Conversations surrounding sexual health and wellness were, until recently, somewhat taboo topics. “Women have always dealt with incontinence, dryness and more, but they did not talk about it because there was not the medium to do so,” said triple board-certified cosmetic surgeon Daisy Ayim, MD (Houston, Texas). However, as society breaks barriers, the dialogue surrounding the look, feel and functionality of the vagina are healthy and inclusive discussions, leaving no woman to feel ashamed or alone.
“It is a sexual revolution for women. They have their needs, and now they can address them,” explained board-certified OB/GYN Russell Bartels, MD, co-founder of VitalityMDs in Scottsdale, Ariz.
Allan Yang Wu, MD, a cosmetic and reconstructive surgeon of Revive Wellness Center in Torrance, Calif., shared, “Baby boomers refuse to compromise on sexual function with maturity while millennials see sexual health as part of normal health. As more healthcare providers realize that sexual function correlates to overall physical and mental health, we move from the traditional doctor’s office to long-term health and wellness,” he continued.
The demand for treatments that rectify sexual health and wellness issues shows no signs of slowing down. According to data from researchandmarkets.com, the global sexual wellness market will reach $125 billion by 2026. From 2014 to 2019, vaginal rejuvenation treatments (surgical and nonsurgical) jumped 220%, with more than 25% of plastic surgeons offering these therapies.1
Common problems include incontinence, dryness, post-partum effects like a vagina that (to the patient) does not feel or look the same, decreased libido and a loss of sensation and pleasure during intercourse. “These days, there is such a push towards self-care, so why not include treatments that rejuvenate the vagina?” Dr. Ayim proposed.
Two groups of women seek help to correct what bothers them, shared Christine Hamori, MD, a board-certified plastic surgeon from Duxbury, Mass. “Menopausal and post-menopausal women who experience laxity, dryness and incontinence; or patients in their late teens and early 20s who do not like their labia and feel it is bigger than normal,” she continued.
But what is a ‘normal’ vagina, and where do women get the idea that theirs is abnormal? “It is a personal perception, but the media and social media may perpetuate this notion,” Dr. Hamori pointed out.
Hormones play a crucial role in sexual health and wellness. During menopause and andropause, sex hormone levels decline. Estrogen, progesterone and testosterone levels decrease in women, leading to dryness and diminished libido. Similarly, men also produce less testosterone, which causes a low sex drive and difficulty achieving and maintaining erections.
“Sexual wellness issues almost always arise due to hormones, poor circulation, or the tissue of the sex organ,” explained Samantha Thiry, FNP-C, APRN of Happy Body in Austin, Texas.
As menopause sets in, Ms. Thiry recommends hormone therapies. Treatments include sprays, sublingual tablets, patches, topical and intravaginal creams, pellet therapy, bioidentical hormones and hormone replacement therapy (HRT) injections. “These therapies alleviate menopause-related symptoms to improve quality of life,” she explained.
Kim Evans, MD, a board-certified OB/GYN from Sugar Land, Texas, runs a niche practice that caters to female sexual health. She remembers purchasing her first vaginal rejuvenation device in 2014. “Women could not believe there was something like it,” she exclaimed.
Since then, Dr. Evans said there have been changes in the nonsurgical device arena, one being combination therapies to fully address patients’ issues. “There are a lot of nonsurgical solutions that we can use together to help patients – that is a game-changer,” Dr. Evans emphasized.
“Although more devices and handpieces are available, the main technologies remain the same,” Dr. Bartels added.
For as much praise as physicians give nonsurgical devices, in 2018, the FDA issued a warning about their use for vaginal rejuvenation. In anecdotal cases outside the U.S., Dr. Wu reported that laser and RF energy were implicated in stenotic scar tissue formation in the vaginal canal. “There is concern that these complications have resulted from inappropriate use,” he explained. “Coinciding with these events, the FDA took notice of the marketing practices of device companies and whether handpieces, and the power unit, had approval for sexual indications.”
Still, RF devices and CO2 lasers are the go-to solutions for treating lax tissues and muscles, leaky bladder, vaginal dryness and lack of sensation. The energies heat the tissue to activate fibroblasts and stimulate collagen production, healthy blood flow, and improve tightness while internally rejuvenating the vagina for better bladder function and enhancing the vaginal skin. In addition, creating a hyperresponsive vaginal mucosa promotes lubrication and also produces collagen and elastin. “The nerve endings become more responsive and reactive to regain feeling,” Dr. Ayim advised. Both modalities are speedy and well-tolerated with no downtime or discomfort but require maintenance sessions.
Laxity is common amongst menopausal and post-pregnancy women. “I am seeing more women complaining of laxity, which they describe as looseness during intercourse, an open look to the back of the vagina when examining themselves with a mirror, or a vagina that does not look like it did before kids,” Dr. Hamori shared. “Women do not feel the same friction and sensation with intercourse, and they want to improve the sexual experience.”
Popular nonsurgical RF treatments to tighten the vagina include ThermiVa RF (Thermi) and the Viveve System (Viveve Medical). EMFEMME 360 from BTL Aesthetics (Boston, Mass.) goes one step further and tracks the tissue’s temperature for a uniform energy delivery. It is also fast – treatment clocks in at eight minutes. “With it, we can adjust the pelvic contractions’ timing, power and strength, and its ergonomic design makes it comfortable for patients,” Dr. Evans noted.
Similar to how EMFEMME 360 monitors the heat, Venus Fiore from Venus Concept (Toronto, Ont., Canada) features an Automatic Temperature Control feature and real-time thermal feedback for safe, consistent results. Multipolar RF and pulsed electromagnetic fields power Venus Fiore, which tightens the labia and reduces the mons pubis. It also creates new blood vessels, collagen and elastin for better sensation, moisture and elasticity.
RF treatments also help with incontinence by improving the tone of the sphincter. “Tightening it controls the urge to urinate,” stated Dr. Ayim. She prefers Inmode’s multimodality Empower RF because, “It works internally to tighten the sphincter to improve incontinence while increasing vaginal lubrication and tightening the vagina.”
Another doctor favorite for treating incontinence (for women and men) is Emsella (BTL Aesthetics), which utilizes electromagnetic energy to strengthen a weak pelvic floor. Flaccid pelvic muscles make it difficult to control the release of urine, and a simple laugh or sneeze can cause leakage. Patients sit clothed on a special chair for 30 minutes for six sessions. The chair delivers energy to the muscles causing them to contract, comparable to doing thousands of Kegel exercises, for better bladder control. “With Emsella, we are treating the problem rather than offering a temporary solution,” Dr. Evans emphasized. According to clinical studies, 95% of Emsella patients report an improved quality of life.
CO2 and erbium:YAG lasers work intravaginally to heat the tissue superficially. Lasers like MonaLisa Touch (DEKA), FemiLift (Alma), Juliet (Cutera) and FemTouch (Lumenis) enhance and thicken the mucosa tissue for improved lubrication. These devices also create microscopic tissue wounds that stimulate a collagen-producing response that increases blood flow. “However, CO2 lasers come with risks like scarring and burning,” warned Dr. Ayim.
A notch down from CO2 laser are hybrid lasers, like DiVa (Sciton). These combine CO2 with erbium for less ablative treatment of delicate vaginal tissue. “Hybrid lasers have a high affinity for water, so they are less destructive to the tissue,” Dr. Ayim clarified.
Ultrasound-based devices, like Cliovana (Cliovana Ltd), are effective for heightened sensitivity. They are not as strong as hybrid or CO2 lasers, yet they are more robust than RF. Cliovana improves sexual responsiveness, as well as orgasm intensity and frequency by creating new blood flow to the clitoris and nerve endings. In addition, it enriches lubrication, so painful sex is less of an issue.
Dr. Bartels says low-intensity soundwave technology, customarily used to treat erectile dysfunction in men, also works for women. Devices like FemiWave (Eclipse) improve blood flow for clitoral enhancement and heightened sensitivity.
Non-invasive options may improve loose labial skin for some, but those with more laxity may need the next step up. “We can do a scarless labiaplasty with InMode’s Aviva,” said Dr. Hamori. This 20-minute, minimally invasive procedure uses heat to reshape the soft tissue of the vulva without excising any skin.
Injectables and Shots
Ever since platelet-rich plasma (PRP) showed evidence for regenerative purposes, it has been a mainstay in aesthetics and medicine. The O-shot uses PRP to increase vascularization in the clitoris and vagina for improved sensitivity. “It uses the body’s ability to regenerate to help with moisture and mild incontinence,” shared Dr. Evans.
In the case of moderate laxity with minor incontinence, EMFEMME 360 can be used with the O-shot to tighten the vagina and outer areas. In addition, some physicians couple the O-shot with Emsella to further strengthen the pelvic floor to improve leaking.
Dr. Evans mixes PRP with hyaluronic acid fillers to stimulate collagen and inflate a deflated labia, known as the Vaginal Wing Lift. “We can also combine it with the O-shot for increased sensation,” she added, “or use it to improve volume loss, looseness and discoloration.”
The G-Shot is intended to increase sensitivity in the area of the Grafenburg-spot (G-Spot). Injecting hyaluronic acid filler directly into the G-Spot pushes it downwards for more contact during intercourse, explained Dr. Hamori. “However, it is a vascular area, and there have been reports of the filler traveling to the lungs, so only an expert should perform this,” she cautioned.
Hyaluronic acid injections can also be used to ‘puff out’ the labial tissues, so that the labia appear less wrinkled. Dr. Bartels shared that using filler with RF treatments tightens the external skin further. Fat transfer is another option.
Let’s Not Forget the Males
Female sexual health treatments may be seeing an uptick, but men want to remedy their issues, too, which according to Ms. Thiry, are often related to circulation problems. Erectile dysfunction (ED) is a lack of sufficient blood flow to the penis and affects men of all ages. Research shows that 40% of men age 40 and 70% of men age 70 suffer from ED.
In younger patients with poor circulation or performance anxiety, Ms. Thiry suggests shock wave treatments, which break down the arteries and veins in the penile tissue, so they regrow stronger and more capable of proper blood flow. Some shock wave treatments have shown an extremely high success rate (75%) in treating ED based on more than 100 clinical studies, as have devices that use pulsed acoustic sound waves.
Peptide injections, specifically PT141, are being hailed as a magic bullet quick fix. Dr. Bartels says that injecting peptides into the lower abdomen increases libido and sexual response for 24 to 48 hours.
The P-shot, PRP injections into the penile tissue, is the male version of the O-shot for longer-lasting increased circulation, firmness and stamina.
Penis enlargement surgery, which places penile implants under the skin, remains the gold standard for increasing size while treating erectile dysfunction issues. “We can transfer fat to add volume and use dermal fillers, which gradually increase girth and provide some length,” expressed Dr. Wu. To straighten the penis, he shares that XIAFLEX® (collagenase clostridium histolyticum) injections break up scar tissue to reduce erectile curvature.
Into the Future
As the sexual health and wellness industry grows, expect new uses of treatments typically reserved for the face and body. For example, Morpheus V8 (microneedling radiofrequency) from InMode is making its way onto other body parts. “It is a new intravaginal microneedling RF device that treats the whole area, including the clitoris, to help with lubrication, incontinence and sensation,” Dr. Hamori revealed.
Nano fat is gaining traction, too, according to Dr. Hamori. “Superficially injecting growth factors derived from fat helps with lichen sclerosus and dryness,” she added.
Dr. Wu and his research team are investigating small molecule screening of FDA-allowed supplements and natural product isolates. One, in particular, is Avogen, which is isolated from avocado. “It has remarkable properties for improving moisture and elasticity in women suffering from menopause-related atrophy,” he shared. “The molecule is neither a steroid nor estrogen related, and we believe it utilizes a novel pathway that could avoid estrogen side effects.”
Dr. Wu disclosed that he is also developing minimally invasive home-based devices that utilize micro-fractionated negative pressure to induce collagen production within the vaginal lining.
As the offerings continue to expand and more women become comfortable with the idea of treatment, Dr. Hamori asserted that there is a direct connection to patient happiness and confidence. “As symptoms subside, women openly share their experiences and gratitude for their improved life, which makes me, as a doctor, very happy.”