GSM symptoms up to 12 months after treatment, regardless of the number of laser therapy sessions. 26 Although not a focus of our study, particularly owing to its qualitative design, there were no obvious trends in outcomes based on number of treatments received or time since treatment. However, further research is needed. A proportion of women reported no changes (physical, psychological, or sexual) after the procedure, even with multiple treatment sessions. This again reflects the mixed findings on the effectiveness of the procedure as some studies did not find notable vaginal symptom, urinary symptom, sexual function, and quality of life outcomes when compared with a control group (ie, sham laser therapy) or topical hormonal treatments. 3 , 11 It is possible that menopausal status plays a role in the effectiveness of laser therapy. All of the women involved in our study were postmenopausal, and the research has suggested that early intervention with fractional CO 2 laser therapy may be more effective in addressing menopausal symptoms. For example, 1 study found that improvements in vaginal health (ie, fluid volume, epithelial integrity, and moisture) were better sustained over time in recently postmenopausal women compared with those who >3 years postmenopausal. 13 This further highlights the individual variation and the possible impact of menopausal changes, warranting further research. This study has some limitations which should be considered. Although our sample captured diverse experiences following fractional CO 2 laser therapy, it is likely biased toward participants who are more comfortable discussing their experiences, potentially excluding the motivations and experiences of those who are less comfortable or who have had less favorable outcomes. Given the sensitive nature of the topic, it is possible that some participants withheld details of certain experiences. Additionally, the sample included women at varying time points posttreatment, which may have impacted the accuracy of retrospective recall of specific motivations and outcomes. Moreover, we did not specifically ask participants to compare their experiences of the procedure to that of vaginal estrogen (if they had experienced this form of treatment), preventing direct comparisons. Despite these limitations, this qualitative approach contributes to our understanding of the diverse priorities and experiences of women undergoing fractional CO 2 laser therapy. It also suggests the need for continued exploration and development of nonhormonal options that will effectively address symptoms of GSM.

This study is the first qualitative exploration of motivations and outcomes associated with fractional CO 2 laser therapy to address symptoms associated with GSM. Despite warnings by international societies against the use of vaginal fractional CO 2 laser therapy because of limited supporting evidence, women pursued this procedure to address symptoms associated with GSM. Although most women reported significant improvements to GSM symptoms, sexual experiences, and psychological well-being, some women reported no changes in symptoms. These findings highlight the need for further research and development of nonhormonal treatment options for GSM.