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Meta-Analysis
. 2025 Aug 4;22(8):1409-1421.
doi: 10.1093/jsxmed/qdaf153.

Efficacy of CO2 laser vs vaginal estrogen in perimenopausal women with genitourinary syndrome of menopause: systematic review and meta-analysis

Aya Mohamed Nasr  1 , Mohab Alsaid Saad  2 , Amer Salah Mohamed  3 , Yousif Ahmad Hanafi  2 , Bilal Walid Bazbaz  4 , Sarra Salah Amer Mohamed  5 , Sayed Mahmoud Selim  6 , Zaid Fatehi Altawallbeh  7
Affiliations
Meta-Analysis

Efficacy of CO2 laser vs vaginal estrogen in perimenopausal women with genitourinary syndrome of menopause: systematic review and meta-analysis

Aya Mohamed Nasr et al. J Sex Med. .

Abstract

Background: Genitourinary syndrome of menopause (GSM) is characterized by vaginal dryness, itching, burning, pain during intercourse, and urinary symptoms. Traditionally, hormone replacement therapy (HRT), specifically estrogen therapy, has been the first-line treatment for GSM, due to its side effects, fractional CO2 laser therapy has emerged as an alternative for managing GSM symptoms.

Aim: The primary focus is to compare CO2 fractional laser therapy and estrogen therapy on postmenopausal women with GSM through systemically reviewing all the randomized controlled trials.Methods: A comprehensive search of electronic databases, including PubMed, Scopus, Web of Science, Medline, Cochrane, Scielo, UC Berkeley library, and Google Scholar, was performed in October 2024. The inclusion criteria targeted randomized controlled trials comparing CO2 fractional laser therapy and estrogen therapy on postmenopausal women with GSM, which used at least 1 of these outcomes: Female Sexual Function Index (FSFI), Vaginal Health Index, Visual Analog Score, and Urinary Distress Inventory 6.

Results: Out of 688 studies, 7 studies were included for final analysis with a total of 302 participants: 154 had CO2 fractional laser therapy with a mean age of 55.9 years, and 148 had estrogen therapy with a mean age of 57.2 years. The analysis revealed no statistically significant difference between CO2 laser and estrogen in Vaginal Health Index (mean difference [MD], 1.60; 95% CI, -0.36 to 3.56; P = .09), FSFI-total (MD, 0.10; 95% CI, -2.03 to 2.23; P = .93), and Urinary Distress Inventory 6 (MD, -3.18; 95% CI, -6.77 to 0.42; P = .08). We used a sensitivity analysis on the FSFI-arousal subscale due to high heterogeneity, excluding 1 study. It showed that the CO2 laser group had a statistically significant difference when compared with the estrogen group (MD, 0.47; 95% CI, 0.15-0.79; P = .01).

Conclusion: CO2 laser therapy is an effective line of treatment for GSM. However, its comparison with estrogen therapy did not reach a statistically significant difference favoring one line over the other.

Keywords: CO2 laser; GSM; estrogen; female genital diseases; genitourinary syndrome; laser therapy; menopause; vaginal moisturizers; vulvovaginal atrophy.

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References