# Fractional CO2 laser therapy for genitourinary syndrome of menopause: symptom-specific trajectories, exposure–outcome associations, and ultrasonographic changes in vulvar soft tissue in a cohort of 826 women

## TL;DR

Fractional CO2 laser therapy improves GSM symptoms like vaginal dryness and dyspareunia, with some long-term durability and vulvar tissue thickening in a large cohort of women.

## Contribution

This study provides real-world evidence on symptom trajectories, treatment durability, and tissue changes following fractional CO2 laser therapy for GSM.

## Key findings

- All six symptoms improved short-term, with the largest improvements in dyspareunia and vaginal dryness.
- Labia majora thickness increased in 81.5% of women with paired measurements.
- Higher responder rates were observed with more treatment sessions, though this may reflect baseline severity and follow-up engagement.

## Abstract

Genitourinary syndrome of menopause (GSM) is a chronic condition that impairs quality of life and sexual function. Fractional CO2 laser therapy is a non-hormonal option, but large real-world data on symptom trajectories, durability, and ultrasonographic vulvar changes are limited. We evaluated symptom trajectories, responder rates, exposure–outcome associations, and vulvar tissue changes in a clinical cohort.

We conducted a retrospective observational study at a single clinic in Japan. From 2016 to 2023, 826 women underwent fractional CO₂ vaginal and vulvar laser therapy (2,129 sessions). Symptoms were assessed using VAS (0–10) scores for six domains. Short-term outcomes were evaluated 20–59 days after the first session (n = 327), and long-term outcomes 10–14 months after the final session (n = 94). Responders were defined as a ≥2-point VAS improvement among women with baseline VAS ≥2.

outcomes included ultrasonographic labia majora thickness; post-treatment imaging corresponded to the same windows when paired measurements were available. Patient satisfaction and adverse events were recorded.

Mean age at first treatment was 61.9 ± 10.2 years (range, 29–87). All six symptoms improved short term, with the largest improvements typically in dyspareunia and vaginal dryness. At 10–14 months, improvements in dryness and urinary leakage attenuated, whereas dyspareunia was most durable. Labia majora thickness increased overall (16.9 ± 4.5–18.9 ± 3.1 mm), with thickening in 81.5% of women with paired measurements. Higher responder rates were observed among women receiving more sessions; however, these findings are associational and may reflect baseline severity and follow-up engagement. Satisfaction was high, and no serious adverse events were observed.

In this real-world cohort, fractional CO2 vaginal and vulvar laser therapy for GSM was associated with reduced symptom severity and ultrasonographic thickening of the labia majora in a subset with paired measurements. Given the retrospective uncontrolled design, incomplete follow-up, and placebo effects in sham-controlled trials, findings should be interpreted as descriptive associations, not causal effects. Controlled studies are needed to confirm effectiveness, durability, and maintenance strategies.