What Does the Science Say About Vaginal Laser? Evidence-Based Options for Dryness and Laxity

With the menopause, many women experience vaginal dryness, burning and painful intercourse; after childbirth, a feeling of “laxity” may also be described. What a woman researching this topic is looking for is often not a device but a reliable answer to her symptoms. This article summarises what independent guidelines and comparative studies say about vaginal laser and similar energy-based devices, then sets out the options for dryness and laxity that have solid evidence behind them.

First, the name for the symptoms: genitourinary syndrome of menopause

Symptoms after the menopause such as dryness, burning, itching, painful intercourse (dyspareunia) and needing to pass urine often are today grouped under the heading “genitourinary syndrome of menopause (GSM)”; vaginal atrophy, as it was formerly called, is one part of this. According to the 2020 position statement of the North American Menopause Society (NAMS; now called The Menopause Society), GSM affects around 27–84% of postmenopausal women; unlike hot flushes, it does not settle on its own over time and, if untreated, usually progresses. Even so, only some of the women with symptoms seek help or are offered treatment ¹.

Laser came to be considered because of a hypothesis: microscopic heat damage created in the tissue is thought to stimulate collagen production, the formation of blood vessels and thickening of the epithelium. Fractional carbon dioxide (CO2) laser is a device that showed effectiveness on the skin of the face and neck and was later adapted for the vagina. Small studies without a sham control have reported improvement in dryness and painful intercourse; in the few studies comparing laser with vaginal oestrogen, neither proved superior to the other. NAMS emphasises that none of these devices has FDA approval for GSM and that there are no sham-controlled studies of adequate size ¹.

What did comparison with a sham procedure show?

The way to find out whether a treatment really works is to compare it with a sham procedure. In a double-blind study published in JAMA in 2021, 85 women after the menopause (postmenopausal) were randomly divided into two groups: one group received fractional CO2 laser and the other a sham procedure in which no energy was delivered. At the end of twelve months, symptom severity had fallen in both groups; the overall vaginal symptom score (visual analogue scale) had dropped by 17.2 points in the laser group and by 26.6 points in the sham group, and the difference between them was not statistically significant ².

A 2024 meta-analysis bringing together randomised studies on the same topic examined 12 studies. CO2 laser, particularly when compared with a sham procedure, was found to be associated with improvement in the vaginal health index and in dryness, burning and dyspareunia scores; no serious side effects were reported. However, the authors rated the certainty of the evidence (GRADE) as “low” and stated plainly that they did not recommend including laser in the management of GSM until this level improves ³. In other words, there are positive signals, but they are not robust enough to base a decision on.

What do regulators and professional societies say?

The US Food and Drug Administration (FDA) issued a safety warning on 30 July 2018: no energy-based device has been approved for cosmetic vaginal procedures, menopause-related symptoms, urinary leakage or sexual function. The FDA warned that these uses may lead to serious adverse events such as vaginal burns, scarring, painful intercourse and recurring or chronic pain ^4,5. NAMS also states that long-term, sham-controlled safety and effectiveness studies are needed before routine use can be recommended ¹.

The 2020 consensus document of the American Urogynecologic Society (AUGS) voted on 40 statements; 28 reached consensus and 12 did not, owing to insufficient evidence. Based on short-term studies, the document accepts that CO2 and Er:YAG laser show promise for dryness and painful intercourse; however, this assessment predates the JAMA 2021 study and the 2025 guideline. Although the short-term safety profile appears favourable, long-term outcomes are not known; reported possible side effects are increased discharge, spotting, bacterial vaginosis, urinary tract infection and mild discomfort, while scarring and burns are rare but reported events. A gynaecological examination should have been carried out within the past year before the procedure ⁶.

The feeling of “laxity”: even its definition is debated

As AUGS also notes, energy-based devices are promoted for a large number of indications, and laxity felt after childbirth or with age is one of them. Yet the same document states that there is no standard anatomical definition of “vaginal laxity”, that the effect of this feeling on quality of life is poorly understood and that well-designed studies are scarce; the statement that radiofrequency shows promise for this indication did not reach consensus ⁶. It is also difficult to measure effectiveness for a problem that has no definition; so it should first be established at examination what the symptom really is: pelvic floor weakness, prolapse or urinary leakage?

For urinary leakage, which may accompany these symptoms, the evidence-based first step is clear. The UK guideline NICE NG123 recommends supervised pelvic floor muscle training lasting at least three months as the first treatment for stress or mixed urinary incontinence; the programme consists of at least eight contractions three times a day and is continued if it helps. For mild (stage 1–2) pelvic organ prolapse that is causing symptoms, a supervised programme of at least 16 weeks is considered as the first option ⁷. This training does not require a device; it is a skill that can be kept up once it has been learned with the correct technique and found to help.

A stepped, evidence-based approach to dryness

For mild symptoms, NAMS lists two non-prescription products as the first step: a lubricant used during intercourse and a long-acting vaginal moisturiser applied regularly several times a week. For moderate and severe symptoms, there are prescription options whose effectiveness has been shown, chief among them low-dose vaginal oestrogen; suitability is determined at examination. If hot flushes are also present, menopausal hormone therapy (MHT) may be considered. It can take 1–3 months for symptoms to ease; because symptoms usually return when treatment is stopped, it needs to be continued ¹.

The 2025 AUA/SUFU/AUGS guideline, endorsed by The Menopause Society (NAMS), reinforces this order: low-dose vaginal oestrogen receives a “strong recommendation”, and moisturisers and lubricants a “moderate recommendation”; the guideline asks that patients be told that the evidence does not support the use of CO2 laser, Er:YAG laser or radiofrequency. At the level of expert opinion, CO2 laser may be discussed only for women who are not candidates for approved treatments or who want an alternative, with it stated clearly that it is considered experimental outside a clinical trial, and by shared decision ⁸. If there is vaginal narrowing or excessive tension in the pelvic floor muscles, gentle use of dilators and pelvic floor physiotherapy aimed at releasing the tension are added to the plan ¹.

Questions to ask when making a decision

When a procedure is suggested, these questions are a good starting point for an informed decision: Which evidence-based options have been tried first for this symptom? Has the device shown a difference when compared with a sham procedure? How many sessions are needed, how long does the effect last, and are there follow-up data beyond one year? What are the possible side effects, and who will follow you up if a problem arises? AUGS emphasises that promoting devices for a large number of indications makes it harder for patients to make informed decisions and can make the possible outcomes appear different from what they are ⁶. In most cases, dryness is a symptom that can be managed effectively ¹; the feeling of laxity, on the other hand, is a symptom that first needs to be named at examination.

If you have symptoms, please consult an obstetrics and gynaecology specialist.