Fractional CO2 Laser Versus Intense Pulsed Light in Treating Striae Distensae

Context:Striae distensae are linear atrophic dermal scars covered with flat atrophic epidermis. They may cause disfigurement, especially in females. Many factors may cause striae distensae such as steroids, obesity, and pregnancy. Although there is no standard treatment for striae; many topical applications, peeling, and light and laser systems have been tried.Aims:To evaluate and compare the efficacy of fractional CO₂ laser with intense pulse light in treating striae distensae.Results:Both groups showed significant improvement after treatments (P < 0.05). Patients treated with fractional CO₂ laser showed significant improvement after the fifth session compared with those treated with ten sessions of intense pulsed light (P < 0.05) in all parameters except in the length of striae (P > 0.05).Conclusions:The current study has provided supportive evidence to the effectiveness of both fractional CO₂ laser and intense pulse light as treatments for striae distensae. Fractional CO₂ laser was found to be more effective in the treatment of striae distensae compared with intense pulse light.     

Efficacy of fractional carbon dioxide laser versus microneedling in the treatment of striae distensae

Background: Fractional photothermolysis is creation of microscopic thermal zones of controlled depth, width and density. Microneedling is a simple treatment modality to reduce striae distensae.

Objective: Evaluate and compare the efficacy of fractional carbon dioxide laser and microneedling as a treatment of striae distensae.

Methods: Individuals with striae distensae received three split-body treatments at four-week intervals. The right side of the body was treated with fractional CO₂ laser, while the other side with microneedling. Assessment was done by comparing photographs before and after treatments by two blinded physicians using a quartile grading scale. Evaluation also included patient satisfaction score and histopathological examination.

Results: In total 33 subjects were enrolled and 30 completed the study. By quartile grading score, we recorded 55% moderate-excellent improvement of striae in the dermaroller-treated side but with fractional CO₂ laser-treated side, we recorded 76% of patients had moderate-excellent improvement. Patients were more satisfied with fractional CO₂ laser than the microneedling. Post-inflammatory hyperpigmentation, as a complication of fractional CO₂ laser, appeared in 11 patients.

Conclusion: Fractional CO₂ laser is more effective in treating striae with acceptable side effects but still microneedling can be afforded as an effective, safe and cheap method.     

Treatment of striae distensae using fractional ablative CO2 laser in skin types II-IV: a retrospective case series study

Striae distensae (SD) are atrophic dermal scars often found on abdomen, breasts, thighs, and hips of pregnant women. The strias’ self-healing without any intervention is a poor possibility. Till now, several lasers and light sources have been used for treatment of SD. However, there are no integrated therapeutic approaches determined for treatment of SD yet. So, in this study, the therapeutic effect of fractional ablative CO₂ laser in women with pregnancy was assessed. Twenty-four ethic Iranian women aged between 20 and 42 years with various severity of pregnancy SD enrolled in retrospective case series study. Participants with skin types II-IV were treated in four sessions with a one-month interval by fractional ablative CO₂ laser. The severity of striae was determined by Daveys scoring. Clinical improvement was assessed by comparing pretreatment and posttreatment clinical photographs based on global improvement scoring. The evaluation of clinical results showed that fractional ablative CO₂ laser was an effective treatment. Twenty of 24 (83.3%) patients showed improvement. Clinical improvement was affected by striae severity (P = 0.03). Also, there were no statistical differences between clinical improvements with skin types, striae scar severity, number of pregnancy, and striae location.     

Treatment of acne scarring with fractional CO2 laser

Abstract

Background: Fractional ablative CO₂ laser therapy is based on the theory of fractional photothermolysis. It can be effective in treating acne scars in a less invasive fashion than conventional ablative CO₂ laser therapy. Objective: In this clinical study, the safety and efficacy of a novel CO₂ fractional ablative laser was investigated for the treatment of facial atrophic acne scarring in Chinese individuals. Materials and methods: A total of 31 patients (11 females, 20 males, Fitzpatrick skin phototypes III–IV) with facial acne scarring received three sequential fractional treatments over a 6-month period. Outcome measurements included blinded evaluations of before and after photographs by two physicians at 3 and 12 months after the final treatment. Global improvement was noted as well as any untoward events. Results: At the 12 months follow-up time period, 12.9% of the patients showed excellent improvement in their acne scars, while 38.71% noted good to fair results. The clinical response at the 12-month follow-up visit tended to be better than at the 3-month follow-up visit, but was not statistically significant. Four patients experienced post-treatment and transient PIH but three patients were noted to have prolonged erythema. There was no evidence hypopigmentation or worsening of the scarring in any of the study patients. Conclusion: This high-energy pulsed and cool-scanned fractional ablative CO₂ laser system is safe and effective for facial atrophic acne scarring. Improvement in scarring was noted in the majority of patients with minimal discomfort and minimal downtime. Continued improvement over time is also an important clinical finding.     

Treatment of Striae Distensae with Nonablative Fractional Laser versus Ablative CO2 Fractional Laser: A Randomized Controlled Trial

Background

Striae distensae are atrophic dermal scars with overlying epidermal atrophy causing significant cosmetic concern. Although a variety of laser and light sources have been used for the treatment of striae distensae, to date no definite ''gold standard'' treatment modality has been determined.

Objective

To assess and compare the efficacy and safety of nonablative fractional photothermolysis and ablative CO₂ fractional laser resurfacing in the treatment of striae distensae.

Methods

Twenty-four ethnic South Korean patients with varying degrees of atrophic striae alba in the abdomen were enrolled in a randomized blind split study. The patients were treated with 1,550 nm fractional Er:Glass laser and ablative fractional CO₂ laser resurfacing. Each half of the abdominal lesion was randomly selected and treated three times at intervals of 4-weeks using the same parameters. Digital photography was conducted and skin elasticity and the width of the widest striae in each subject were measured at the baseline and 4 weeks after the final treatment. Clinical improvement was assessed by comparing pre- and post-treatment clinical photographs by two blinded physicians and participant satisfaction rates were evaluated. Skin biopsies were taken from three participants. All adverse effects were reported during the study.

Results

Although they do not statistically differ, both treatments with nonablative fractional laser and ablative CO₂ fractional laser showed a significant clinical and histopathologic improvement of striae distensae over pretreatment sites.

Conclusion

These results support the use of nonablative fractional laser and ablative CO₂ fractional laser as effective and safe treatment modalities for striae distensae of Asian skin. However, neither treatment showed any greater clinical improvement than the other treatment.     

Evaluation of autologous platelet-rich plasma plus ablative carbon dioxide fractional laser in the treatment of acne scars

Introduction: Acne scar is a common distressing complication of acne vulgaris. CO₂ laser resurfacing proved effective for the treatment of this problem, but the associated complications may limit its use. Platelet-rich plasma (PRP) may increase the chance of favorable outcome. Aim of the work: To evaluate the synergistic effects of autologous PRP with fractional CO₂ laser resurfacing in the treatment of acne scars among Egyptian patients. Patients and method: This study included 30 patients suffering from post-acne scars. CO₂ laser treatment was applied to both sides of the face followed by PRP injection for the right side. Evaluation was carried out through operating physicians, two blinded physicians as well as through patient’s satisfaction. Result: The right side of the face (PRP-treated side) achieved excellent improvement in 13.3% of the patients, while there was no excellent improvement on the left side. Conclusion: Combination of fractional CO₂ laser resurfacing and intradermal PRP was superior to CO₂ laser alone for acne scar treatment.     

Effectiveness of CO2 laser with subcision in patients with acne scars

Background: Post-acne facial scarring has always been a challenge to treat. It requires multiple therapeutic modalities as single modality is not hundred percent effective. Therefore, we have combined CO₂ laser resurfacing with subcision in patients with acne scars for better results. Objectives: The aim is to study the effectiveness and side effects of CO₂ laser with subcision in patients with atrophic acne scars. Methods: Fifty patients were selected for the study. Baseline grading was done with Goodman and Baron grading system. Twenty-five patients were randomly selected for subcision followed by CO₂ laser and the remaining patients were selected for CO₂ laser alone. The treatment was done for four sessions at 4-week interval. Clinical photographs were obtained for evaluation. Results: CO₂ laser with subcision showed excellent response in grade-2 and -3 acne scars. Statistically there is a significant difference between CO₂ laser following subcision and CO₂ laser alone at 5% level (p < 0.05). Both procedures were well tolerated with minimal side effects. Conclusion: The highly versatile CO₂ laser is useful for treating acne scars. Subcision prior to the CO₂ laser procedure showed better improvement when compared to CO₂ laser alone. Thus, in acne scars, multiple therapeutic modalities achieve better results.     

Treatment of striae distensae with needling therapy versus microdermabrasion with sonophoresis

Striae distensae (SD) is a challenging cosmetic problem for which various treatment modalities have been applied. Our aim was to evaluate the efficacy and tolerability of needling therapy versus microdermabrasion with sonophoresis in the treatment of SD. Materials and methods: Forty female patients with SD (mean duration 2.98 ± 2.66) were enrolled in this study. Patients were assigned to two groups, Group 1 treated with needling therapy and Group 2 treated by microdermabrasion with sonophoresis. In Group 1, three sessions of needling therapy were performed for each patient with 4-week interval between the sessions, while in Group 2, ten sessions of combined microdermabrasion and sonophoresis were performed for each patient. Skin biopsies were taken from the most atrophic site stained with hematoxylin and eosin stain and Masson trichrome stains to study the histopathological changes and efficacy of treatment, respectively. Results: There was a significant clinical improvement in SD in Group 1 compared with Group 2. Amount of collagen, number of fibroblasts, and epidermal thickness increased in the dermis at the end of treatment sessions (90% in Group 1 compared to 50% in Group 2). Conclusion: Needling therapy is an easy, safe, and economic method and considered as a suitable modality in management of striae.     

Successful treatment of malar dermal melasma with a fractional ablative CO2 laser in a patient with type V skin

Abstract

Background/Objective: Melasma is a common disorder of hypermelanosis, and although numerous treatment modalities have been employed, many cases are refractory to treatment or the improvement after therapy is temporary. Methods: The clinical files, treatment parameters, and photographs of a 59-year-old female with black skin with refractory malar dermal melasma treated using a fractionally ablative CO₂ laser (Affirm 10 600 nm) for seven sessions were carefully reviewed. Results: After treatment, clinical improvement was achieved. Conclusion: The fractional ablative CO₂ laser is a potentially safe and effective modality for the treatment of dermal melasma in Fitzpatrick type V skin.     

The efficacy and safety of subcision using CO2 gas combined with fractional laser for acne scars: Clinical and microscopic evaluation

Background: Various modalities have been used to treat acne scars. CO₂ fractional laser is an effective and commonly used treatment. CO₂ gas injection into the dermis by needle with high pressure can cause fibrotic collagen breakage, producing the effects of subcision. CO₂ also stimulates collagen synthesis by increasing neovascularization and releasing oxygen. Objective: This study evaluated the efficacy and the safety of the combined treatment with CO₂ gas subcision and CO₂ fractional laser for acne scars. Methods and materials: Fourteen patients with acne scars were treated with three sessions of CO₂ gas subcision at 2-week intervals and two sessions of fractional laser at 4-week interval. The clinical improvement was assessed using a 4-point scale. For histologic analysis, punch biopsy was performed before and after treatment in 10 patients. Results: All patients experienced clinical improvements. Excellent, marked, moderate, and mild response was achieved in 1 (7%), 8 (57%), 4 (29%), and 1 patient (7%), respectively. Histologic evaluation of the biopsy specimens showed increased dermal collagen with dermal thickening and elastic fiber straightening in the reticular dermis after the treatment. Conclusion: The combination therapy with CO₂ gas subcision and fractional laser was satisfactory and safe for treating acne scars.

Abbreviation and acronym:

CO₂: Carbon dioxide

GAS: Global assessment scale

H&E: hematoxylin and eosin; SD: standard deviation     

Comparing the effectiveness of fractional CO2 laser and the combination therapy with micro-needling and topical 10% trichloroacetic acid to remove infra-orbital dark circles in Tehran women

Background: Infra orbital dark circles are now recognized as being a cosmetic problem that should be considered in treatment issue. The present study aimed to assess and compare the clinical efficiency of the combination of micro-needling and 10% trichloroacetic acid (TCA) cream as well as carbon dioxide laser in the management of infra-orbital dark circles. Methods: This randomized clinical trial was performed on women aged 28–62 years who complained of infra-orbital dark circles. The patients were randomly assigned to be treated with micro-needling combined with 10% TCA cream topically or CO₂ laser. The treatment period in each group included three sessions with an interval of one month between sessions. The assessment was based on both subjective and objective methods. Results: the mean of ΔE (the difference in the intensity of darkening at infra-orbital points and other points of the face) was significantly higher in the laser group than in the other group in all sessions. The patients who were treated with laser were found to have a higher level of satisfaction in the fifth visit when compared to those who received the other treatment method. Conclusion: Regarding clinical effectiveness and the patients’ compliance, fractional CO₂ laser was more preferred in the combination therapy with micro-needling and topical TCA for removing infra-orbital dark circles.     

Carbon dioxide laser combined with botulinum toxin A for patients with periorbital syringomas

Background: Although various destructive methods have been described for treating syringomas, they are often associated with significant scarring and recurrence. In 2007, multiple-drilling method using carbon dioxide (CO₂) laser was introduced as an alternative modality to gain good cosmetic results. Objective: To retrospectively evaluate the effectiveness of CO₂ laser combined with botulinum toxin A (BTXA) as treatment for syringomas. Material and methods: Forty-eight patients with periorbital syringomas were treated with topical application of BTXA immediately after CO₂ laser treatment. Forty-four patients were treated with CO₂ laser only. Results: Patients who were treated with CO₂ laser combined with BTXA required significantly (p = 0.038) fewer treatment sessions compared with those treated with CO₂ laser only. When the clinical improvements of the two treatment sessions were compared, the combined therapy (CO₂ laser and BTXA) had significantly (p = 0.044) higher rate of results showing good (disappearance of 60–80% of lesion) or excellent (80–100%) than the CO₂ laser only therapy (87.5% vs. 70.5%). Conclusions: CO₂ laser combined with BTXA showed better effect than CO₂ laser only.     

Comparison of Q-switched Nd:YAG laser alone versus its combination with ultrapulse CO2 laser for the treatment of black tattoo

Background: Q-switched lasers are conventionally used for the treatment of black tattoo. However, they require multiple sittings, and the response may be slow due to competing epidermal pigment in dark skin. Objective: To compare the efficacy of Q-switched Nd:YAG laser alone with its combination with ultrapulse CO₂ for the removal of black tattoo. Materials and methods: Sixty patients with black tattoo were randomized into two groups viz., group A and group B. Group A was treated with QS Nd:YAG laser (1064 nm) alone, and group B received combination of ablative ultrapulse CO₂ followed by fixed-dose QS Nd:YAG laser (1064 nm), at 6-week interval for a maximum of 6 sittings. After each sitting, 3 independent physicians noted percentage of improvement that was evaluated using visual analogue scale (VAS) and grading system for tattoo ink lightening (TIL). Results: Combination laser (group B) showed statistically significant improvement in mean VAS score in the last 2 noted visits as compared to 1st session (p < 0.007, p < 0.001) and TIL mean score in last three noted visits as compared to 1st session (p < 0.008, p < 0.020, and p < 0.004). There was no statistically significant difference in the side effect profile of both the groups. Conclusion: For refractory professional tattoos, combination of ultrapulse CO₂ laser and QS Nd:YAG laser is superior to QS Nd:YAG laser alone.     

Retrospective analysis of earlobe keloids treated with the carbon dioxide laser ablation or cold steel debulking surgery

Abstract

Background: Treatment of keloids is a therapeutic challenge. Objectives: To determine the outcome and the risk of recurrence after debulking cold steel surgery or carbon dioxide (CO₂) laser ablation of earlobe keloids. Material and methods: The case records of 16 patients with earlobe keloids managed at Changi General Hospital, Singapore, from 2003 to 2009 were reviewed retrospectively. Results: Fourteen patients were females, and the mean age at presentation was 20 years. Eight patients underwent CO₂ laser ablation, six patients underwent cold steel surgery, one patient underwent both surgery and CO₂ laser ablation, and one patient received only 40 mg/ml of intralesional triamcinolone acetonide. Fourteen patients were followed up for 1–24 months post procedure, and two patients defaulted. Both modalities were equally effective in debulking the earlobe keloids. All 13 patients who had either CO₂ laser ablation or cold steel surgery had recurrence of keloid growth at 2–18 weeks post procedure. The patient who received intralesional triamcinolone acetonide therapy alone had only partial response to the therapy. Conclusions: Both the CO₂ laser ablation and cold steel surgery were equally useful in reducing the size of the earlobe keloids, but were not effective in preventing regrowth of the keloids, even with adjunctive intralesional steroids. Patients should be clearly counselled regarding this.     

Combination of CO2 and Q-switched Nd:YAG lasers is more effective than Q-switched Nd:YAG laser alone for eyebrow tattoo removal

Background: The eyebrow tattoo removal using Q-switched lasers is usually prolonged. Other modalities may be required to enhance the efficacy and shorten the treatment course. Objective: To compare the efficacy of Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser alone versus combination of Q-switched Nd:YAG and Ultrapulse CO₂ lasers for eyebrow tattoo removal after a single session. Patients and methods: After local anesthesia, the right eyebrow of 20 patients was treated with Ultrapulse CO₂ laser with the parameters of 4 J/cm² and 3.2 J/cm² for the first and the second passes. Both eyebrows were then treated with 1064-nm and 532-nm Q-switched Nd:YAG laser. The spot size and pulse duration were 3 mm and 5 nanoseconds for both wavelengths, and the fluence was 7 J/cm² for 1064 nm and 3 J/cm ² for 532 nm. Results: The side treated with combination of Q-switched Nd:YAG and CO₂ lasers improved 75–100% in 6 of 20 patients versus only 1 of 20 in the side treated with Q-switched Nd:YAG alone. Similarly, the right side in 13 of 20 patients showed more than 50% improvement with combination therapy versus the left side (the monotherapy side), where only 6 of 20 cases showed more than 50% improvement. The Mann–Whitney test was 2.85 for the right side and 1.95 for the left side (P value = 0.007). Conclusion: Using Ultra pulse CO₂ laser enhances the efficacy of Q-switched Nd:YAG laser in eyebrow tattoo removal.     

The efficacy of fractional carbon dioxide (CO2) laser combined with terbinafine hydrochloride 1% cream for the treatment of onychomycosis

Background: Although systemic and topical antifungal agents are widely used to treat onychomycosis, oral medications can cause adverse effects and the efficacy of topical agents is not satisfying. Currently, laser treatment has been studied for its efficacy in the treatment of onychomycosis. Our study was aimed to evaluate the efficacy of fractional carbon dioxide (CO₂) laser treatment combined with terbinafine cream for 6 months in the treatment of onychomycosis and to analyze the influencing factors. Methods: A total of 30 participants (124 nails) with clinical and mycological diagnosis of onychomycosis received fractional CO₂ laser treatment at 2-week interval combined with terbinafine cream once daily for 6 months. The clinical efficacy rate (CER) was assessed from the percentage of fully normal-appearing nails or nails with ≤5% abnormal appearance, and the mycological clearance rate (MCR) was assessed from the percentage of nails with negative fungal microscopy. Results: The CER was evaluated at 3 time points: at the end of treatment (58.9%), at 1 month after the last treatment (63.5%), and at 3 months after the last treatment (68.5%). The MCRs at 1 month and 3 months after the last treatment were 77.4 and 74.2%, respectively. The evaluation of influencing factors showed significantly higher CER (p < 0.05) in nails of participants with age <50 years, distal lateral subungual onychomycosis (DLSO), superficial white onychomycosis (SWO), nail thickness <2 mm, affected first-to-fourth finger/toenails, Trichophyton rubrum, and Trichophyton mentagrophytes. All participants experienced tolerable mild burning sensation during laser treatment, but there were no other adverse reactions reported. Conclusions: Fractional CO₂ laser treatment combined with terbinafine cream for 6 months was an effective and safe method for the treatment of onychomycosis. There were 5 factors that positively influenced the treatment outcome: age, clinical type of onychomycosis, nail thickness, involved nail, and species of fungus.     

A systematic review of comparative studies of CO2 and erbium:YAG lasers in resurfacing facial rhytides (wrinkles)

Background: Laser resurfacing is used to minimize wrinkles, solar scars and sequelae of acne. Objective: Purpose of the systematic review was to compare resurfacing outcomes of CO₂ laser and erbium: yttrium aluminium garnet (erb:YAG) laser therapies. Materials and methods: Medline, Cochrane Library, EMBASE and Google Scholar databases were searched until 9 April 2015 using the following terms: laser, carbon dioxide/CO₂, facial wrinkles, rhytides and erbium-doped yttrium aluminium garnet/erbium:YAG/Er:YAG. Two-armed controlled split faced studies that compared CO₂ laser and erbium:YAG laser in patients with mild-to-moderate facial wrinkles or rhytides were included. Results: The pooled data in this study and findings of other studies support the greater efficacy with the CO₂ laser in improving facial wrinkles, but the erb:YAG laser was associated with a better complication profile compared with the CO₂ laser. Except one case of hypopigmentation, other complications (i.e., erythema, hyperpigmentation and crusting) and their rates were reported by studies examining both lasers. Conclusion: In general, the CO₂ laser appeared to be more efficacious then the erb:YAG laser in treating facial wrinkles. Both lasers treatments were well tolerated.     

Inflammatory linear verrucous epidermal nevus: why a combined laser therapy

Abstract

Inflammatory linear verrucous epidermal nevus (ILVEN) is a benign cutaneous hamartoma, and more precisely an uncommon variant of the verrucous epidermal nevus. In our case report we describe an ILVEN female patient, resistant to previous treatments but responsive to a combined laser therapy, 10,600-nm CO₂ laser and Fractional CO₂ laser, with good and longstanding results. A complete resolution of the lesion was observed at the 9-month follow-up. The application of lasers has been reported in literature over recent years for resolving ILVEN lesions. Based on our clinical experience, 10,600-nm CO₂ pulsed laser therapy seems to be the best treatment and Fractional CO₂ laser treatment can be regarded as a very promising technique to combine with CO₂ laser for reducing pigment modifications and endowing a more youthful appearance to the treated areas.     

Treatment of periorbital syringoma by the pinhole method using a carbon dioxide laser in 29 Asian patients

Background: Pinhole method has been used to treat various types of scars and dermal tumors by making multiple small holes in target tissues of the deep dermis using an ablative 10,600-nm carbon dioxide (CO₂) laser. Objectives: We prospectively investigated the efficacy and safety of using a CO₂ laser to treat periorbital syringomas via the pinhole method. Methods: A total of 29 patients with periorbital syringomas were treated with two sessions of CO₂ laser treatment using the pinhole method at two-month intervals. Laser fluences were delivered under the following settings: pulse duration of 200 μs, frequency of 50 Hz, on time of 0.04, and an off time of 0.01. Results: Among the 29 patients, 13 patients (44.8%) presented with small discrete papular syringomas, 10 (34.5%) had plaque-type lesions, and six (20.7%) had mixed lesions. Evaluation of the clinical results at 2 months after the second treatment session revealed marked clinical improvement (51–75%) in 10 of the 29 patients (34.5%), moderate clinical improvement (26–50%) in eight (27.6%), near-total improvement (≥ 75%) in seven (24.1%), and minimal improvement (0–25%) in four patients (13.8%). Conclusions: Our observations indicated that application of the pinhole method using a CO₂ laser exerts positive therapeutic effects in Asian patients with periorbital syringomas.     

The effects of fractional microablative CO2 laser therapy on sexual function in postmenopausal women and women with a history of breast cancer treated with endocrine therapy

Purpose: To examine the outcomes of sexual function in postmenopausal women and women with a history of breast cancer treated with endocrine therapy who were experiencing the symptoms of GSM for which they were treated with fractional microablative CO₂ laser. Materials and Methods: From July 2015 to October 2016, a retrospective chart review of women who underwent fractional microablative CO₂ laser therapy (MonaLisa Touch, DEKA) for GSM was conducted. Several validated questionnaires were used to assess changes in symptoms and sexual function including the Female Sexual Function Index (FSFI), the Wong-Baker Faces Scale (WBFS), and the Female Sexual Distress Scale—Revised (FSDSR). Comparisons of mean symptom scores were described at baseline and six weeks after each treatment. Results: There was a statistically significant improvement in every domain of FSFI, WBFS, and FSDS-R when comparing baseline symptom scores to after treatment three symptom scores for all patients. The secondary outcome was to evaluate the differences, if any, in outcomes of sexual function between postmenopausal women and women with a history of breast cancer treated with endocrine therapy. Both groups had statistically significant improvements in many domains studied. Conclusions: Fractional microablative CO₂ laser therapy (MonaLisa Touch, DEKA) is an effective modality in treating the symptoms of GSM in postmenopausal women and women with a history of breast cancer treated with endocrine therapy.