Impacto da radiofrequência fracionada microablativa na saúde vaginal, microbiota, celularidade e função sexual de mulheres com síndrome geniturinária da menopausa

In recent decades, the increase in women's life expectancy has culminated in the appearance of conditions arising from aging and ovarian failure (menopause), where hormone scarcity directly affects the female genital tract, coursing with signs and symptoms of urogenital atrophy, that characterizes the Genitourinary Menopause Syndrome (GMS) that significantly impacts the sexual function and quality of life of women of the 21st century. Hormone replacement has been the most used therapeutic option; however, several contraindications exist, such as hormone-dependent neoplasms and thromboembolism. Physical energies (laser and radiofrequency) have emerged as a new therapeutic option in this scenario. Objective: To understand and evaluate the therapeutic effect and safety of the use of physical energies in postmenopausal women with symptoms of GMS. Methods: Seven publications were carried out on this theme: Two systematic reviews, a randomized controlled clinical trial, an Overview with network meta-analysis, and two updates (mini review). Systematic reviews followed the PRISMA guidelines and were registered in PROSPERO. Searches were performed in PubMed, Embase, Scopus, Web of Science, SciELO, Cochrane (CENTRAL), and CINAHL databases. Outcomes evaluated included symptoms of GMS such as vaginal atrophy, sexual dysfunction, and urinary incontinence. Studies were selected, and three independent reviewers extracted data. The risk of bias assessment for clinical trials was performed using the Cochrane Collaboration risk of bias tool; we used the Newcastle-Ottawa Scale for observational studies. Performing the meta-analysis was impossible due to the high heterogeneity between the studies. The randomized clinical trial included postmenopausal women diagnosed with urogenital atrophy. Treatment consisted of three sessions of RFFMA, compared with vaginal estrogen administration and an untreated control group. Assessments took place at the beginning and 30 days after the last session. The primary endpoints were sexual function, as assessed by the Female Sexual Function Index (FSFI), and vaginal health, as set by the Vaginal Health Index (VHI). Secondary outcomes included the Nugent score and the Vaginal Maturation Index (VMI). In the Overview with network meta-analysis, five databases were searched from inception to December 2022. We included all Cochrane and non-Cochrane systematic reviews with or without meta-analysis. Methodological quality assessment of systematic reviews was performed using AMSTAR 2. We conducted network meta-analyses using frequentist methods, calculating standardized mean differences (SMDs) and their corresponding 95% confidence intervals (CIs) for the results of the sexual function. Results: Systematic reviews included a total of 104 studies, of which: 37 studies dealt with CO2 laser, 10 with Erbium laser, 2 with radiofrequency, 18 with lubricants and moisturizers, 14 with phytoestrogens, 8 with dehydroepiandrosterone, 5 with ospemifene, 4 of vaginal testosterone, 2 of pelvic floor muscle exercises, 2 of oxytocin, 1 of lidocaine and 1 of vaginal vitamin E suppository. The physical methods of laser and radiofrequency are well tolerated and may be an alternative option in managing MGS. However, randomized clinical trials with robust methodology and long-term follow-up are needed to confirm these results. Regarding the clinical trial, 120 patients completed the follow-up and had the results analyzed. Regarding FSFI, both treatment groups (median [interquartile range], RFFMA (4.8 [2.4]) and vaginal estrogen (4.8 [2.3])) experienced improved sexual desire when compared to the group control (3.6 [2.4]), (p=0.020 and p=0.014), respectively. Regarding the total VHI score, we observed an increase in the RFFMA (25.0 [2.0]) and vaginal estrogen groups (25.0 [3.0]) when compared to control (15.0 [5.8]), (p < 0.01), for both groups. There was a decrease in the median Nugent score in the RFFMA groups (0.0 [3.0]) (p < 0.01) and vaginal estrogen (0.0 [1.0]) (p = 0.003) for both groups. For IMV, there were significant differences in the RFFMA score (52 .3 [3.0]) and vaginal estrogen (53.0 [3.0]) when compared to the control group (48.0 [6.0]), (p < 0.01 and p < 0.01), No significant differences were observed between the RFFMA and vaginal estrogen groups in the variables studied. Nine systematic reviews were included in the overview, of which 6 performed meta-analyses. Four RCTs, representing 218 participants and nine different study arms, met the criteria and were included in the network meta-analyses. Confidence in the review results was considered low in 6 reviews and critically low in 3. The results showed that Premarin (SMD 2.60; 95% CI 7.76 to 3.43), conjugated estrogens (SMD 2.13; 95% CI 1.34 to 2.91), CO2 Laser (SMD 1.71; 95% CI 1.10 to 2.31), Promestriene (SMD 1.41; 95% CI 0.59 to 2.24) and vaginal lubricant (SMD 1.37; 95% CI 0.54 to 2.20) were more effective than sham in reducing sexual dysfunction. Conclusion: Laser and radiofrequency can be safe and promising therapeutic options for SGM. However, further randomized, and blinded clinical trials are needed to confirm the strength of the evidence.

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