Vaginal laser vs vaginal estrogen: what does the evidence show?
For genitourinary syndrome of menopause (GSM), low-dose vaginal estrogen has strong guideline support, while current evidence does not support energy-based treatments like the vaginal laser. Estrogen is the better-supported choice.
What vaginal laser is
Vaginal laser is an energy-based device, not a hormone. The category includes the fractional CO2 laser (marketed under brand names such as MonaLisa Touch), the Er:YAG laser, and radiofrequency devices applied to vaginal tissue. They are promoted for vaginal rejuvenation and for the dryness, irritation, and painful sex of GSM, once called vaginal atrophy. The FDA has not approved any energy-based device for vaginal rejuvenation or sexual dysfunction, and in 2018 it issued a safety communication warning against using these devices for vaginal cosmetic purposes, stating that their effectiveness and safety have not been established.
What the guidelines say about laser
The 2025 AUA/SUFU/AUGS guideline on GSM is direct. It concludes that the evidence does not support the use of CO2 laser, Er:YAG laser, or radiofrequency for GSM-related vaginal dryness, discomfort or irritation, dysuria, quality of life, change in bothersome symptoms, treatment satisfaction, or painful sex. That statement carries a Moderate Recommendation at Evidence Level Grade C.
The 2020 North American Menopause Society position statement reaches a similar conclusion. It finds there are insufficient placebo-controlled trials of energy-based therapies, including laser, to draw conclusions on efficacy and safety or to make treatment recommendations.
How vaginal estrogen compares
The same 2025 guideline gives low-dose vaginal estrogen a Strong Recommendation, Grade C, for improving the vaginal discomfort, dryness, and painful sex of GSM. For preventing recurrent urinary tract infections it carries a Moderate Recommendation at Grade B, the highest evidence grade anywhere in that guideline.
Vaginal estrogen also acts locally, with minimal systemic absorption, so at low doses it needs no added progestogen and no routine endometrial surveillance solely because of its use.
When laser has been tested head to head against vaginal estrogen cream, no treatment came out ahead. Several trials found no treatment superior to another, and they were not designed to prove one was no worse than the other. The 2025 guideline’s own analysis found little to no difference between CO2 laser and vaginal estrogen cream. That is not evidence that laser works. It reflects short trials with low-certainty evidence, not a demonstrated benefit.
The combination question
The AUGS energy-device consensus agreed there may be a benefit to combining vaginal energy devices with a medical therapy such as estrogen for menopausal painful sex, dryness, and vulvar pain, while noting that the optimal regimen and sequence are not known. The same group did not reach consensus that CO2 laser combined with vaginal estrogen improves outcomes over either treatment alone. So combination is a plausible research question, not an established benefit, and it does not show that laser on its own works.
Cost and safety
Long-term data on energy devices are thin. Both the menopause society and the energy-device consensus conclude that larger, sham-controlled trials are needed before these devices can be recommended for routine use. Reported harms from laser include discomfort during treatment, vaginal scarring, vaginal lacerations when intercourse resumes, and persistent or worsening painful sex. There are also few comparative cost-efficacy data for these devices against available medical and surgical therapies.
Laser is sometimes offered to women who cannot use estrogen. The energy-device consensus lists inability to use vaginal estrogen as a possible pretreatment criterion for these devices, but that positioning does not establish that laser is effective.
Bottom line
Start with vaginal estrogen, or a nonhormonal alternative if estrogen is not appropriate. Vaginal laser is not a proven substitute for it. For women with a personal history of breast cancer, nonhormonal options come first, and low-dose vaginal estrogen may be recommended after multidisciplinary shared decision-making.
References
- Kaufman MR, Ackerman AL, Amin KA, et al. Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline. American Urological Association. 2025.
- Faubion SS, Kingsberg SA, Clark AL, et al. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020. doi:10.1097/GME.0000000000001609
- Alshiek J, Garcia B, Minassian V, et al. Clinical Consensus Statement: Vaginal Energy-Based Devices. Urogynecology. 2022. doi:10.1097/SPV.0000000000001241
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