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PubMed This is a summary of 20 peer-reviewed journal articles Updated
Gynecology · Genitourinary Syndrome of Menopause

Special Considerations and Alternative Therapies

At a Glance

Genitourinary Syndrome of Menopause (GSM) in cancer survivors requires careful coordination between gynecologists and oncologists. While non-hormonal options are first-line, laser therapies offer an alternative but lack long-term safety data and carry FDA warnings for potential complications.

Managing Genitourinary Syndrome of Menopause (GSM) can become more complex if you have a history of certain health conditions or if you are looking for non-hormonal alternatives. For these situations, the focus shifts to finding a balance between effective symptom relief and your overall long-term safety [1].

GSM and Cancer Survivorship

For survivors of breast or gynecological cancers, the management of GSM requires a highly individualized, multidisciplinary approach involving your gynecologist and your oncologist [1][2].

  • Non-Hormonal First: Guidelines generally recommend starting with non-hormonal moisturizers and lubricants as the first step for cancer survivors [3][4].
  • Revisiting Local Hormones: If non-hormonal options do not provide enough relief, recent evidence has brought more clarity to the use of local (vaginal) estrogen. Large studies have shown no increased risk of breast cancer recurrence within five years for survivors who use low-dose vaginal estrogen [5][6].
  • The Oncology Consultation: Decisions about using local hormones (estrogen or DHEA) are always made in consultation with your oncology team [7][5]. The type of cancer medication you are on matters significantly. For example, oncologists are often much more cautious about prescribing even low-dose local estrogen to patients taking Aromatase Inhibitors (AIs) (which block all estrogen production) compared to those taking Tamoxifen (which has a different mechanism) [7][8].

Energy-Based Devices (Lasers)

In recent years, energy-based devices like fractional CO2 lasers and Erbium (Er:YAG) lasers have been marketed as non-hormonal treatments for GSM [9].

  • How They Work: These devices deliver controlled energy to the vaginal tissue to create “micro-injuries.” This is intended to trigger the body’s natural healing response, promoting new collagen growth and increasing blood flow to the area [9].
  • The Evidence: Short-term studies (lasting a few months) have shown that laser therapy can improve dryness and pain during intercourse at a level similar to vaginal estrogen [10][11]. However, we currently lack large-scale, long-term data (lasting years) to confirm how well these results last or if there are long-term risks [10][12].

Important Safety and Regulatory Warnings

It is essential to understand the current medical consensus on these devices:

  • FDA Warning: In 2018, the FDA issued a safety communication cautioning against “vaginal rejuvenation” procedures [13]. The warning highlighted a lack of evidence for the safety and effectiveness of these devices in treating menopausal symptoms and warned of potential risks like vaginal scarring, burning, and chronic pain [14][15].
  • Professional Consensus: Major medical societies, such as NAMS and ACOG, currently view laser therapy as an “alternative” or “investigative” treatment rather than a standard first-line therapy [16][17]. They emphasize that while lasers may be a promising option for those who cannot use hormones, patients must be informed that high-quality, long-term research is still needed [18][19].

While these newer therapies offer hope for many, they are best viewed as a secondary option to be discussed when standard treatments have not provided the relief you need [20][17].

Common questions in this guide

Can breast cancer survivors use vaginal estrogen for GSM?
Cancer survivors should generally start with non-hormonal moisturizers and lubricants. If these fail, low-dose vaginal estrogen may be an option, but this must always be decided in close consultation with your oncology team based on your specific cancer medications.
Does laser therapy work for atrophic vaginitis?
Laser therapy can provide short-term relief for vaginal dryness and pain by promoting new collagen growth. However, major medical societies consider it an alternative or investigative treatment because long-term safety and effectiveness data are still lacking.
Is vaginal laser treatment safe?
The FDA has issued warnings about using energy-based devices for vaginal treatments due to potential risks like vaginal scarring, burning, and chronic pain. It is important to discuss these risks with your healthcare provider before proceeding.
Can I use vaginal estrogen if I am taking an aromatase inhibitor?
Oncologists are usually much more cautious about prescribing even low-dose local estrogen to patients on aromatase inhibitors compared to those on Tamoxifen. This is because aromatase inhibitors work by blocking all estrogen production in the body.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.As a cancer survivor, how do we balance my need for symptom relief with the specific risks of my cancer history?
  2. 2.Is my oncology team comfortable with me using low-dose vaginal estrogen or DHEA if non-hormonal options fail?
  3. 3.If we consider laser therapy, do you have specific experience using it for GSM in patients with my medical history?
  4. 4.What are the potential complications of laser therapy, such as scarring or persistent pain, and how common are they in your practice?
  5. 5.Since lasers are often considered 'investigative,' are there any ongoing clinical trials I should be aware of?

Questions For You

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References

References (20)
  1. 1

    Treating Genitourinary Syndrome of Menopause in Postmenopausal Women with a History of Breast Cancer.

    Ferguson D, Pederson H, Kling JM

    Drugs & aging 2026; (43(3)):211-221 doi:10.1007/s40266-026-01287-9.

    PMID: 41758440
  2. 2

    Update on Genitourinary Syndrome of Menopause: A Scoping Review of a Tailored Treatment-Based Approach.

    Cuccu I, Golia D'Augè T, Firulli I, et al.

    Life (Basel, Switzerland) 2024; (14(11)) doi:10.3390/life14111504.

    PMID: 39598302
  3. 3

    What should guide our patient management of vulvovaginal atrophy?

    Shapiro M

    Climacteric : the journal of the International Menopause Society 2019; (22(1)):38-43 doi:10.1080/13697137.2018.1527306.

    PMID: 30452294
  4. 4

    Physical methods for the treatment of genitourinary syndrome of menopause: A systematic review.

    Sarmento ACA, Lírio JF, Medeiros KS, et al.

    International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2021; (153(2)):200-219 doi:10.1002/ijgo.13561.

    PMID: 33354773
  5. 5

    Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer.

    Agrawal P, Singh SM, Able C, et al.

    Obstetrics and gynecology 2023; (142(3)):660-668 doi:10.1097/AOG.0000000000005294.

    PMID: 37535961
  6. 6

    Vaginal estrogen use for genitourinary symptoms in women with a history of uterine, cervical, or ovarian carcinoma.

    Chambers LM, Herrmann A, Michener CM, et al.

    International journal of gynecological cancer : official journal of the International Gynecological Cancer Society 2020; (30(4)):515-524 doi:10.1136/ijgc-2019-001034.

    PMID: 32075898
  7. 7

    Genitourinary syndrome of menopause in women with cancer - a narrative review.

    Ryan HM, Brennan DJ

    Maturitas 2026; (211()):109004 doi:10.1016/j.maturitas.2026.109004.

    PMID: 42224847
  8. 8

    WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history.

    Kingsberg SA, Larkin L, Krychman M, et al.

    Menopause (New York, N.Y.) 2019; (26(2)):124-131 doi:10.1097/GME.0000000000001194.

    PMID: 30130293
  9. 9

    Microablative and non-ablative laser and radiofrequency treatment of genitourinary syndrome of menopause: A randomised controlled trial with four different energies.

    Slongo H, Henriques DCP, Ongaratto APN, et al.

    Maturitas 2025; (202()):108737 doi:10.1016/j.maturitas.2025.108737.

    PMID: 41061454
  10. 10

    Efficacy of CO2 laser vs vaginal estrogen in perimenopausal women with genitourinary syndrome of menopause: systematic review and meta-analysis.

    Nasr AM, Saad MA, Mohamed AS, et al.

    The journal of sexual medicine 2025; (22(8)):1409-1421 doi:10.1093/jsxmed/qdaf153.

    PMID: 40622331
  11. 11

    Histological study to assess CO2 laser therapy for the treatment of vaginal atrophy.

    Antono AC, Kopkin R, Karram M, et al.

    European journal of obstetrics, gynecology, and reproductive biology 2026; (323()):115210 doi:10.1016/j.ejogrb.2026.115210.

    PMID: 42202723
  12. 12

    Efficacy and Safety of Energy-Based Device Therapy in Women Diagnosed with Vaginal Relaxation Syndrome: A Systematic Review and Meta-analysis.

    Chen H, Meng J, Li Q, et al.

    International urogynecology journal 2026; doi:10.1007/s00192-026-06700-w.

    PMID: 42274731
  13. 13

    Revitalizing research in genitourinary syndrome of menopause.

    Chang OH, Paraiso MFR

    American journal of obstetrics and gynecology 2019; (220(3)):246.e1-246.e4 doi:10.1016/j.ajog.2018.12.032.

    PMID: 30586548
  14. 14

    In response to the FDA warning about the use of photomedicine in gynecology.

    Escribano JJ, González-Isaza P, Tserotas K, et al.

    Lasers in medical science 2019; (34(7)):1509-1511 doi:10.1007/s10103-019-02744-1.

    PMID: 30830556
  15. 15

    Rethinking the techno vagina: a case series of patient complications following vaginal laser treatment for atrophy.

    Gordon C, Gonzales S, Krychman ML

    Menopause (New York, N.Y.) 2019; (26(4)):423-427 doi:10.1097/GME.0000000000001293.

    PMID: 30640806
  16. 16

    Vaginal Energy-Based Devices.

    Alshiek J, Garcia B, Minassian V, et al.

    Female pelvic medicine & reconstructive surgery 2020; (26(5)):287-298 doi:10.1097/SPV.0000000000000872.

    PMID: 32324684
  17. 17

    Efficacy and safety of carbon dioxide laser therapy compared with sham for genitourinary syndrome of menopause management: a meta-analysis of randomized clinical trials.

    Gunawan YW, Erlina Y

    Menopause (New York, N.Y.) 2023; (30(9)):980-987 doi:10.1097/GME.0000000000002220.

    PMID: 37490650
  18. 18

    Clinical Consensus Statement: Vaginal Energy-Based Devices.

    Alshiek J, Garcia B, Minassian V, et al.

    Urogynecology (Philadelphia, Pa.) 2022; (28(10)):633-648 doi:10.1097/SPV.0000000000001241.

    PMID: 36256959
  19. 19

    CO2 Laser versus Sham Control for the Management of Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

    Prodromidou A, Zacharakis D, Athanasiou S, et al.

    Journal of personalized medicine 2023; (13(12)) doi:10.3390/jpm13121694.

    PMID: 38138921
  20. 20

    Biostimulation with polynucleotide cream during adjuvant therapy for breast cancer.

    Lavitola G, Foreste V, Borrelli D, et al.

    European journal of obstetrics, gynecology, and reproductive biology 2025; (315()):114754 doi:10.1016/j.ejogrb.2025.114754.

    PMID: 41061414

This page provides information on alternative GSM treatments for educational purposes. Always consult your gynecologist and oncologist before starting new therapies, especially if you have a history of cancer.

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