Vaginal laxity (loosening or loss of tonicity of vaginal wall & vaginal opening) is a common presentation among women after childbirth and menopause with physical and psychological impact such as diminished or loss of sensation during intercourse that leads to unsatisfied sexual life, loss of confidence and low self-esteem affecting the intimate relationship.1-3
Vaginal Laxity is the main cause of sexual dissatisfaction. Vaginal laxity lacks standardized diagnosis and severity criteria. It is considered as a subjective complaint that reflects decreased sexual satisfaction due to vaginal loosening.
It has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm.4-6
Vaginal Laxity, How it Happens Following Childbirth?
Vaginal laxity occurs during childbirth, when the vaginal tissue and lining is thinned out and stretched to accommodate the delivery of the baby.
Vaginal Laxity happens after several deliveries or big size baby, where the vaginal wall & its opening become unable to retract back to its initial shape or size due to overstretch & loss of the pelvic muscles’ tone that surround the vaginal opening -either due to mechanical overstretch or due to birth tears/injuries- resulting in looseness & weakness of vaginal tissues.
Vaginal laxity syndrome is the term describing a group of symptoms resulting from the disruption of the pelvic floor muscles & manifesting as loose vaginal opening, diminished sexual sensation, urine leakage & stool leakage (foecal urgency or incontinence) 7-9
Vulvovaginal Atrophy (VVA)/ Genitourinary Syndrome of Menopause (GSM), What is it?
Vaginal laxity at menopause is due to decline of Oestrogen hormone production that leads to loss of volume & strength of many feminine tissues that contain Oestrogen receptors that help to maintain the youthful shape & function. At menopause, atrophy (shrinkage) of tissues happens. There is a reduction in the plumpness (bulk/mass) of the pelvic floor muscles and in the vaginal and urinary areas due to diminishing of Oestrogen & its receptors mediating or responsible for both the wellbeing & function of the structures in the feminine area. Deficiency of Oestrogen hormone eventually leads to vaginal dryness and laxity.
Vaginal Laxity is a taboo! Women are reluctant to talk about it because they think it is embarrassing! Many women suffer in silence. They are convinced that the condition of vaginal laxity is part of the natural aging process & that is inevitable to happen and there is nothing would correct it but surgery. They struggle with a decrease in sexual satisfaction due to lack of enough physical friction during intercourse, (due to loose vaginal opening & the surrounding muscle tone) and diminished or loss of sensation and natural lubrication function. This elicits the symptoms of pain during intercourse (dyspareunia) or sensation of “cactus dryness” or irritation or burning sensation or uncommonly cracks in the vaginal wall with occurrence of spotting or bleeding following intimacy. The combination of all these symptoms come under the terminology or the diagnosis of Vulvo-Vaginal Atrophy (VVA) or Genitourinay Syndrome (GSM) is a combination of vulvo-vaginal laxity, vaginal atrophy, urinary incontinence, and orgasmic dysfunction). The GSM symptoms include genital symptoms (dryness, burning, itching, irritation, bleeding), sexual symptoms (dyspareunia and other sexual dysfunctions) and urinary symptoms (dysuria, frequency, urgency, recurrent urinary infections 10-12
Vaginal Laxitys: How to Treat- options
I) Surgical treatment
Vaginal Laxity can be treated by traditional surgical procedures called vaginoplasty (Anterior Coloporrahpy, Posterior Colpoperineorrahpy, Manchester-Fothergill repair, , perineoplasty and vaginal vault prolapse etc. Surgical option requires lengthy preparation, aenesthesia, stay in hospital and long time for recovery for weeks, not to mention the inherent risks of surgery & potential complications including scar tissue formation. 13-15
Female sexual dysfunction following vaginal surgery.
A significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence.
It is worthy to mention that the purpose of surgery is achieving anatomical tightening of the vaginal wall, but it does not lead to improvement in the function or the quality of the already atrophic vaginal tissues.16, 17 -By Dr. Nadia Yousri (FRCOG)
II) Non-Surgical Options: What are they?
1.1. Pelvic Floor Exercises (Kegel’s)/physiotherapy
These aim to tighten the muscles surrounding the vaginal opening and improving the resting muscle bulk & tone. These exercises should be routinely done at least 3 times a day for 10-15 minutes daily & indefinitely.18, 19
1.2 Hormonal Replacement Therapy? How useful in VVA?
Use of Oestrogen Hormone Replacement (EHT) is meant to improve & reverse the atrophic changes happened in the vaginal wall. It improves the quality of vaginal tissues enhancing blood flow and thickening & abundance of the cellular element of the lining vaginal skin; an effect mediated by the Oestrogen receptors. Topical applications are usually advised to avoid or minimize the side effects. Forms like Creams, pessary, vaginal rings are usually prescribed to be applied for a two or three month-course that can be repeated every 3 months. [By Dr. Nadia Yousri (FRCOG)]
Vaginal Laxity is not expected to be improved by the ERT, but the lubricating function will be regained.20-22
What Are the New Trends in Non-Surgeical Treatment of Vaginal Laxity?
1.3 Non-Hormonal Non-Surgical “Aesthetic/Regenerative Gynaecology procedures
Nowadays most women are choosing the non-surgical “Aesthetic” better called “Regenerative Gynaecology”TM options such as use of Hyaluronic Acid Fillers or autologous cell grafting or autologous lipofilling, or Gold Thread Implantation radiofrequency and laser; all these aiming to tighten and rejuvenate vaginal tissues.23-28
Platelets’ Rich Plasma Injections (also known as O Shot): the use of autologous platelets’ sample after centrifuging the person’s blood sample and inject in certain points -by the experienced Gynaecologist Dr. Nadia Yousri- to stimulate tissue regeneration & vaginal rejuvenation. It has excellent results with the expert hand. Platelet-rich plasma (PRP) can be incorporated into genital rejuvenation.29-34
The use of PRP as a supplement of cell culture media has consistently shown to potentiate stem cell proliferation, migration, and differentiation. In addition, the clinical utility of PRP is supported by evidence that PRP contains high concentrations of growth factors (GFs) and proteins which contribute to the regenerative process. PRP based therapies are cost effective, also benefit from the accessibility and safety of using the patient’s own GFs. In the last years, a great development has been witnessed on PRP based biomaterials, with both structural and functional purposes. By Dr. Nadia Yousri (FRCOG)
Genital rejuvenation involves the management of extrinsic (traumatic) and intrinsic (aging) changes of the vagina and scrotum. Lipofilling-with the additional injection of PRP (with or without hyaluronic acid)-has been used to successfully treat vaginal atrophy and vaginal laxity; the unexpected resolution of Lichen Sclerosis in one of the women prompts the consideration to initially use PRP for the treatment of this condition not only in women but also men.35-38
Vaginal Laxity & Laser treatment for vaginal tightening- By Dr. Nadia Yousri (FRCOG)
Laser vaginal tightening has become increasingly popular for enhancing/gratification of sexual & orgasmic function along with the treatment of vaginal laxity by gently ablating the weakened tissue in the vaginal wall that improve vascularization & stimulates the natural body healing process promoting fibrin and collagen deposition. The new collagen and elastin formation improves lubrication and restores the strength and elasticity of the vaginal wall and the supporting connective tissue matrix.
The procedure is painless, takes few minutes, with 5-7 days downtime. It may take to 3 sessions to achieve the targeted success rate.
In a study -published in 2021 that included 84 pre-menopause women, with a mean age of 47.7 years who had CO2 Laser treatment for vaginal laxity with diminished sexual satisfaction, it was shown that CO2 laser treatment has both a statistically and clinically significant effect on participants’ complaints and sex-life, which wanes by 6 months post-treatment. And that Laser therapy seems to be safe in the short term, with no serious adverse events reported in that current study.39-43
Radiofrequency for vaginal tightening- carried out by Dr. Nadia Yousri (FRCOG)
Radiofrequency is used to induce regeneration of the tissues through warming up the lining of the vagina and the vulva to induce collagen and elastin formation, improve blood flow and increase moisture in the vagina which makes the tissues tighten so the vaginal walls are stronger and plumper.
The treatment is painless and takes about 20 minutes and creates a gentle warming sensation. 44-53
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Published by Dr. Nadia Yousri, FRCOG, Aesthetic Regenerative Gynaecology Consultant©
1-British Menopause Society update on HRT supply shortages. published: 23/08/2019.
2-Menopause Matters: https://www.menopausematters.co.uk/tree.php
3-British Society of Urogynaecology (BSUG); https://pcwhf.co.uk/resources/british-society-of-urogynaecology-patient-information-leaflets/