Laser therapy tops the rankings for genitourinary symptoms of menopause

Genitourinary syndrome of menopause, the cluster of vaginal dryness, painful sex and urinary symptoms driven by menopause, seriously affects quality of life, including for women treated for breast cancer. Several treatments exist, from moisturisers and vaginal oestrogen to laser therapy, ospemifene and DHEA, but which is safest and most effective has remained controversial. Because few trials compare these options directly against each other, the authors turned to a Bayesian network meta-analysis, a method that combines direct and indirect evidence to rank multiple treatments at once. The goal was a practical one: identify the safest and most effective option across the syndrome's many symptoms.

Working from a protocol pre-registered on PROSPERO, the authors searched PubMed, Embase, Scopus, the Cochrane Library, Web of Science, ScienceDirect, clinicaltrials.gov and OVID for randomised controlled trials in women with signs or symptoms of genitourinary syndrome of menopause, up to March 2020. Twenty-nine RCTs covering 8311 patients and five different treatment regimens were included. Data were analysed using Bayesian network methods, supplemented by standard pairwise comparisons, network sub-analyses, regression analysis, and subgroup and sensitivity analyses. Effects were expressed as odds ratios or mean differences with 95% confidence intervals.

Laser therapy showed excellent effects on vaginal dryness, dyspareunia, urinary incontinence, the proportion of parabasal cells, vaginal pH and the vaginal health index. Vaginal oestrogen also improved these outcomes significantly, though its effect ranked below laser therapy. Both approaches carried relatively low risks of adverse events. Ospemifene outperformed laser and vaginal oestrogen for sexual function, as did DHEA, but ospemifene came with a high risk of adverse events and endometrial hyperplasia. Moisturisers and lubricants were effective for dyspareunia, parabasal cell proportion and vaginal pH. Regression analysis found that age was an essential factor shaping the treatment effect on vaginal dryness and pH.

This analysis brings some order to a genuinely contested area, where guidance has differed on how laser therapy, local hormones and oral options compare. Its ranking, laser first, vaginal oestrogen second for most outcomes, comes from indirect Bayesian comparisons rather than large head-to-head trials, so it should be read as the current best synthesis rather than a final verdict. The strong relationship between age and treatment effect is an important lead for future work, suggesting the best option may differ by life stage. Longer-term safety, especially for laser therapy and for higher-risk drugs like ospemifene, remains an open question.

If menopause-related dryness, discomfort during sex or urinary symptoms are part of your life, the useful message is that several evidence-backed options exist and they have different strengths: laser therapy and vaginal oestrogen ranked best for most physical symptoms with relatively low adverse-event risk, while ospemifene and DHEA stood out for sexual function but ospemifene brought meaningfully more risk. Age appears to influence how well treatments work, which is a reason to expect the right choice to be individual. This is information to bring to a conversation with a clinician, not a treatment ranking to act on alone.