Vaginal dryness after menopause/Juliet Laser treatment.

Vaginal dryness after menopause is extremely common that it has now been given a new name, “The Genitourinary Syndrome of Menopause (GSM)” iGSM affects at least 50% of post menopausal women. Previously referred to as “ Vaginal Atrophy” it is now recognised that after menopause women commonly experience a number of symptoms related to the decrease in oestrogen levels due to the depletion of eggs in the ovaries. These include vaginal mucosal thinning, vaginal collagen depletion and increased urinary incontinence. Traditionally the treatment has included oral hormone replacement or vaginal oestrogen creams.

The Juliet laser treatment makes the use of a specialised Er: YAG laser which emits infrared light pulses. It is a gentle laser also used in facial resurfacing. A grid of tiny laser induced “ holes” are made in the mucosa of the vagina which promotes an influx of new blood vessels and cells that heal the vaginal mucosa and in doing so, make the mucosa thicker and healthier.

The Juliet laser treatment is quick and effective and involves two treatment sessions 4-6 weeks apart. Each treatment takes 15 minutes to perform in the rooms and is generally painless with topical anaesthetic cream only needing to be applied if the skin around the opening of the vagina is also treated. Normal activities can be resumed immediately after the procedure. Patients can normally resume sexual activity within 72 hours.

Two passes of the laser are performed. The first treats the vaginal mucosa with heat induced fractional ablation and the second generates a deeper heat which stimulates contraction of the collagen layers.

The goal of the Juliet laser treatment is to improved the thickness and elasticity of the vaginal mucosa and to restore the original metabolism of the connective tissues but stimulating a process of neocollagenesis.

The contraction of the collagen fibres strengthens the vaginal tissue beneath the bladder and the urethra and contributes to the reduction in stress incontinence. The increased thickness of the vaginal mucosa means a return of the normal vaginal ruggae, restoration of vaginal lubrication and a return to the normal vaginal acidity levels. Vaginal dryness, itching and pain with intercourse are improved substantially, with more sexual satisfaction and less urinary stress incontinence. The effects of the Juliet laser treatment have been shown to last for 18 months and often beyond.

Vaginal laxity after childbirth.

Many women experience laxity of the vagina and bladder symptoms which are often caused by the stretching and distension of the vagina during childbirth. Age related and hormonal changes of menopause may also compound these problems. Traditionally, the only treatments available were surgical.

Viveve radio-frequency vaginal treatment.

The Viveve system involves a single 40 minute vaginal treatment using radio-frequency heating to stimulate new collagen formation. This treatment tightens the vagina without the need for surgery. It takes up to 12 weeks to reach it’s full effectiveness and studies have shown sustained results for over 12 months. Both stress and urge incontinence are reduced and both partners generally report that sex feels more like it used to “ before kids”.

The Viveve device is a new FDA and TGA approved radio-frequency wave emitting vaginal treatment. The Viveve device has a cryo-cooled tip so that the radio-frequency heat waves penetrate deep into the collagen layers of the vaginal causing tightening without damaging the vaginal mucosa.

Vaginoplasty /Anterior and posterior vaginal repair.

The indications for an anterior vaginal repair are to reduce prolapse of the bladder and or the urethra and to treat urinary stress incontinence. Disposable sutures of differing sizes and strengths are used without vaginal mesh to remove excess stretched vaginal tissue and to re-join the natural vaginal fascial strength layers.

The procedure can be performed under regional or general anaesthesia depending on the size of the bladder cystocoele bulge. The vagina overlying the bladder and urethra is incised in the midline and dissection in a plane directly below the vagina allows the damaged fascia supporting the bladder and urethra to be exposed. The fascial “ strength layers are re-joined in the midline and excessive vaginal skin is removed. The vaginal skin is then closed with a single suture.

This type of surgery used the advanced vaginal surgical skills of a gynaecologist in combination with cosmetic techniques to both a functional and cosmetic appearance.

When the back wall of the vagina has been stretched, usually during childbirths, there is often some tearing and separation of the connective tissues between the vagina and the rectum leading to a large soft bulge on the back wall of the vaginal. This can be so large as to be visible from the outside and often is associated with some gaping of the vaginal entrance and extra skin tissue folds in the perineum between the vaginal and the anus.

Sone women find that they often need to put their fingers into the vagina to push this bulge back in to place in order to empty their bowels. The aim of a posterior vaginal repair is to correct defects in the rectovaginal fascia separating rectum and vagina while allowing bowel function to be maintained or corrected without interfering with sexual function. The cosmetic result is the same as the simpler “ Vaginaplasty” but in addition, the core functional defects have been addressed.

The Viveve treatment works via a small probe that is inserted into the vagina containing a cryogen-cooled tip to protect the vaginal mucosal tissue whilst emitting radio frequency waves to heat tissue in the deeper vaginal layers. This heat promotes the production of new collagen and allows the vagina to regain its prior structure and function. In turn, when vaginal laxity is decreased, sensation is restored. When the tip of the viveve probe is specifically focused on either side of the urethra, the increased natural collagen builds a natural tissue, non-mesh sling that supports the urethra and treats stress incontinence.

Vaginismus/pain with sex.

It’s the most natural thing in the world to have sex and yet for women with vaginismus, sex can be so painful it becomes impossible. To make matters worse, many women who have this condition don’t have a name for it. It’s just an unbearable pain and a feeling of dread that increases with every attempt to overcome it. It is called vaginismus and it affects up to 7% of women

It is the involuntary spasm or contraction of the muscles surrounding the lower third of the vagina with attempts at any form of vaginal penetration. It involves the muscles just below the skin called the perineal muscles and the deeper pelvic floor muscles. Vaginal Botulinum involves the injection of a form of Botulinum Toxin – a purified toxin from bacteria. The toxin (“Botulinum”.,Xeomin” “Dysport”) is injected into multiple specific points in the tight, spasmed lower vaginal muscles. This is generally performed under general anaesthetic or in the rooms under a light sedation.

The Botulinum toxin acts as a selective muscle weakening and/or paralysing agent, and helps reduce nerve pain. The effect is reversible but provides a temporary window of opportunity to rehabilitate and stretch the over contracted spastic vaginal muscles that are obstructing penetration. Very small needles are used to inject 100 units of Botulinum into the three key vagina muscles that can obstruct penetration. Only the areas in the vaginal side walls that are palpably spasmed and sore are injected. Once these muscles can no longer tighten, it is usually possible to have comfortable intercourse. Once a woman experiences sex without pain, she can relax and begins to enjoy it. The vaginal muscles can then stretch and start to relax of their own accord.

Botulinum takes approximately 10 days to begin to work. By week 1-2 post injection it will be starting to have its effect on the muscle which will then reach a plateau at around a month post injection. Usually, once the muscles have been relaxed, no further treatments are required, although some women benefit from a second or third treatment to fully and permanently relax their pelvic floor and vaginal muscles. The treatment has been shown to be effective in around 90% of women.

Hymen surgery - opening up of the vaginal orifice.

The vaginal anatomy is different in every woman. Some women have very soft and stretch hymens that allow them to insert tampons as teenagers and have minimal bleeding with their first experience or sexual intercourse. Other women are born with a hymen that closer resembles the opening of a “ life saver” lolly. These hymens are strong, do not stretch and in many cases it is impossible for a young woman tp insert a tampon, which may be almost essential if she is a sportswoman or a dancer that needs to be able to perform on any given day.

These same young women, when starting to become sexually active suffer pain and frustration of not being able to have penetrative intercouse. Such is the discomfort and mental anguish, that many women in this situation go on to develop a condition called vaginismus when even after surgery may have been preformed to correct the anatomical variation, they continue to have fear and pain sensations associated with potential vaginal penetration.

If a tight or stenosed hymen is diagnosed before this circle of pain sets in, a simple procedure can be performed to open and dilate the tight hymen to a point that the insertion of tampons or sexual intercourse is possible with minimal discomfort. Taking action at an early stage can prevent potentially very serious and long term psychological effects going forward. Sometimes hymens can be prematurely loosened, and in some cultures, the re-apposition of a hymen is important for family and marital reasons. Hymenal surgery can be performed under local anaesthetic or general anaesthetic depending on the individual.

Vaginal Botulinum injection.

We all know that “Botulinum” ( or some variation o botulism toxin) is a wonder drug. Frown wrinkles disappear and we all appear about ten years younger. Vaginal “Botulinum” is a slightly different scenario. Once the cycle of pain and psychological feedback of pan is established some women have ongoing vaginal pain secondary to an initially trauma of the vaginal muscles that at some point caused pain. Just as we can get a sore spot in our back from lifting something heavy or sleeping in an odd way, the vaginal muscles can spasm. It is generally not possible to “ relax” and make the spasm go away. Even when Dr Jessup is treating a patient in the operating theatre when they are deeply sleep the tight vaginal muscle bands can still be easily palpated.

No amount of suggesting that the woman “relax” is going to be effective in these cases but the neurochemical relaxation that is produced by the botulism toxin can significantly help to allow pleasura ble intercouse which in time results in normal vaginal function.

Lichen sclerosis - Juliet laser of vulva +/- PRP.

Lichen sclerosis is a chronic condition, a bit like eczema or psoriasis, where the vulval and external vaginal tissues develop a condition that causing scarring, fusion of the labia minor and pain with intercourse. Traditionally, lichen sclerosis has been treated with long term topical steroid creams but sometimes this is not enough to improve the pain and splitting of tissues with intercourse. A new treatment for Lichen Sclerosis involves the use of a vaginal laser. Dr Jessup uses a Juliet Erbium yag vaginal laser to make multiple tiny holes in the areas of the vulva affected by lichen sclerosis, which encourages new blood vessel formation and remodelling of the affected areas. The addition of the patients own plaza ( PRP) improves the healing process and often leads to superior outcomes