A Delicate Subject

Vaginal rejuvenation treatment options.

Concerns that lead patients to seek vaginal rejuvenation treatments—procedures that alter the female genitalia, both functionally and aesthetically—are varied and complex, ranging from robust (excess) skin to urinary incontinence, loss of sensation, atrophic internal tissues and vaginal laxity. Just as symptoms vary, treatment options range from surgery to topicals to noninvasive energy-based devices.

Gynecological surgery is generally employed for vaginal laxity, while device-based treatments offer relief from external aesthetic concerns, urinary incontinence and lack of regional sensitivity. Experts on vaginal rejuvenation typically concur that each patient presents unique challenges, therefore combination treatment methods are most likely to achieve optimal outcomes.

Treatment Indications

The term “vaginal rejuvenation” encompasses all procedures developed to improve and restore the natural youthful state of the vagina, but the generality of the term belies the wide range of concerns with which patients present.

“Let me start out by saying that it’s the worst, God-awful term,” says Michael Goodman, MD, a gynecologist in Davis, California. “If someone wants vaginal rejuvenation—and by that they mean vaginal tightening—then they are not going to get that from any machine.”

Duxbury, Massachusetts-based plastic surgeon Christine Hamori, MD, agrees: “Vaginal tightening is not synonymous with vaginal rejuvenation, even though many equate the two terms.” She explains that only surgical vaginoplasties can help to rebuild the muscles of the pelvic floor that become loose or slack due to age or childbirth. Recovery from this type of surgery is painful and sexual activity is restricted for up to six weeks. Noninvasive vaginal rejuvenation, on the other hand, refers to the improvement of vaginal health.

As women age, they may develop dryness, urinary incontinence, decreased orgasm strength and decreased sexual satisfaction. Laser and radiofrequency (RF)-based devices have been shown to improve these symptoms but the jury is still out on vaginal tightening. “CO2 laser devices create columns of coagulation of the mucosa extending to the lamina propria. New collagen formation has been proven by histological studies, and women report decreased stress incontinence and improved sexual satisfaction,” says Dr. Hamori.

RF devices also stimulate collagen production and can be used internally and externally to temporarily tighten tissue. “The RF energy gently heats the tissue to revive feminine wellness with no discomfort or downtime,” says Dima Ali, MD, of WellMedica Aesthetic & Anti-Aging Medicine in Reston, Virginia, who works with the ThermiVa RF device in her practice. “A specially designed handpiece is applied externally to the labia and vulvar tissues to restore normal tissue tone and function; as well as to the inside of the vagina to revive atrophic tissue and other structures.”

“In the beginning, we looked at RF devices as a way to tighten the vaginal canal but now we are using them for far more,” says Red Alinsod, MD, a gynecologist in Laguna Beach, California, who helped develop the second-generation ThermiVa device. “We’re addressing the appearance of the entire vulval/vaginal structure and how it functions. With RF, we can treat all the way to the top of the vaginal canal, and treat the bladder side and the rectal side to obtain feminine restoration. It’s not just skin tightening, it’s improvement of blood flow and tissue softness.”

Dr. Goodman offers a range of vaginal tightening and rejuvenation treatments. He finds that lasers are effective for urinary incontinence issues; vaginoplasties are necessary to restore the pelvic floor; and patients with very thin skin due to lichen sclerosis benefit from a combination of hormone cream, platelet-rich plasma (PRP) and laser resurfacing.
“RF energy and laser energy resurface the skin but don’t help if you just want to tighten the vagina or if you want to bulk up the opening,” he says. “If you perform laser or RF treatments up at the very top of the vagina underneath the base of the bladder, it helps to strengthen the area, improves incontinence and it may help with widening way up at the top.”

For patients with excess external tissue, Dr. Goodman recommends surgery or RF treatments, though he notes that the results with the latter are temporary. “With these cases, I can surgically remove that excess skin, charge $5,000 and once it’s done, it’s done. Or I can administer RF treatments if the patient does not want surgery,” he says. “Noninvasive RF can ‘shrink’ skin. This typically requires three to four sessions about a month apart, and it gives pretty decent shrinkage that will last about a year—if they’re lucky.” This method costs about $1,000 to $1,500, and the majority of Dr. Goodman’s patients opt for the one-time surgery despite the higher cost.

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Choosing a Device

Both laser and RF devices induce collagen regrowth, so selecting the right device for your practice is often a matter of comfort for the provider. Dr. Alinsod suggests that doctors who own laser centers—and are primarily “laser people”—may benefit from starting with a CO2 or erbium laser system, because that is already the core of their practices. A gynecologist who does not have a lot of experience with lasers, on the other hand, may feel more comfortable using an RF-based device because it’s very similar to doing a vaginal ultrasound. “Each doctor has to see what they are comfortable with,” says Dr. Alinsod, noting that once a provider masters RF, it’s an easy step to advance to using laser-based devices. “Once you learn the laser-based system, there is less manual work because you use small movements and don’t have to move back and forth so much—it’s actually fairly simple. Conversely, RF allows more variability, so you can tailor the treatments.”

Laser treatments typically require two to three sessions spaced anywhere from two to eight weeks apart and do require the patient to abstain from sex for up to a week following treatment; RF procedures require two to six treatments spaced one to six weeks apart with minimal downtime.

Dr. Hamori uses the ThermiVa RF platform in her practice. “It was one of the first devices available on the market; it offers both external and internal vulvar treatments and was shown to have high patient satisfaction rates,” she says. She uses the device to address labia majora skin laxity, vaginal dryness, urinary incontinence and decreased sexual satisfaction.

Dr. Goodman employs the Ellman Surgitron Radiofrequency Generator, which he calls a “wondrous device for very intricate cutting in the vagina and the labia.” He can also de-focus the RF waves to shrink tissue in the same manner as the ThermiVa.

Additionally, Dr. Goodman uses Ellman Pelleve RF treatments to tighten skin on the vulva and the Ellman pixelated fractional CO2 laser platform to treat the vagina, the perineum and vulvar skin. “I also use PRP, known as the ‘O-Shot.’ It is injected into the G-spot and the clitoris for increased sexual satisfaction,” he says.

Promoting Vaginal Services

The first step in providing vaginal treatment options is getting a sense of whether or not your patients are seeking these services. Talking to patients and conducting surveys can help you gauge their interest level.

Some of the most effective in-house marketing options for promoting noninvasive vaginal rejuvenation procedures include signage and seminars, such as open houses or video loops played in the reception room.

Dr. Goodman attracts new patients via online marketing. “I find that RealSelf.com is a good platform to help patients, answer questions and get exposure in many different markets,” he says. Online specialist directories, such as LabiaplastySurgeon.com, are also effective for helping patients find doctors in their areas.

Dr. Alinsod first markets to current patients, then adds second-tier internet marketing on his own and other websites. “I run a program that’s confined to teaching surgical and nonsurgical aesthetic gynecologic treatments,” he says. “I teach doctors how to identify patients who may benefit from procedures, how to present these services to patients, how to avoid over-promising results and how to stay within FDA guidelines.”

While many women can benefit from these procedures, there are certain patients who may be less than ideal candidates. Dr. Goodman, who has 40 years of experience, lists the following examples of patients he would likely turn away from vaginal rejuvenation treatments.

  • Patients with body image disorders. “I would be very concerned about someone who brings in a Playboy pic­ture and says, ‘I want to be like that,’” he says. “There’s no way you can achieve that look because that’s not who she is. I cannot ‘fix’ people with body image disorders.”
  • Patients with potential mental disorders. “When patients have disorders such as anxiety or depression, things generally affect them more than a person without these issues. It can upset them and make them even more anxious about treatments and outcomes,” says Dr. Goodman.
  • Patients with sexual function disorders. “Certain patients who suffer from sexual dysfunction may think that these treatments can fix their disorders, but that person would probably benefit from sexual counseling rather than a physical procedure,” he says.
  • Smokers, and patients with diabetes and hypertension. “This is elective surgery, so a patient really needs to show me that she is in control of her diabetes or hypertension,” says Dr. Goodman. “I generally will not operate on smokers. They have small vessels so there’s not as much blood flow to the skin’s periphery. They don’t heal as well.”

Both Dr. Ali and Dr. Alinsod report high rates of patient satisfaction with RF and laser treatments. “Patient satisfaction is universally high whether you use RF or laser,” says Dr. Alinsod. “With RF, there is no painful surgery and zero downtime. You have a treatment, and you can go home and go to the gym, have sex—do whatever you want. With laser treatment, patients can’t have intercourse for five days but otherwise can do pretty much anything.”

As options for vaginal rejuvenation continue to evolve, so does societal acceptance of treatment. What at first seemed like a superficial procedure-du-jour for only the wealthy is in reality a life-changing array of procedures that can help women with very real physical problems.

Dr. Ali explains that not many women are aware that they can have these treatments performed noninvasively, and vaginal rejuvenation remains somewhat of a secret topic. “Much like Botox was 20 years ago, I think 20 years from now women are going to be much more aware of these treatments, and they are going to be talked about and received by women all over the world,” she says. “Taking care of your feminine wellness is nothing to be ashamed of, and I’m happy to talk about it with anyone who will listen.”

Shelley Moench-Kelly is a freelance writer based in Newport, VT.

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