Louise King

Good evening, welcome to our webinar on MonaLisa Touch® and female health. I am your host Louise King and our consultant Gynaecologists this evening is Miss Anahit Zakaryan and Mr Rowan Connell. So welcome.

This session will be a presentation first from Ana, and then from Rowan, and then we will have a Q&A session. You can, however, ask questions throughout by pressing the Q&A button at the bottom of the screen and we will answer your questions at the end. You can do this with or without giving your name and just to note this session is being recorded so if you do give your name, your name will be noticed by others. However, we will be able to get back to you afterwards with questions and answers if we have not managed to get through them.

At the end of this session, we have a lovely Private Patient advisor on the end of the phone called Sarah, prepared to book an appointment if you wish to do so and we will provide the phone number at the end.

That is everything so I will now hand it over to Miss Zakaryan.

Miss Anahit Zakaryan

Thank you, thank you very much and welcome everyone. Good evening, thank you for joining us today. as you are all aware, there is an increased awareness about...oh sorry, that's about me! So, I graduated abroad but I tick all the necessary boxes here, MRCOG member and I specialise in general gynaecology, bleeding disorders, vulval problems, contraception, HRT, fibroids and vaginal prolapse.

So, there is an increased interest in post-menopausal women's health these days and we just decided we will give you this webinar just to improve your knowledge and understanding of the issue and the changes and treatment necessary for that.

So vaginal health in post-menopausal women. Age-related changes in women, can result in an increased occurrence of vulva vaginal dermatological conditions such as vulva dermatitis and lichen sclerosis along with associated issues such as incontinence, recurrent urinary tract infection and sexual dysfunction. Atrophic changes during and after menopause due to declining oestrogen levels can result in a range of symptoms including vaginal dryness, irritation, increased susceptibility to trauma and infection.

Vulvovaginal atrophy is the term used for  vulvovaginal changes after menopause. It occurs due to decreasing oestrogen levels. Oestrogen is the primary hormone that regulates the physiology of the vulvovaginal tissue. As a woman ages, the progressive decline in circulating oestradiol, which begins in the perimenopausal period, results in a number of changes that can affect the health of the whole genitourinary tract.

There is an increased sensitivity of vulvovaginal skin, progressive oestrogen deficiency and the close proximity of the urethral opening as well as the anus combined with the skin changes due to ageing, make conditions affecting the vulvovaginal skin common and cause a lot of distress for postmenopausal women.

Changes that occur with ageing and decreasing oestrogen levels include atrophy of vulval tissue, thinning of the skin, atrophy of subcutaneous fat, decreased hair growth. There is atrophy of the vagina, narrowing and shortening of the vagina with destruction of the introitus, the lining of the vagina tends to become thinner, less elastic and smoother due to decreasing vaginal walls. In all other oestrogen-dependent tissues, pelvic low muscles, urethral mucosa, uterus, and ovaries there is ongoing decreased vascularity and decreased vaginal secretion which contributes to alteration in the vaginal microflora and changing of the pH which is responsible for maintaining appropriate levels of so-called lactobacilli, which are responsible for maintaining normal vaginal flora.

So vulvovaginal atrophy is the term that is used to describe these specific trophic changes, it progressively occurs in all women after menopause. It is considered a condition by itself because of these characteristic changes due to decreasing oestrogen and can result in the characteristic symptoms such as vaginal dryness, irritation, discomfort. And that makes vulvovaginal skin more vulnerable to trauma and infections.

So, the other vulvovaginal conditions that have become more common after menopause - you can see them listed on the screen - they are vulval dermatitis, lichen sclerosis, less frequently lichen planus and lichen simplex may occur in postmenopausal women - but it is more frequent in younger women.

The pattern of symptoms, though, of all these conditions can be often very similar. The majority of women present with each to be the primary symptom and no specific nature of these presenting symptoms sometimes makes it very difficult to distinguish between the various conditions involved. And in some women, one condition can present simultaneously with the others or develop on the background of an underlying dermatological condition such as psoriasis,

Atrophy of oestrogen-dependent tissues can contribute to other gynaecological problems including uterine prolapse, urinary incontinence and recurrent urinary tract infections.

Women who are postmenopausal may also continue to have problems with candidiasis and bacterial vaginosis without the infections related to the vulvovagina. For several reasons, sexually transmitted infections are not often considered a diagnosis in older women, however many postmenopausal women remain sexually active and actually they are at higher risk of STIs due to increased susceptibility to infection and lack of condom use, particularly if the woman is in a new relationship. And women can also have concerns about their sexual function, which is caused by effective vulvovaginal atrophy and skin conditions.

Women usually are very reluctant to talk about vulvovaginal problems. It is difficult conversation to be started with anyone and it is estimated that only 25-50% of women with these symptoms seek help from their GPs. The research did show that women find it an embarrassing and uncomfortable private matter, they believe that it is a normal part of getting older, and they are not aware of the treatment available - and they simply do not know how to initiate a conversation about all these issues.

But hence the increased topics and widespread knowledge information just to acknowledge that those changes are happening, they are expected part of ageing and initiation of conversation is very important for understanding and better compliance with the treatments.

So, management of common conditions. So symptoms of vulvovaginal atrophy include irritation, vaginal dryness, dysuria, other urinary symptoms, dyspareunia which is the pain on intercourse and can have abnormal vaginal discharge.

Atrophic vaginitis is the term often used when inflammation accompanies all this changing. And that results in the patchy redness and tenderness in the vaginal introitus. In the woman with vulvovaginal atrophy without inflammation, the tissue tends to be thin, pale and dry. Fissuring of the posterior fourchette, which is the margin of the skin fold which forms the margin of the vagina, is very often seen on an attempt to have intercourse or a basic vaginal examination.

So, the local oestrogen treatment is usually the preferred treatment option, rather than oral or transdermal oestrogen treatment, when the sole aim of the treatment is just a relief of vulvovaginal symptoms. Treatment with topical oestrogen estriol cream or pessaries is regarded as safe and effective. The initial advice should be that it be applied daily, in the evening, until the symptoms improve. Usually, that takes two to three weeks and then reduce the application to one evening, twice a week. There is no need for a progesterone backup for this treatment. It is important to know for patients that the initial application of this cream can cause some burning, but that usually improves within two weeks of use.

Non-oestrogen-containing vaginal moisturisers can be used as well. Bio-adhesive gel may be used in the conjunction with topical oestrogen, but they are less effective in relieving symptoms on their own. Water-based vagina lubricants may be required to again help with dryness and friction-related trauma, especially during sexual intercourse. It is important to note that even those gels can cause some stinging and burning on initial use.

One of the other conditions is uterovaginal prolapse. Women of perimenopausal and postmenopausal age may present the symptoms due to pelvic organ prolapse. The symptoms include a dragging sensation in the pelvis, urinary incontinence, and difficulties with micturition or defecation.

The examination will usually establish some lump or bulging in the vaginal wall due to prolapse of the uterus, bladder wall, rectal wall or even the cervix. You know women who had a hysterectomy it could be a vault. Depending on the stage of prolapse, some of it may even extend through the introitus with straining.

Treatment options include pelvic floor exercises, which should at least be a minimum of three to four months and it is better to have it guided by physiotherapists; topical oestrogen, pessary or surgery.

Vulva dermatitis in post-menopausal women is more likely to be caused on the contact due to some irritants such as soap, fragrances, over washing, urine and faces on an affected area. They cause inflammation of the skin, which is often aggravated by atrophy and can cause each burning and non-specific irritation. The clinical findings on examination may vary. A woman with mild dermatitis will have mild redness, swelling and scaling of the affected area - whereas  in the severe dermatitis, the skin may be markedly red, swollen with obvious erosions and ulcerations. And it is important in those cases to have these areas biopsied.

Initial management, obviously, will be the avoidance of these irritants and use of emollients. Low potency corticosteroids, such as 1% hydrocortisone, can be trialled to reduce the inflammation. In women with a severe itch, oral sedating antihistamine or antidepressants may be required at night. If there is a matter of suspicion of an infection, which can be due to discharge or smell swabs will need to be taken and treated appropriately.

The use of topical oestrogen can increase, in those cases, candida infection which is not that common in a postmenopausal woman.

Next condition is a lichen simplex. Lichen simplex arises as a result of excessive scratching and rubbing of an area affected by an underlying condition such as dermatitis. Or it could be neuropathic pruritus, which is itchiness. This leads to lichenification of hair-bearing skin, usually on the labia majora or perineum, where the skin becomes thickened, with increased skin markings and follicular prominence. Lichen simplex is itself intensely itchy and causes a lot of exfoliations - broken hair. It characterises in each scratch cycle with symptoms often worse at night or aggravated by heat, humidity, soap or the presence of urine. Sometimes there might be also some burning and pain.

Simplx can occur anywhere on the body, but the vulva area is one of the commonest affected areas. On the vulva, lichens complex can be localised to one area or be widespread. But it doesn't affect hairless areas or mucosas.

Management again comes down to managing the itch and allowing healing of the area. So it first of all needs to identify the condition, manage the condition that caused the primary itch dermatitis, identify the irritant, allergen. Neuropathic pruritus could be due to potential nerve entrapment or radiculopathy and that can explain the symptoms if no other irritant or dermatosis is identified.

So oral antihistamines, as I’ve mentioned, or low dose tricyclic antidepressants at night required to break this itch-scratch-itch cycle to assist with sleep and healing. Potent topical corticosteroids in this case will need to be applied. Betamethasone valerate ointment to be applied once daily to the thickened skin to reduce the lichenification, and then gradually the frequency needs to be reduced until the symptoms are fully resolved - usually four to six weeks after daily use.

If the treatment with Betamethasone ointment doesn't appear to be beneficial enough, stronger corticosteroids can be prescribed such as clobetasol. Ointment should be used daily, only by the specialist, preferably after diagnosis has been confirmed.

In addition, simple things can be applied such as cool packs, emollients to reduce dryness and itch. Erosion and fissures can be caused by scratching and they can predispose to a secondary infection that would require treatment with antibiotics. Treatment sometimes can be quite complex and long-term but usually, they result in resolution of the symptoms.

When it becomes chronic and causes significant distress, antidepressants are important to again allow a break at night, allowing some sleep and some time for it to heal.

Lichen sclerosis is one of the commonest conditions and commonest presentation to gynae clinic of post-menopausal women with a vulval condition. It is an inflammatory skin disorder thought to be of autoimmune origin but obviously influenced by genes, hormones, irritants, infections. It can occur in a woman of any age, but it is most common in women over the age of 50.

It primarily affects the hairless vulva perenial skin, it doesn't involve the vagina itself. Only long-standing disease can affect labia majora and spread even further. Approximately 10 percent of women with vulval lichen sclerosus will also have non-genital areas of skin affected and 20 percent may have another autoimmune disease such as thyroid dysfunction, vitiligo, psoriasis or anaemia.

The most common symptom in a woman with lichen sclerosis is severe itch, though women can also be asymptomatic. They can may complain of pain aggravated by development of fissures secondary scratching, friction from sexual intercourse. Chronic lichen sclerosus can cause distortion of the genital anatomy including adhesions, fusion of labia, partial or full, narrowing of the vaginal introitus causing significant dyspareunia, which is pain on intercourse. Obviously this is aggravated by all post-menopausal changes from atrophy and loss of elasticity.

Scarring and fissure development around the anus can cause pain and bleeding and aggravate constipation. On examination the affected area, the skin may appear white and thickened and there might be some petechia and purpura, which are reddish and purple spots. Scratching again can result in fissure formation and secondary infection. So treatment by a specialist is more recommended, especially in some cases when there is active ulceration a biopsy would be required.

It's not always easy to distinguish lichen sclerosis from any other condition affecting the vulva area and, again, biopsy is quite differential in this case. It's very rarely curable although it can usually be improved, so a long-term plan of management is essential. It can be associated with the development of a vulva intra-epithelial neoplasia so-called v-i-n which is very similar to c-i-n and invasive squamous cell carcinoma with an incidence of approximately five percent. So ideally, these vulvas, these affected vulvas, will need to be checked annually or more often if there is an additional symptom.

Treatment again with ultra-potent topical corticosteroid ointments such as betamethosone or Clotrimazole at night to the affected areas for up to 3 months. It is aimed at reducing symptoms to a tolerable level and the duration of the daily treatment will depend on the severity and the response to the treatment. The frequency of application can gradually be reduced once symptoms have begun to settle more limited use of potent or ultra-potent corticosteroids is recommended in women when lichen sclerosis is affecting the anal area. It's usually recommended no longer than for two weeks.

The majority of these women with the vulval lichen sclerosus should be treated with intravaginal oestrogen cream. The response can be quite variable; each can improve within a few days but the appearance of the skin returning to normal may take weeks or even months. So maintenance treatment is very important. Women should understand that they will have to continue the treatment for a very long time to prevent and reduce the possibility of the scarring. If scarring has already occurred this is not reversible with corticosteroids.

If there is a narrowing of the vaginal intriotus, the use of dilators can be trialled. These are progressively used, starting from a smaller size and increase to a bigger size as they are tolerated. Surgery may be required in the cases where there is a partial or even full fusion of the labias, especially if there is a problem with micturition and the vaginal dilators did not resolve the problems.

I will not be talking about any other conditions. There are a few of them. Lichen planus, severe dermatitis or malignant changes. They are not as common and anything beyond these simple situations will require referral to specialists where it can be assessed and managed accordingly.

I just would like to touch on one more thing. Sexual health for older women. That's another hot topic that is usually addressed in general practice and usually talk about it is limited to excluding sexually transmitted infections. But in women of older age it's assessing their sexual functioning and general well-being associated with that.

Sexual response and what is considered normal varies from person to person. In general a sexual health dysfunction should be only be considered a problem if it causes distress to the person or their partner. For example vaginal dryness or loss of libido may not be an issue for a woman who is not sexually active. However if the woman meets a new partner, this may become something that she will need help for.

So the problems, sexual problems, for all the women may include loss of libido and that can be improved with a medication and counselling. Vaginal discomfort and dryness, as I’ve mentioned, can be significantly improved with lubricants, use of topical oestrogen. Vulvovaginal pain; again the recommendation of lubricants, pelvic floor exercising, incontinence should be managed accordingly and with a modifying factors  recommending incontinence wear and pelvic floor exercises sometimes due to comorbidities and medications. This can affect the sexual function by reducing the libido so if it's possible, the medication should be reconsidered or those reduced to help the situation. It mainly relates to antidepressants.

Social factors can play a big role in causing sexual problems and that's the next slide saying about a lack of privacy, say, in a residential care setting. Self-esteem issues which will require some counselling and talking, coping strategies, relationship issues with a new partner, pressure to have sex again, encourage discussion, consider referral for counselling and generally have knowledge about the whole problem - especially knowledge about STIs - take appropriate protection and treatment if required.

So there is a website attached which has been used as a main backup for this information.

I will now allow my colleague Mr Connell to take the subject further and discuss how he can improve their sexual life with the treatment he provides.

Mr Rowan Connell

Thank you very much, Ana, hopefully, you can hear me? Yep, great.

So I’m also a Consultant Gynaecologist at Benenden and I specialise in urogynae, which is prolapse and incontinence and vaginal and pelvic floor reconstruction surgery. And with Dr Zakaryan at Benenden we offer a menopause service as well. And thank you very much for allowing me to just touch on MonaLisa Touch® which is a sort of continuation of what Ana was talking about.

And we've had quite a lot of people who've asked for a little bit more information about it and as Ana said, it's a very private and difficult thing for some people to talk about and a lot of GPs are also a little bit reluctant to talk about it.

So essentially the MonaLisa is a non-hormonal laser treatment for the prevention or treatment of the symptoms, a lot of which Ana's talked about, and it's really about vaginal dryness in the menopause. And, as she said, it affects at least 40% of menopausal women and what we found with the MonaLisa Touch® is that we're also seeing some women after they've had their babies and especially young women who've had chemotherapy for breast cancer. The newer tablets and so forth the breast cancer treatments are very anti-oestrogenic, and a lot of these problems are because of the lack of oestrogen.

I’ve just said, you know, what is it for? Well it's for vaginal dryness, vaginal itchiness, burning etc. A lot of work is being done also into bladder weakness, so urinary incontinence. I’m still slightly nervous about selling it as a great treatment for urinary incontinence, but almost everyone we've seen with some bladder issues has noticed an improvement.

And Ana mentioned lichen sclerosis; we've also seen that this can help with treatment of lichen sclerosis that causes, because it's mimicking a lot of ways the oestrogen effects. What I have put down here as well is it is not, the MonaLisa Touch® is not for vaginal tightening, and this is a very low-power laser compared to the higher-powered lasers that people will sell for laser tightening. So that is as a laser treatment rather than having vaginal repairs. And you will have heard conditions like genitourinary symptoms of the menopause.

Just very briefly, from the history, it started in Milan in 2012 and it was noted that this low-power laser was used on burns on the faces. And Salvatore - or Stefano Salvatore - used it on a very bad scar on the vagina of a lady that had a baby, and noticed an improvement on that. And so since then he's been pushing that and I got my training in Milan in 2014-15, and we've brought the laser to Benenden in 2017 and we've been treating women since then. And as I said, it's a very low power laser treatment.

We now treat the inside of the vagina and the outside because it seems to balance the treatment and, of course, it's non-hormonal. So in women who can't take hormones like the oestrogen and the gels and the creams that Ana was mentioning -  or they don't want to try it, or they feel there's a contraindication for example, if they've very recently had breast cancer - then the MonaLisa Touch® is one of the only things that we can use to help after all the emollients and the creams and has been mentioned.

I put this up because, when Stefano wrote his paper, he put down symptom improvement. What I tend to say to people is that everybody will improve, so rather than saying 84% improvement, what I say is that everybody has improved - but I can’t tell you how much the improvement will be. And so some women will have very minor improvements and some will have a huge amount of improvement, so it's very variable in how different women respond to that.

And of course the symptoms that Ana's been mentioning are the burning, the itching, the dryness and, of course, painful intercourse.

He put down the feeling of laxity and that's the sort of thinness in the vagina and the lack of fats that you quite often get after the menopause, and when you thicken up the skin that feeling of laxity can improve.

The machine itself is this little box. It's like a very small filing cabinet, and what it does it stimulates the cells in the skin of the vagina and on the outside. When we treat that and the collagen in that is changed into a - the easiest way of putting it is - a younger collagen, so more elastic and less brittle. It also thickens the skin by increasing the skin production.

The procedure itself is in Outpatients in a specialised private room, a little bit like when you have colposcopy or an examination. The treatment itself takes about five minutes and, most importantly, there are three sessions which are approximately six weeks apart. So some women will notice a huge improvement after the first treatment and less after the second and third, and other women will have very little improvement after the first and second and a bigger improvement after the third. But it is important with the data that we've got that you have those three treatments.

And possibly if the symptoms recur or you get deterioration after the improvement, you may need a top-up which is one top-up somewhere between a year and two after the treatment starts. I use an awful lot of oestrogen in the vagina as Ana mentioned, so I use Vagifem which is a little pessary, like a lozenge, or cream. And when you use that in combination with the MonaLisa Touch® there's a bigger improvement and the treatment seems to last longer.

Just going on to exactly what happens. The probe itself is about the same size as your thumb, so even in women with very sore vaginas, this is fairly well tolerated. The treatment itself is it fires little lasers, which are about the same temperature as a 20 watt bulb, so you can barely feel it. And they fire little holes - and I’ve just shown you this dot arrangement - and you fire it, twist it and pull it out a millimetre or two - and fire it again. And the pattern inside the vagina is very similar to what you can see on the screen, and you can see these little measurements which are two millimetre measurements.

And that's essentially what happens. So it lasts about 40 goes, if you know what I mean - it's the best way I can describe it. The side effects, which very rarely happen; sometimes we have some bleeding especially in women who've got very, very sore vaginas and, of course, because it is - in theory - a very light burn, you can get some discharge after that, which is not usually infection, but just a mild discharge. And, of course, there'll be some tenderness and swelling.

For the treatment itself we give you some local anaesthetic on the skin of the outside of the vagina, because the inside the vagina doesn't actually get affected by the MonaLisa Touch® laser. So women will turn up about five or ten minutes before their appointment, have some local anaesthetic like endo cream when children have needles in the back of their arms, put that on it just takes the edge off.

Very rarely - because of course the urethra, the wee tube is very close to the area that we're treating - so very occasionally you can have a little bit of discomfort or irritation when you pass urine.

The first treatment is always the worst because people don't know what to expect, but it's so well tolerated that people usually then come on their own the second time. But it's usually quite a good idea to come with a friend or a partner.

What you can do before it is, we don't recommend using any creams or the HRT cream for a day or two beforehand because you ideally wants as little product inside the vagina as possible. And certainly afterwards we don't recommend much exercising for two or three days, because if the vagina is sore, and then you're running and swimming and exercising it'll cause some friction and some more discomfort. And those exercises are the worst: swimming, running, cycling.

We don't recommend sex for a week or so after the treatment and, as far as driving is concerned, a few minutes after the procedure most people are quite happy to drive except for the first time when you'll be you'll have some anxiety about it.

So hopefully that's just gives a very brief overlay of what the MonaLisa Touch® is about and I think that Louise will take over for the Q&A session. Thank you. 

Louise King

Thank you very much, Rowan and Ana. Okay, we do have a few questions. The first one is “I am thirty and have bad periods that are affecting my life. Would I be eligible for a hysterectomy?”

Ana, do you want to go with that?

Miss Anahit Zakaryan

So, well it's not directly a related question. She's 30 years of age and she has bad periods. Well it's a difficult question to answer without any detailed history. There are a lot of parameters involved before making any final decision. It will take a lot of discussions needs to know exact details of the periods, which aspect are bothersome, what treatment has been applied yet.

And unfortunately, in this country, hysterectomy cannot be considered if treatments leading towards have been tried, attempted and failed. There are so many less invasive, less destructive options to be considered before hysterectomy. But again the woman's choice is always considered and applied given the circumstances obviously. It's not a question for yes or no.

Mr Rowan Connell

I agree, and we do have protocols in place for women of any age and we have to go through various treatments first.

Louise King

Okay, and this one's for you, Rowan. This lady is 57 and she thinks Mona Lisa Touch would be ideal for her. She's always been quite hesitant though to have clinical treatment. Are there any serious risks during or after the treatment?

Mr Rowan Connell

Yeah, as I said we've had very few problems. We’ve had one or two ladies that had a little bit of bleeding after the first treatment and one lady that had some bleeding after the second treatment, but it's very minor.

I suppose it is impossible to say there is no risk but certainly, discomfort, pain, bleeding are the other side effects. But it is a very well tolerated procedure, we’ve been doing it as I said since 2017. So we've had  quite a lot of ladies coming back for their second or third treatments now.

As I said, when it works really well, if you use the oestrogen creams and pessaries afterwards you can sometimes delay the treatment -  the second treatment - for one or two years. We've had quite a few ladies coming back. So I’d say side effects, not clinical problems really.

Louise King

Okay thank you, Ana, this lady is asking can the topical oestrogens be used if someone has dermoid cysts which appear to be getting bigger when scanned randomly?

Miss Anahit Zakaryan

The oestrogen topical creams - did you mention oestrogen creams - can be used. They should not have a direct impact on a dermoid. A dermoid is not considered to be hormone-sensitive, so if there is an enlargement in size on the subsequent scans, I will suggest it be tested further and may be considered for removal.

Louise King

Thank you. Okay, Rowan, this lady is considering MonaLisa Touch® and she has tried creams and herbal remedies already. Is this the best laser treatment for a vaginal atrophy or are there other lasers used for this type of treatment?

Mr Rowan Connell

Yeah, there's three or four different types of lasers out there. We went for the MonaLisa Touch® because, in my view, well I helped develop it and Salvatore gave us all the information for nearly a decade now. It's also low power laser and when some of these treatments were being done in the late 2008-2009, people were using quite high-powered lasers and that to me is not what we're doing this for.

The high powered lasers tend to burn and scar so they can be used, for example, as I said urinary incontinence to tighten up the collagen but I don’t use any other treatments. And we looked at another laser and again I don’t think the data is particularly good but, of course, I’m biased because I love the late MonaLisa Touch®.

I think the data and the results we've got are very good so I’m not going to completely disrespect the other lasers, but we looked into it quite heavily five or six years ago and thought that the MonaLisa Touch® was the best and there are treat there are other treatments available.

Miss Anahit Zakaryan

I’m going to back up Mr Connell on this. I think that's the one that is widely used by Gynaecologists other than plastic surgeons and for plastic purposes I think that's the commonly-used one, a wider used one with better data available.

Louise King

Yeah, that's good to know. Thank you. Okay, this lady has suffered with many menopausal symptoms over the past 10 years. Her doctors dismissed the idea of her using HRT as there's a history of blood clots in the family. Would it be safe for her to try hit the HRT gel now at the age of 60? This for you, Ana.

Miss Anahit Zakaryan

Again, obviously an ongoing problem for at least ten years, it will take a deeper discussion and understanding of the problem and family history. Usually the risks associated with a hard increase every decade. It is not recommended to be started so far after the menopause. The risk of increasing clot is still there even with the gel or patch, and I usually would advise considering non-hormonal management options first, because there are alternatives available - before embarking on something so risky that can be potentially cause problems that can be life-threatening. Why not to try something less invasive, a safer option?

Louise King

Okay, thank you. For MonaLisa Touch®, you mentioned the treatment itself is very short. Will they be in pain afterwards and how long does it take to fully recover?

Mr Rowan Connell

Okay, so as I said, we give local anaesthetic. Local anaesthetic is put on by the ladies when they come in, so very few will feel it.

Because it fires off - kind of - 16-18 little tiny lasers, you can sometimes feel that as little irritation like tiny, tiny pin pricks - generally in the skin, not in the vagina. So if you do have discomfort afterwards and, as I said, that was one of the side effects is bleeding and potentially some discomfort or pain, then the women go home with local anaesthetic cream which they can then reapply. And literally we've had a handful of people that have needed that.

Sometimes you'll have, of course, because where Benenden is in the South-East, before COVID we were having women coming from France, the Channel Islands and Scotland  but, of course, now we train more people it is more widely available.

But women were then going home all the way to Scotland on a slightly sore vagina already and bouncing in a car, or so on. So that can be an issue, I suppose, but as I said the treatment itself causing problems; we give you local anaesthetic so that should take the edge of it.

Louise King

Thank you, okay this lady is post menopause and seems to have a bulging sensation and mild discomfort passing urine. They are worried that this could be a prolapse. Are these symptoms normal or should they see a Gynaecologist?

Miss Anahit Zakaryan

As I mentioned earlier, the symptoms, ongoing along with vulvovaginal atrophy - just the shrinking of the tissues - can cause the sensation of dragging sensation and sitting on something that should not be there.

It can also affect the urinary function, frequency, give them false sensation of MTI. Obviously to rule out prolapse, the only way is the examination and I will recommend this woman to be examined to rule out prolapse or not.

It is recommended to start the treatment with oestrogen -  topical oestrogens - first to eliminate some of the sensation and, as I’ve mentioned earlier, prolapse - the treatment of the prolapse - will vary, depending on the stage and location of the prolapse. But topical oestrogens are very successful in providing the first initial treatment and especially if there is no prolapse on examination, topical oestrogens will be the first line of treatment for that.

Louise King

Okay, Sue asked can anything go wrong with the laser treatment if so, what could that be?

Mr Rowan Connell

Not really because, it's an as a CO2 laser, a carbon dioxide laser. I suppose what people are worried about is it's such a low power that doesn't cause any issues but of course, laser safety means you come in and you have special glasses put on and so on. There aren't any glass wires that some of the other lasers - the YAG lasers go down wires - so you can see it glowing.

And this is all done within the machine, so it's all covered in metal. So I can’t think of anything that would go wrong. We've not had any problems apart from as I said the slight issue behind sometimes getting some bleeding and sometimes having a bit of discomfort.

Louise King

Okay, thank you. Okay Sue says Hi Ana, I’m looking forward to having a hysterectomy with you later on this year. She's been reading about prolapse, however, post-hysterectomy and asks is surgery often the only answer for prolapse?

Miss Anahit Zakaryan

If there is indeed a prolapse, the treatment of the prolapse - the superficial one with topical oestrogens, pelvic floor exercising - following the guidelines these days we have to follow the protocols as Mr Rowan Connell said.

Energy will be conducted without trying  proper pelvic flow exercising for at least three-four months because there is very good evidence that it does help a lot of symptoms and along with the topical oestrogen if the products are not bad that may be enough at least for some period of the time the other treatment options are vaginal ring pessaries and come in all various forms and shapes and sizes can be trialled that's too that's considered as a conservative management non-surgical management and there is surgical management again in all variety of ranges depending of the location of the prolapse the degree of the prolapse and the surgeon.

Louise King

Okay, thank you. Okay, Mr Rowan Connell, this lady suffers from dry vaginal dryness and usually prefers to take the most natural option please could explain the benefits of using oestrogen cream versus pessaries over coconut oil?

Mr Rowan Connell

She is asking the wrong person because I love coconut oil, so a long time ago we used to use, well I was recommended in my training, that ladies would use olive oil because it's quite easy to get hold of because the problem the problem a lot of women find is that when the vagina starts getting sore and that and then they're walking normally and they get a rub you'll have a bit of a discharge and then a lot of ladies will then think that's abnormal and risk of infection etc so then starts washing their vagina out either with water or with water and soap. Of course both of those are very drying so think about your fingers when you're in the bath they go a bit dry so the first thing I would say, this lady obviously knows me, the first thing I would say is use some coconut oil for cooking because it's very natural and you use that as a soap and you use it around the outside of the vagina and inside the vagina as well and Intend to recommend that in the morning and in the evening and if the woman's at home to use it every time they go to pass urine the huge advantage of coconut oil is that nobody I’ve never known anybody to be allergic to it. It's a very good soap it's a very good moisturizer because you never think about moisturizing the vagina whereas if you wash your face in the winter time and go out you can feel your face cracking and that's what happens to some women with their vaginas when they wash and it's a very good lubricant so as you're walking with this slightly sore vagina you're rubbing it in a much more oily and more lubricated way and the other huge advantage of coconut oil is it's mildly antiseptic and as Miss Anahit Zakaryan said about the different types of bugs in the vagina the lactobacillus which keeps other infections at bay it just helps with the acidity and the naturalness in the vagina so yes that in answers the question I love coconut oil. In those women who can't or won't take the oestrogen, it's a really good way of keeping things at bay. Oestrogen as Miss Anahit Zakaryan said to me there's very little else you can do to thicken the skin brackets apart from the MonaLisa Touch® because it is so well-tolerated with so few risks and it's the one thing to thicken up the skin and those women who have problems and Miss Anahit Zakaryan and I tend to see the peri-menopausal women because I think there is a group of perimenopausal women who are very sensitive to the hormones going down so when we started MonaLisa Touch® we were passing that 70 and 80-year-old women would come but the ones with the biggest problem tend to be 45 to 60 and those women as I said you do all these things to try to make it as natural as possible to make to reduce the symptoms, so great question coconut oil.

Louise King

Catherine says there's a nationwide shortage of, is it oestradiol? and she says what would you recommend as an alternative for her HRT? She also takes progesterone tablets.

Mr Rowan Connell

Yes yeah I’ve just heard from our pharmacy that apparently the lonzetto is a problem now oestradiol Buckingham sales now so unfortunately all these products are delivered I believe from Europe so distribution is going to be a problem one or the other one if the jealous problem spray could be used as a substitute and pharmacies are very good to swapping and switching them it sprays currently as far as I’m aware it became a problem jail is back in the stock so it should be all right to get hold of jail these days but if that's a problem patch isn't another transdermal alternative all this can be switched and swapped just to cross cover for each other unfortunately the problem is ongoing I don’t see any light at the end of that tunnel so we'll just have to be able to use what is available yeah I’d agree with that and also of course it there's a double whammy that thankfully in our view more and more women are wanting HRT so of course if you're a manufacturer of easter gel thinking there'd be a million women there are now three times as many  and they haven't quite caught up with manufacturing it as Miss Anahit Zakaryan said but yeah I mean short term any type of eastern HRT is great yeah.

Louise King

Okay, I’m just going to ask a couple more questions because we're running out of time. I think I’ll focus on anonymous questions and then they're ones with names we can answer via email afterwards, I hope that's okay. So, one is a very quick one, Mr Rowan Connell, how many MonaLisa Touch® treatments a year do you carry out?

Mr Rowan Connell

Well, you have the treatment six weeks apart so we have a clinic every two weeks, before covid, it's now every three weeks and then in the last four months, we've gone back to two every two weeks so we're treating between two and twelve women at the in each clinic so it's slightly variable and it's a little bit of a chopping change but we can do up to 12.

Louise King

Okay, thank you and which one should I ask now. This lady is 58 and she's been on HRT for almost two years many symptoms are improved but could testosterone help with fatigue and brain fog? Ana, I guess?

Miss Anahit Zakaryan

Not necessarily, testosterone is not recommended for those usually oestrogen and progesterone are the ones helping those symptoms testosterone is mainly prescribed to support the libido it can increase metabolism because it's a male hormone to some degree but it is not recommended for a brain fog and memory if oestrogen is not helping cognitive function I would prefer to have antidepressants as an alternative rather than testosterone.

Louise King

Okay, thank you. Can the MonaLisa Touch® cause cysts especially if someone suffers badly and regularly with these please?

Mr Rowan Connell

So, I’m assuming this is vaginal cysts, so it's completely non-hormonal so it can't do anything to the ovaries can it cause cysts in the vagina no because the process of cyst formation is nothing to do with this if anything. So, for example, if you've got a bathroom cyst which is the two very large cysts at the bottom of the vagina when those become blocked you can get large cysts forming but the laser won't do that.

Louise King

Thank you, okay. What are bioidentical hormones, and can these do the same thing as oestrogen topical cream?

Miss Anahit Zakaryan

The evidence now suggests that they almost do not help as such so by under the goal they are in our plant and food and all these kinds of things they should not be used for a very long time anyway and as I said there's no evidence that they are being particularly helpful, so alternatives are always better. Louise King

Okay, thank you. I’m just going to answer a couple more as we have a few more minutes. This lady has, sorry if I pronounce it incorrectly, Ehlers Danlos syndrome and asks if when Mona Lisa would be appropriate? She's 58 and was over the menopause at 43. She didn't have any HRT but had lots of symptoms incontinence vaginal dryness and painful intercourse for many years she's newly married and embarrassed by all of this.

Mr Rowan Connell

Yeah, okay so that goes back to what I was saying about the new partners, Ehlers Danlos is a condition I suppose very simply it's a mouth malformed collagen let's say the sake of argument so the MonaLisa Touch won't make the Ehlers Danlos better, but it will certainly make the vaginal skin better. Just like it would in any other woman if you've got laxity depending on what type of Ehlers Danlos, you've got laxatives means very elastic tissues so there's lack of formation but if you're menopausal and you've got sore you're having sore intercourse because the skin is so thin of course the Mona Lisa will help but it's not going to cure the Ehlers Danlos but I appreciate I did say that it changes collagen but it won't it won't cure the yellow tunnels at all. Okay so yeah I mean she should consider it but as I said again, I would use the vegetable oil first the hormones in the vagina first and if that doesn't help with my coconut oil to then also use the to think about the MonaLisa Touch.

Louise King

Okay, thank you. Okay, I think we've run out of time really so sorry we didn't answer all your questions. However, we do have all your names so we will email you with the answers over the next day or so and thank you very much for asking so many interesting questions. It's been a really good session and thank you both Miss Anahit Zakaryan and Mr Rowan Connell for your great answers and if anyone wants to book a consultation Sarah is on the private patient’s team is available until 8 pm this evening. She can book you in, we are quite busy at the moment because of due to high demand so will be booking you in from kind of August onwards. You will receive a short survey at the end of this session, and we'd appreciate it if you could complete it, it won't take a minute or two, it just helps ask some questions for future events and give the speakers feedback as well. Our next webinar is on Tuesday the fifth of July at 6pm, it's with Mr Daniel Neen and it's on shoulder replacement surgery and that's the first one we've done on shoulder replacement so if you know anyone that would be interested in that please do pass that on. So, thank you very many speakers and thank you to our listeners and our audience. Have a nice evening, we'll see you soon. Thank you, bye.