Introduction
Vaginal rejuvenation is a topic that has been discussed with increasing frequency recently not only by doctors, but also by cosmetologists. It is gaining clinical significance among women of all ages, but is particularly relevant for those with various hormonal disorders (peri-menopausal and postmenopausal period), complications after childbirth or simply with changes in the female body occurring with age (vaginal atrophy) [1, 2]. In recent years, gynaecology and modern aesthetic medicine have offered a range of different treatments aimed at restoring functional comfort and improving a woman’s quality of life. The most widely employed therapeutic modalities include laser vaginal revitalisation and radiofrequency therapy but the use of injectable tissue stimulator is also becoming increasingly popular, while nanoultrasound and bio peeling, platelet-rich plasma (PRP) injections are additionally used [3, 4]. All these treatments have their clinical merits and limitations. Thanks to their regenerative and hydrating properties, they significantly improve tissue elasticity, reduce vaginal dryness and thus restore coital comfort. In this article we will critically examine these techniques, their advantages and disadvantages and the effects they provide [5–7].
Causes of disorders
Premenopausal
Vaginal dryness is a common condition affecting women of all ages. It can be a symptom of various disorders and diseases and is particularly prevalent during the menopausal transition. According to a study conducted by Tarabini et al. [7], approximately 20% of premenopausal women report experiencing vaginal dryness, and this prevalence doubles after menopause. This condition is associated with a decline in sexual quality of life and may lead to discomfort or even pain during sexual intercourse (dyspareunia) [7, 8].
Menopausal and postmenopausal
Vaginal dryness is a condition caused by the hypo- estrogenism of vaginal tissues. Studies have demonstrated the presence of oestrogen receptor α and β in these tissues, which are influenced by oestrogen. It is also known that β receptors are downregulated following the onset of menopause. The reduced levels of oestrogen result in a decrease in the number of vaginal epithelial cells, thinning of the vaginal wall, and loss of its elasticity. The mucosa becomes thinner, and vaginal secretions are significantly reduced. These changes lead to symptoms such as vaginal pruritus, burning, chronic and distressing dryness, discomfort during sexual intercourse, and even dyspareunia. Additionally, reduced oestrogen levels decrease fibroblast activity in the extracellular matrix, impairing collagen production and further diminishing tissue elasticity [9–11].
Vaginal atrophy affects approximately 50% of postmenopausal patients, although it can also result from surgical or pharmacological ovarian insufficiency. One of its primary symptoms is vaginal dryness. Other symptoms include pruritus, vaginal irritation, and pain during sexual intercourse. This condition is primarily associated with reduced estradiol levels in the female body. Approximately 79% of menopausal women experience vaginal dryness, with nearly half describing it as moderate to severe in intensity [9, 12–14].
Women during oncological treatment for breast cancer are also at risk of adverse effects, including vaginal dryness. Treatments for cancer, such as tamoxifen and aromatase inhibitors, significantly impact oestrogen levels, often leading to hypoestrogenism. As a result, early onset of menopause may occur. It is estimated that approximately 70% of breast cancer survivors experience genitourinary syndrome of menopause and report related symptoms, including vaginal dryness and dyspareunia [15].
Radiotherapy is a component of treatment for endometrial and cervical cancer. Although research confirms its efficacy in cancer treatment, it can cause vaginal toxicity. Patients undergoing radiotherapy often report symptoms such as vaginal dryness and itching. It is known that the radiation dose affects the severity of vaginal toxicity, and 98% of patients consider it an acceptable side effect given the treatment benefits [16].
Hormonal disorders
Thyroid dysfunction has been associated with reduced libido and vaginal dryness in women, primarily due to altered levels of thyroid hormones. Premenopausal women diagnosed with hypothyroidism, Hashimoto’s thyroiditis, or nodular goitre were found to report vaginal dryness twice as often as their healthy counterparts. However, among menopausal and postmenopausal women, the prevalence of vaginal dryness did not differ significantly between those with and without thyroid disorders [17].
Another group at an increased risk of vaginal dryness includes women with polycystic ovary syndrome (PCOS). This condition is characterised by disrupted oestrogen cycling and an altered oestrogen-to-androgen ratio. Moreover, certain treatments for PCOS may increase circulating free androgens, further contributing to hormonal imbalance. These factors can impair the structure of the vaginal epithelium, including the function of exocrine glands. Studies have shown that a significant proportion of women with PCOS (p = 0.023) experience impaired vaginal lubrication, negatively affecting their sexual quality of life [18, 19].
Additionally, women with type 2 diabetes frequently present with sexual dysfunction, particularly in relation to arousal and vaginal lubrication. In one study using the female sexual function index, approximately 75% of premenopausal women with diabetes reported insufficient vaginal lubrication, which contributed to an overall decline in sexual satisfaction [20].
Side effects of pharmacological treatment
The use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) has been associated with a decline in female sexual satisfaction. A substantial proportion of women taking these medications report difficulties with sexual arousal. This effect is largely attributed to serotonergic modulation of central nervous system pathways involved in sexual response. Pharmacologically induced inhibition of arousal frequently results in inadequate vaginal lubrication, contributing to discomfort during intercourse and a reduction in sexual desire [21].
Similarly, oral hormonal contraceptives may increase the risk of vaginal dryness. Numerous studies have documented a negative impact of oral contraceptive use on various aspects of female sexual function. One proposed mechanism involves a reduction in bioavailable oestrogen within vaginal tissues, leading to epithelial thinning and a decline in the activity of secretory glands. Additionally, certain progestin-containing formulations may disrupt the vaginal microbiota by lowering levels of Lactobacillus species, which are crucial for maintaining vaginal moisture and pH balance. Women using these contraceptives frequently report orgasmic difficulties, decreased libido, and insufficient lubrication during sexual activity [22, 23].
Infections
Bacterial vaginosis and vaginal candidiasis are common infections affecting women. During these infections, there is an increase in pro-inflammatory cytokine levels within the vaginal epithelium, which triggers an inflammatory response and leads to impaired secretion from exocrine glands. This condition often results in discomfort and vaginal dryness. The infection also causes an elevation in vaginal pH and a reduction in the abundance of Lactobacillus species, particularly Lactobacillus crispatus, within the vaginal microbiota. Such changes contribute to decreased vaginal lubrication. Moreover, episodes of infection frequently predispose to recurrent or chronic vaginal inflammation, which further compromises adequate vaginal moisture [24, 25].
Smoking
Research indicates that women who smoke more than nine cigarettes per day experience a reduction in active oestrogen metabolites, which adversely affects the function of the exocrine glands within the vagina. Moreover, tobacco use compromises blood circulation in the tissues of the female reproductive system, resulting in reduced plasma transudation and diminished vaginal lubrication. In addition, smoking has been found to disrupt the vaginal microbiome by lowering the abundance of Lactobacillus species, thereby promoting vaginal dryness and inadequate hydration [26, 27].
Diseases associated with vaginal dryness
Primary Sjögren’s syndrome (pSS) is an autoimmune inflammatory disorder characterised by the immune-mediated destruction of exocrine glands, resulting in dryness of the oral cavity, eyes, and vagina. The disease process involves glandular tissue damage and induces inflammation around vaginal tissue, which impairs its regenerative capacity. Additionally, microcirculatory disturbances and reduced blood flow within the vaginal tissue, alongside impaired plasma filtration, contribute to diminished vaginal lubrication. These pathological changes significantly affect sexual satisfaction in women suffering from pSS. The majority of patients diagnosed with pSS report symptoms of vaginal dryness and dyspareunia [28, 29].
Infection with the human T-lymphotropic virus type 1 (HTLV-1) is also implicated in decreased vaginal lubrication. During infection, pro-inflammatory cytokines such as IL-2, IL-4, IL-10, IL-17, and TNF-α are secreted into the cervicovaginal fluid. The presence of microcirculatory impairment and altered plasma filtration in the vaginal walls further exacerbates vaginal dryness. Moreover, in the neurological manifestation of HTLV-1 infection, known as HTLV-1-associated myelopathy/tropical spastic paraparesis, impaired sexual arousal response contributes to an additional reduction in vaginal moisture [30].
Treatment modalities for vaginal mucosal atrophy
Oestrogens, by acting on oestrogen receptors (ER) located in the vagina, vulva, and lower urinary tract, improve epithelial nutrition, vascularisation, and overall epithelial condition. They increase hydration and reduce vaginal dryness and dyspareunia [31, 32].
Selective oestrogen receptor modulators, such as tamoxifen and ospemifene, are classified as non-hormonal therapeutic options for vulvovaginal atrophy (VVA), thereby providing an alternative to oestrogen-based treatment. In studies evaluating intravaginal tamoxifen, 68.6% of women reported complete resolution or only mild severity of their most bothersome VVA symptoms at the end of treatment, compared with 9.1% in the placebo group. Treatment was also associated with improvements in the clinical appearance of the vaginal mucosa and a reduction in vaginal pH. Similarly, in a study evaluating systemic ospemifene, significant alleviation of VVA symptoms was observed, together with favourable effects on bone metabolism [33, 34].
Hyaluronic acid (HA), administered locally as injections into the mucosa of the vaginal vestibule and/or the vaginal wall, improves tissue hydration and restores tissue tension in atrophic vulvar vestibular tissues. This effect is related to HA’s ability to bind water molecules and to promote increased synthesis of collagen and elastin [35–37].
Radiofrequency is a therapeutic modality that uses high-frequency electric current. As the current passes through tissues, it induces controlled, microscopic, focal thermal injuries. Areas of intact tissue remain between the microlesions, which enables rapid tissue regeneration. This method leads to improved vaginal hydration, increased epithelial elasticity, normalisation of vaginal pH, increased volume of vaginal secretions and epithelial maturation, as well as improvement in sexual function, coital comfort, and vulvar aesthetics [38–40].
CO2 laser therapy (microablative fractional laser) delivers energy that is absorbed by water contained within mucosal cells, resulting in focal and fractional microinjuries. This initiates a controlled healing process that induces neocollagenesis, remodelling of existing collagen fibres, neovascularisation, and improvement in tissue perfusion, elasticity, and hydration [41, 42].
In the treatment of vaginal atrophy, microfocused ultrasound using low energy and frequency (approximately 4–10 MHz) is applied to induce a controlled thermal effect. Ultrasound energy is focused at a specific depth corresponding to the full thickness of the vaginal wall (1.5–3 mm). Energy delivery results in microscopic focal thermal coagulation, leading to contraction of degraded collagen fibres, stimulation of neocollagenesis, collagen and elastin remodelling, improved vascularisation, and secondary thickening of the vaginal epithelium. The therapeutic effect has been shown to persist for approximately 3–6 months [43, 44].
High-intensity focused ultrasound (HIFU) is a technique that uses mechanical waves to increase the temperature of intracellular water, resulting in cavitation, apoptosis, and coagulative microdamage. These changes lead to increased vascularisation, neocollagenesis, epithelial thickening, increased glycogen content, and an increase in the expression of ER [45, 46].
Moisturising agents act superficially; they are not absorbed through the mucosa and do not affect trophic processes within the tissues. The use of lubricants provides immediate relief; however, the effects are short-lived [47, 48].
Platelet-rich plasma exerts a regenerative effect on the vaginal mucosa through the release of growth factors and cytokines from platelets. This results in stimulation of angiogenesis and activation of tissue repair processes, leading to improvement in the condition and function of the vaginal mucosa. The preparation, obtained from the patient’s own blood, is administered as local injections into the vaginal wall, vaginal vestibule, or the subcutaneous tissue of the labia majora [49, 50].
Table 1 summarises the indications, advantages, and disadvantages of individual treatment methods for vaginal mucosal atrophy.
Table 1
Indications, advantages and disadvantages of treatment modalities for vaginal mucosal atrophy
| Method | Indications | Advantages | Disadvantages |
|---|---|---|---|
| Radiofrequency [38, 39] | Genitourinary syndrome of menopause (GSM), vulvovaginal atrophy, vaginal dryness, burning and pain, dyspareunia, reduced sexual quality of life, decreased tissue elasticity and tone, patients with contraindications to hormone therapy (e.g., oestrogen-dependent malignancies) or unwilling to use oestrogen therapy | Non-hormonal, minimally invasive treatment; efficacy comparable to oestrogen therapy; short recovery period; no significant adverse effects; good tolerability; rapid return to daily activities; painless or associated with minimal discomfort; simultaneous improvement of function and aesthetics | Outcome dependent on the operator experience and device type; need for multiple treatment sessions; non-permanent effect; cost of the procedure; limited number of long-term studies |
| CO2 laser [3] | Genitourinary syndrome of menopause; intolerance to pharmacological treatment; contraindications to oestrogen therapy; unwillingness to use oestrogen therapy; post-breast cancer treatment with aromatase inhibitors or when local hormone therapy is contraindicated | Non-hormonal method; suitable for oncological patients; no need for hospitalisation; short procedure time; rapid return to daily activities; very good tolerability; absence of serious adverse effects | Cost of the procedure; lack of standardised treatment parameters; outcome dependent on the operator experience; need for repeat treatments |
| Microfocused ultrasound [43] | Vaginal atrophy; genitourinary syndrome of menopause; contraindications or reluctance toward oestrogen therapy; post-oncological treatment; vaginal dryness, dyspareunia, burning, and reduced sexual quality of life; vaginal laxity | Non-invasive, non-hormonal method; precise action across the full thickness of the vaginal wall; short recovery period; rapid clinical effect (maximum at approximately 21 days); high safety profile; improvement in sexual function | Does not address the underlying cause of hypoestrogenism; cost of the procedure; outcome dependent on the operator experience; need for repeat treatments |
| High-intensity focused ultrasound [45, 46] | Genitourinary syndrome of menopause; stress urinary incontinence (SUI); vaginal laxity; reduction of GSM symptoms; improvement of sexual quality of life; enhancement of vaginal tissue tone and elasticity | No significant complications; minimal pain; long-lasting effect (at least 6–12 months) | Short duration of follow-up for treatment outcomes; lack of efficacy in severe cases of SUI |
| Hormone therapy [31, 32] | Vaginal dryness; dyspareunia; burning and pruritus; recurrent urinary tract infections; significant reduction in quality of life | Most commonly used method; high clinical efficacy; local oestrogen therapy associated with minimal systemic absorption and no need for concomitant progesterone | Contraindicated in women with oestrogen-dependent malignancies |
| Moisturisers and lubricants [47, 48] | Symptomatic treatment of vaginal dryness; dyspareunia; patients unable or unwilling to use oestrogen therapy | No systemic effects; rapid onset of action; good tolerability of products with physiological pH and osmolality | No effect on underlying pathophysiology; short duration of effect; some water-based lubricants may disrupt the vaginal environment |
| Hyaluronic acid [35, 36] | Moderate to severe vaginal mucosal atrophy; genitourinary syndrome of menopause; vaginal dryness; dyspareunia; pruritus and irritation; reduced quality of life and sexual function; postmenopausal patients; contraindications to oestrogen therapy; intolerance to hormonal treatment | High efficacy; improvement in sexual function; rapid onset of action; long-lasting effect; local, non-hormonal mechanism; low incidence of adverse effects; simple procedural technique | Risk of genitourinary infection; pain, oedema, and discomfort at the injection site; limited number of long-term studies; occasional local symptoms such as burning, pruritus, and vaginal bleeding |
| Platelet-rich plasma [49, 50] | Contraindications or intolerance to hormone therapy; moderate to severe symptoms of vaginal dryness; reduction of dryness, burning, irritation, and dyspareunia; improvement in quality of life and sexual function | Comparable to hyaluronic acid therapy | Limited number of clinical studies |
| Selective estrogen receptor modulators [33, 34] | Vulvovaginal atrophy | Effective relief of vulvovaginal atrophy symptoms (vaginal dryness, dyspareunia, irritation), reduced vaginal pH and improved vaginal mucosa, alternative for women who cannot use oestrogen therapy, ospemifene has also demonstrated beneficial effects on bone mineral density and bone turnover markers | Evidence is still limited for some SERM therapies |
Discussion
The analysis of the existing literature and clinical studies reveals that vaginal dryness is a highly prevalent and multifactorial condition affecting women across all life stages [9, 10 12, 14]. The highest incidence is observed in menopausal and postmenopausal populations, where up to 79% report varying severity of symptoms [9, 11–13]. However, significant prevalence is also noted in premenopausal women with endocrine disorders such as hypothyroidism, PCOS, and type 2 diabetes [10, 11]. In these groups, altered hormonal profiles, particularly decreased oestrogen or imbalanced androgen levels, correlate strongly with reduced vaginal lubrication and sexual discomfort [11, 13].
Pharmacological treatments – especially SSRIs, SNRIs, hormonal contraceptives, and cancer therapies – are associated with a marked decline in sexual satisfaction, arousal, and vaginal hydration [10, 13, 15]. These effects arise from systemic hormonal modulation and local suppression of exocrine gland activity [13, 15]. Women using such medications frequently experience thinning of the vaginal epithelium and disruption of the microbiota, further exacerbating vaginal dryness [9, 14].
Infectious and autoimmune conditions (e.g., bacterial vaginosis, candidiasis, pSS, HTLV-1 infection) were shown to initiate chronic inflammatory responses, resulting in decreased mucosal secretion and structural damage [9, 10 14]. These pathological states also compromise the vaginal immune environment, reducing Lactobacillus species and increasing pH, contributing to symptom persistence and recurrence [9, 12].
Lifestyle factors such as smoking have a demonstrable impact on vaginal health by reducing oestrogen metabolism and impairing local vascular perfusion, resulting in lower plasma transudation and lubrication [9, 11].
In terms of treatment outcomes, procedure-based interventions demonstrated modality-dependent efficacy. Energy-based treatments, including radiofrequency, CO2 laser therapy, microfocused ultrasound, and HIFU, were associated with significant improvement in vaginal hydration, elasticity, epithelial thickness, and reduction of dyspareunia. These effects were attributed to collagen contraction, neocollagenesis, improved vascularisation, and epithelial remodelling, with clinical benefits lasting from several months to over one year depending on treatment protocol and device parameters [48, 50].
Injectable therapies, particularly HA and platelet-rich plasma, demonstrated regenerative and hydrating effects through water-binding capacity, stimulation of fibroblast activity, angiogenesis, and extracellular matrix remodelling. Hyaluronic acid injections were associated with rapid symptom relief and sustained improvement in sexual function, while PRP showed comparable regenerative potential, though supported by a more limited number of clinical studies [35, 36].
Hormonal therapies (systemic and local) remain effective, especially in hypoestrogenic women, though contraindicated in certain oncological populations [13, 16]. Topical moisturisers and lubricants offer accessible, low-cost symptom management, particularly for those unable or unwilling to pursue procedural treatments. Local moisturising preparations are effective only transiently during active application [10, 14, 16].
Overall, treatment efficacy varied according to the underlying aetiology, hormonal status, symptom severity, and comorbidities. Multimodal and individualised treatment strategies, including combination or sequential use of procedural and pharmacological therapies, were associated with the most favourable clinical outcomes and patient-reported satisfaction [13, 16, 35].
Conclusions
Vaginal dryness and atrophy are common, multifactorial conditions that require an individualised treatment approach based on the underlying aetiology and hormonal status [1, 2, 9 12]. From a medical perspective, local oestrogen therapy remains the most effective, safe, and cost-effective option for hypoestrogenic patients without contraindications [4, 13, 31, 32]. From an aesthetic and cosmetological standpoint, non-hormonal energy-based therapies – particularly radiofrequency and laser treatments – represent the most effective alternatives, offering high safety and patient satisfaction [38, 42, 48, 50].
