Laser for genitourinary syndrome of menopause: what we know and what we need to know

Energy-based treatments, including the fractional CO₂ laser, have been widely used for treatment of genitourinary symptoms associated with menopause. With the availability of data from seven double-blind sham-controlled randomized trials, the evidence does not support the fractional CO₂ laser as an efficacious treatment for genitourinary syndrome of menopause (GSM). A 2024 meta-analysis of these trials demonstrated that the symptom with greatest absolute improvement was dyspareunia at 16.3%, although not statistically significant. This improvement is far less than previously anticipated based on prospective data that suggested promising improvements of more than 90% satisfaction following laser treatment. Other data, including those from unblinded studies which are subject to a placebo effect, and outcomes that are not participant-reported including the appearance of the vagina on examination and histology, are not reliable in determining efficacy of laser treatment for GSM. While there may be a clinical effect of laser over sham treatments for GSM, the effect is unlikely to be clinically meaningful. Until we define and demonstrate a minimal clinically important difference in a robust and appropriately powered study, the laser should not be used in a clinical context for GSM.