Aesthetics interviews three practitioners who explore the causes of vaginal laxity and their tips for treatment using radiofrequency
Designer vagina. It has a ring to it, doesn’t it? It is a term that has been frequently used by the media to describe the cosmetic surgical intervention of the female genitalia and, more recently, the non-surgical rejuvenation alternatives such as dermal fillers, platelet-rich plasma, chemical peels, and energy-based devices.
However, contrary to popular belief, practitioners treating this area say patients very rarely present to clinic with requests of a ‘designer vagina’ and their concerns usually run deeper than improving just the appearance.
Aesthetic practitioner Dr Shirin Lakhani has worked in women’s health, as a GP, and holds a Diplomate of the Royal College of Obstetricians and Gynaecologists. She says that when it comes to the intimate area, the main reason women present is to address issues with their functionality. “I would say that for 99% of my patients the motivations to seek help are to improve discomfort, sexual function, incontinence and the overall feeling they have down there, rather than their aesthetic appearance,” Dr Lakhani explains. For many patients, these issues stem from vaginal laxity, which according to practitioners interviewed, can be successfully managed using radiofrequency (RF) technology – a familiar tool to many aesthetic practitioners.
Aesthetic practitioner and former surgeon Miss Mayoni Gooneratne has a PhD in the neurology and control of the bowel and pelvic floor, and specialises in feminine health. She defines laxity as a symptomled problem that women describe when their vagina feels looser than normal. She states, “Vaginal laxity is not a physiological measurement and it’s more about how the woman feels.” Dr Nataly Atalla, a senior consultant gynaecologist specialising in fertility, reproductive medicine and menopause, adds, “Vaginal laxity is when the vagina becomes loose, has no tone, hangs below and becomes wider, so the normal feel that women are used to becomes very different. It’s commonly associated with other symptoms related to failed pelvic floor support like vaginal prolapse and urinary control problems such as frequency, urgency or stress incontinence/leaks.”
Much like other areas such as the face, with age brings collagen and elastin loss to the vaginal canal, says Dr Lakhani, which will contribute towards laxity. However, she says that childbirth and the menopause significantly accelerate this. Dr Atalla emphasises, “Childbirth is the first related cause of vaginal laxity. Following childbirth, women commonly suffer from muscle weakness, pelvic floor muscle tone loss and looseness which, if not recovered, can cause weak pelvic floor support. It can also influence organs around and supported by the vagina to hang down loose or sink. These organs include the uterus, bladder or bowels, causing a different effect on their feeling inside and down below. It can also impact these organ’s functions, such as bladder or bowel function and, essentially, sexual sensitivity, function and satisfaction.”
The second main trigger for vaginal laxity occurs with age from around the mid 30s onwards, adds Dr Atalla. “This is a crucial factor far underestimated and falsely assumed to only happen at or after menopause, while in fact all female ageing is more relevant to hormones. Hormones start changing as women start to enter the pre or perimenopause stages. Women exhibit changes in both ovarian hormone levels and balance changes, which includes oestrogen, progesterone and testosterone.” She adds, “So, even women who have never had children will find that their vagina will begin to feel different, with tone, moisture, and sensitivity changes and it will become devitalised over time. This is related to loss of elastin and collagen, with loss of sensitivity, normal texture and blood flow in the vagina and its underlying tissues.”
Dr Atalla adds that patients may present with a perceived enlargement or hypertrophy of the labia, with surrounding vulva and labial skin, and tissues may become atrophic and wrinkled. This can change not only the feel but the appearance of the vulva and labial area. She says, “Exactly what happens to your face also happens down below – dryness, skin wrinkling and loosening – so practitioners need to educate patients that this is all part of hormone changes and ageing and discuss how we can improve it.”
Symptoms can directly impact quality of life, such as mental health and relationships and it is an underreported condition, practitioners note.1
All practitioners interviewed agree that these are sensitive patients and there needs to be a large focus on education. In the consultation, as with other treatments, practitioners also need to include a patient history, evaluation of the symptoms and examination to make a correct diagnosis and treatment plan.
According to practitioners, a consultation of around 45 minutes is normal, and Dr Lakhani highlights that patients should have the option to come back if needed. Miss Gooneratne adds, “For this area, the consultation absolutely must focus on the patient’s gynaecological and sexual history to ensure that they are having true symptoms that are going to be treatable in your hands. If you find in the consultation that they fall outside your remit, or that they would benefit more from other approaches, then you must refer to a specialist.”
First and foremost, making patients feel comfortable to talk about their issues is key. “In the consultation you need to reassure women that they are not alone, because every single person that comes in thinks that they are the only one who is suffering – so it’s important to educate,” Dr Lakhani comments, adding, “Practitioners also need to be very comfortable in discussing every aspect of a patient’s sexual behaviour, such as the symptoms they are having, how often they are having sex, or if they have ever even had an orgasm. Practitioners need to be direct, but sensitive, and you can’t be embarrassed yourself, otherwise you are never going to make your patients feel at ease.”
In the consultation, Dr Atalla will always look at a patient’s lifestyle factors and how to make improvements to this before any treatment. “I will assess women from A-Z and this includes diet changes, fitness and exercise, essential menopause vitamin supplements, weight control, and hormone therapy. I will always address lifestyle and hormone issues first because this will give me maximum success when I do the non-invasive procedures for rejuvenation.” If practitioners do not currently provide hormone services, Dr Atalla suggests to work alongside a gynaecology reproductive specialist.
Miss Gooneratne uses a scoring system called the Female Sexual Function Index (FSFI) that allows her to quantify the problems a patient has, how it affects them and then how this may be improved by treatment. “I get patients to do this before, then one month and three months after treatment. It allows me to monitor results and help manage patient expectations, as non-surgical treatments are never going to be able to completely resolve their problems, but with proper patient selection we can make a good improvement,” she says.
When assessing patients, Dr Lakhani will rate vaginal laxity as mild, moderate or severe and discuss with them how she can make improvements. She will also delve into the patient’s motivations for coming to clinic. “You need to sensitively find out if there is any pressure from someone else to have treatment – such as a male partner. Practitioners need to highlight that treatment isn’t likely going to be an option to fix a relationship. I don’t treat anyone who comes in for their male partner,” she explains. A physical assessment of their intimate health is also really important Miss Gooneratne says. “You need to ensure they don’t have prolapse and are without infections or diseases by doing a proper examination. They also need to have a recent smear that’s negative,” she explains, adding, “In the consultation, I will explain to them the treatment approaches in a very practical level – they know they will be lying in a certain position and I show them a demo tip so they know what to expect.” Miss Gooneratne will always give them a cooling-off period of about two weeks.
“Even if you don’t treat patients externally, with RF you will get some degree of cosmetic improvement as the tightening pulls everything back up"Dr Shirin Lakhani
To improve vaginal laxity and its associated symptoms, practitioners state that the overall aim of treatment is to induce new collagen and stimulate remodelling of vaginal tissue to have a tightening effect on the vaginal canal.1,2 Studies suggest that other energy-based devices such as CO2 laser and Er:YAG laser can have positive rejuvenating effects,2,3,4 however all practitioners interviewed prefer to use RF to treat this condition.
Dr Atalla explains, “I use RF over lasers as I find that I get excellent effectiveness and results with less downtime, they are less expensive and I believe there are lower risks of complications like burns, scarring or any deformations. I think that the risks of complications are reduced with RF owing to automatic temperature controlled therapy. I am glad I have not seen complications in any of my patients.”
Dr Lakhani, says, “In my hands, RF is a great treatment option for vaginal laxity and is very popular amongst practitioners. RF at a temperature of around 43 degrees achieves the required depth of penetration needed for sufficient tightening via elastogenesis and collagenesis.” Dr Lakhani adds, “We don’t have the same heat receptors in the vaginal canal so this temperature is bearable and patients will feel something similar to a warm massage.”
Miss Gooneratne highlights that she is confident in the safety profile of RF because it has been used in other areas of the body for many years. She states, “When done well and effectively it can result in really nice results, with a high safety profile, and without mass downtime as you are not ablating the skin. It’s easy to deliver and it’s comfortable for patients.” Another positive about RF is that it can also be used to address cosmetic concerns, practitioners suggest.
Miss Gooneratne says, “I am happy to do this given the safety profile and the evidence I have seen with RF – it really helps to tighten the tissue and with the device I use you can see an instant result. The treatment is a bit longer, by around 15 minutes.” Dr Lakhani adds, “Even if you don’t treat patients externally, with RF you will get some degree of cosmetic improvement as the tightening pulls everything back up. The labia majora will tend to close a little and have a shrinking effect.”
Choosing a RF device
There are many different devices available, each with a different treatment protocol. When choosing a device, Miss Gooneratne considered the number of treatments, deciding that for practicality she didn’t want patients to come in several times for an effective treatment. “You also need a comfortable device with safe delivery and a good cooling system. The business and commercial aspect also plays a part; it had to be cost-effective for both myself and patients,” she says. Miss Gooneratne uses the Viveve monopolar RF device. She states, “From a practical standpoint, this device has a two-pence head size, the tip is directed exactly where you want it and so you know exactly where you are firing the energy. You treat in quadrants in a clock face formation and you treat each quadrant five times. You don’t need to move in and out of the vaginal canal and the handpiece flashes blue when you make contact with the tissue, which helps me deliver a controlled treatment.” Viveve is a one-off treatment, says Miss Gooneratne, and results last for around 12 months. She adds, “It should be noted that we are treating the single muscular tube, not the pelvic floor, so I always encourage patients to continue their pelvic floor exercises for maximum results.” Comfort is a priority for Miss Gooneratne, as the treatment will last around 45 minutes. “I make sure they have pillows for support and that they have a phone or something to do as patients will get bored very quickly otherwise.”
Dr Lakhani chooses to use the Ultra Femme 360 device. “I looked at the other devices on the market and assessed the treatment efficacy, procedure and consumables costs – the detachable probe that is inserted is single use and this needs to be considered as the cost of this impacts patient costs,” she says, adding that a big selling point for her was the shorter treatment time. “I feel that as a patient having a treatment in the intimate area, you want it to be as quick as possible. One of the big draw factors for me was its circumferential tip – it treats all around the vaginal canal at the same time. From my perspective, this takes out practitioner error and it shortens the treatment time to around eight minutes.” Dr Lakhani says that patients need one treatment each week over a three-week period and results last around nine months. “I tend to bring my patients back at six months before it gets to that so that we are constantly building on what we have already achieved,” she says.
Safety, cost-effectiveness and patient satisfaction are also a priority for Dr Atalla, who chooses to use the Votiva FormaV device. “When I was looking for a non-surgical treatment solution I wanted something that would not be painful, didn’t have a long treatment time, had a short downtime and good efficacy. It also needed to be readily available and be provided in my comfortable outpatient clinic settings. As a woman myself at this stage of my life, I also needed to question whether I would have the treatment myself. For me the Votiva FormaV was the best option.” She adds, “Improvements are immediately noted after the first session, but for longevity I will do three sessions of around 30 minutes about two to four weeks apart and results last for around two years onwards, provided patients continue with their positive lifestyle factors, vitamins, pelvic exercises and optimised hormone therapy levels – these are crucial. If patients are also concerned with their outside vulval and labial appearance I will treat the vulva skin directly using the partner Fractora handpiece to Votiva after the first or second session, depending on the severity of the area. My patients love this treatment.”
Miss Gooneratne advises others to look for a device that has good long-term data showcasing treatment efficacy. She says, “Viveve did an interesting sham study that found that after three months, the treated group and the sham group had really similar results in FSFI improvement, but the laxity score in the sham group begun to drop down to being dysfunctional again after three months.5 This highlights the importance of long-term data; practitioners should also be mindful of how patients potentially have a large psychological bias and may think the results are better than they actually are as they want this treatment to work so badly – this is why I always get them in for a review after three months.”
All practitioners advise against entering the world of intimate women’s health unless you have a real passion and invested interest for helping change the lives of those affected by vaginal laxity and other intimate concerns. Miss Gooneratne says, “I am keen to encourage my fellow practitioners to have a background and interest in women’s health and gynaecology. It’s not for someone who just wants to make a quick dollar.” Dr Lakhani also believes that only practitioners with experience in women’s sexual health should be both consulting and performing these treatments. “I have had several cases where I have had to refer on and I am concerned that those without a gynaecological background will not be able to see the red flags.”
Dr Lakhani adds, “Treating these patients is seriously the most rewarding thing I do. Before implementing this into your practice you need to know that it’s changing someone’s life and it can even be emotionally draining as a practitioner. If you are not interested in women or talking to them about their most intimate concerns then don’t offer this treatment.”
Reflecting back to the ‘designer vagina’ terminology, Dr Lakhani says, “I am glad to see that more and more headlines are shifting their focus from the designer vagina angle; anyway, technically speaking, it’s not a designer vagina it’s a designer vulva, but it doesn’t really have the same ring to it!”
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