Vicky

Just going to wait a few seconds for everyone to join.

Okay, good evening, everyone. Welcome to our webinar on MonaLisa Touch® treatment for vaginal dryness. My name is Vicky, and I'm hosting this session. I'm joined by our presenter, Consultant Gynaecologist, Mr Rowan Connell. The presentation will be followed by a question-and-answer session. So if you'd like to ask Rowan a question during or after the presentation, please do so by using the Q&A icon, which is at the bottom of your screen. This can be done with or without giving your name, and please note that this session is being recorded. If you do want to provide your name. If you'd like to book a consultation with us, we'll provide contact details at the end of the session. I'll now hand over to Mr Rowan Connell, and you'll hear from me again shortly.

Mr Rowan Connell

Thank you, Vicky, and welcome to everybody, and I'm delighted that I've been asked to give another talk on the Mona Lisa and more women than ever are now on this webinar, which is great, and also more health professionals than ever, and hopefully, that means that the information about MonaLisa Touch® is getting out there, but also that we're talking about the general atrophy and the Mona Lisa itself. From my point of view, I'm a general Gynaecologist, and I've been a Consultant since 2003, and I started my career more as a general gynaecologist, looking at fibroids and heavy periods with keyhole surgery, and slowly that morphed into a urogynaecologist, where I deal with incontinence and prolapse and pelvic floor reconstruction, and of course, that then morphed a little bit more into menopausal symptoms, because a lot of the symptoms I deal with are in the perimenopause and the menopausal woman and through Stefano Salvatore, who's a colleague of mine that I worked with as a junior doctor who is a Consultant in Milan who developed the Mona Lisa. I've morphed into doing a little bit of that as well. Thank you. Next slide. Vicky.

So there've been a lot of questions that we've tried to amalgamate into this talk, and obviously, if there are extra questions, please feel free, as Vicky said, to ask those at the end. But really we want to go through. Who is the MonaLisa Touch® for, and what is it used to treat? We'll talk about the MonaLisa Touch® treatment itself because some people are quite nervous about what it actually entails. what to expect from the treatment and what symptoms. We hope to improve the risks and the recovery, and then we'll talk, as you'd expect, about our gynae service at Benenden Hospital and what we can offer from the four Consultants that work at Benenden, and then the question and answer session at the end, which Vicky will host, and thank you for some of the questions that we've already had in the next one, please, Vicky.

So what we started off? We'll start off with just talking about who the Mona Lisa is for, and essentially it's a low-power laser treatment in the vagina. It works by thickening up the skin inside the vagina. So therefore it's very good for vaginal dryness, for whatever reason, and vaginal discomfort, and a lot of ladies will have discomfort as they get older, as the skin thins in the perimenopause and the menopause. I'll talk about what it's not used for later on and this is one of those conditions a little bit like, I suppose, male impotence, where it's a very unspoken disease. Men don't talk about impotence, and women of old wouldn't be speaking about the soreness in the vagina and inability to have intercourse, etc. It tends. We tend to see women who are in that perimenopause and early menopausal stage, which is about to—and certainly when we were looking at it and developing it in Milan, we assumed it would be much more of the women. But we're seeing much more of the younger women. It's very much also we use it in younger women or any women, I suppose, but younger women who are having breast cancer treatment. Some of the breast cancers, as you know, are oestrogen positive, and therefore people are very nervous about having oestrogen treatments, and the oestrogen treatment can help with thin skin in the vagina. But women who've had breast cancer treatment, or who are undergoing breast cancer treatment, are very reluctant, understandably, to use it, and lots of the drugs that are also used to treat breast cancer are very anti-oestrogen-type tablets, and this has a really bad effect sometimes on the soreness and the thickness of the skin in the vagina and the Mona Lisa, because it's not hormonal, can really benefit those younger women who are on breast cancer treatment. Yes, thank you. So it's used for vaginal dryness. The sort of itchiness that you can get with that. It's a burning pain. Quite often some women will. When you go through the menopause, you lose a lot of the fat in the vagina, and therefore the vagina can feel quite lax, almost like a prolapse. We do use it for mild bladder weakness, and by that I mean people who perhaps would leak urine or have an urgency, an urge incontinence, and obviously, as we've talked about pain during intercourse and the general thinningness, the thinness of the skin and the vagina. It has been used and is used for lichen, sclerosis, and lichen. Sclerosis is a skin condition that we think is quite often because of an autoimmune condition. But again, it's because of thinness in the skin around the vagina. We don't sell it as a treatment of lichen sclerosis at Benenden, and we also don't sell it as a urine incontinence treatment. But almost every woman that we've seen with lichen sclerosis and urgent incontinence and stress incontinence has gotten better. So really, we're using it for laser vaginal rejuvenation. I've put in this term, genitourinary symptom of the menopause, and this was bandied around about four years ago. But I don't like this term. because it implies that only women in the menopause will have this issue, and, as we've said already, this does affect women who are younger and in their thirties and forties sometimes. Thank you, Vicky.

So the way it was developed was that Stefano Salvatore, who's a gynaecologist, was literally seeing a young woman who'd had very bad scarring after giving birth, and nothing that he could do seemed to make that scarring better, and in the Milan hospital where he was working, one of the dermatologists, that's a skin doctor, was using a very low-power laser to treat burn victims with burns on their faces, and he suggested that he try it on this one woman who'd got scarring from childbirth and the results were quite startling and quite marked that it softened that scarring, and so he started a process of research from looking at women with scarring in the vagina, thinness of the vagina, and atrophy, and through him we brought it to Benenden, the MonaLisa Touch®, and we've been using it at Benenden since. It's not the same as laser treatment in the vagina, where people are using that to tighten the vagina or to cause scarring, if that's the right word, to tighten the bladder up. If you've got stress incontinence where you leak when you cough, this is not a laser for doing that. This is merely a laser to thicken the skin in the vagina, and it uses a very low-power laser compared to these other lasers, which are much more high-power. May I have the next slide, please? Vicky? So in the research, this was looking at the first, women, but the numbers are very similar for the next, that we treated in, or Stefan is treated in Milan. But this is looking at the symptom. Improvement in women having Mona Lisa, and of course they're coming in with burning and itchiness in the vagina and dryness in the vagina and pain with intercourse, and what we found is there's a very, very good response with between 50% and 80% improvement in all of these symptoms. And, as I said, that feeling of laxity is almost like a prolapse in the vagina is also improved, and this is not necessarily because of the tightening factor that everybody thinks of. But it's the fact that you're plumping up the tissues in the vagina, and therefore it doesn't feel as lax inside the way that the hormones work. If you're using hormones in the vagina, is that it thickens the skin in the vagina but also increases the amount of fat in the vagina, and we think that the laser works in a very similar way in the vagina with that laxity? But the obvious things of pain with intercourse, the dryness, the itching, and the burning all improve, and what I say to ladies that come to see me is that everybody will improve. It's just that some improve more than others, and that's certainly shown through in our research. Thank you, Vicky.

So how does it work? Well, I think we can now say it's a proven procedure, although we used to say that the data was very limited, but more women have been treated between us and in Milan, and we're training more and more people in the UK and abroad in this treatment. So which is great news? The problem, of course, is that it's still only a private procedure, which is a shame, but it has been proven, and I think it's a good adjuvant to other treatments. I said it was a low-powered Co. laser, and just to give an idea of the power of it. If you've got a Watts light bulb, you can hold that light bulb in your hand, and the Co. laser that we use is about 2 watts. So it's of that sort of power and what it does is it stimulates the collagen and the fibrocytes in the skin to grow more quickly and to thicken up the skin. It changes the menopausal or older collagen into the younger type of collagen, and then the complicated things are the glycosaminoglycans and high hyaluronic acid production. I've left that in because if you think about it, a lot of skin products now have got collagen in them, and a lot of them have hyaluronic acid in them as well, and what that does is it makes the collagen and the skin feel younger, and that's exactly what the Mona Lisa is doing by stimulating the fibrocytes, which are a type of skin cell, into making this younger type of collagen and younger type of glycosaminoglycans. Thank you, Vicky.

So if you come to the hospital or any of the units around the country, obviously we want you to come to Benenden. It's very much an outpatient setting. It's a private environment where there's just, most of the time. I should say it's only the laser that's been used is being used in that clinic. The whole thing takes about five minutes to perform. Importantly, you have three sessions, which are about six weeks apart. The data shows we did lots of different sessions. Whether it was two or three or four. We tried four weeks apart, two weeks apart, six weeks apart, eight weeks apart, ten weeks apart. But on average, most women, the vast majority of women, are having three sessions, each of them about six weeks apart. Sometimes you'll have, assuming everybody improves, Sometimes you'll have a little bit of improvement after each session. Sometimes you'll have a lot of improvement after the first session and much less after the second and third. But it's still important. You have that second and third treatment, and sometimes there'll be very little after the first and second, and then more improvement after the third. It's very variable. We have a top-up session, and certainly in Milan when we started, because it's funded very much by the Vatican, and therefore much, much cheaper. We were finding that women wanted to come back a lot earlier. So we essentially have a cutoff in Milan where they can only come back in a year. The Italians don't tend to use or didn't tend to use very much in the way of hormones and HRT. At Benenden we started off where I started off with hormones in the vagina, so that's called VagiFem, or vagitus, or the cream, and we found that if you use that, if you're able to use the hormones in the vagina, if we use that at the same time as the laser treatments, and you persist in using it, we find that rather than coming back at a year. Most women are coming back at months, or sometimes even longer, and in Milan now they're giving the VagiFem as part of that treatment, and they're finding exactly the same effect that that annualised top-up session, which is one session, not, but that one session. They're now coming back at months, sometimes longer, with the use of the hormones. But obviously not all women can use the hormones. Thank you, Vicky.

I put a little photo of what the device is, and that's just sitting in the vagina and that thing on the right. The lumpy thing on the right is the womb, and it's next to the cervix, and just above it is the bladder, and the ring is on the outside of the vagina, and it shows how close the bladder is to the vagina. So obviously, if you're getting soreness and thinness in the skin of the vagina because you're losing the hormones, you're also getting thinning of the bladder, and this is why most of the women who have bladder problems when they have the MonaLisa Touch® treatments will also help to thicken up the bladder, and their bladder symptoms will also improve. The device itself, or the probe, is about the same size as your middle finger or thumb.

So, of course, a lot of women are having this because of soreness in the vagina and inability to have intercourse. So we can't have a big device. It's not like having a smear done. It's literally like having a thumb or a finger put in the vagina, so it is relatively comfortable. What I now do is treat the inside of the vagina, which is relatively, isn't very uncomfortable with the laser, but I also treat the outside as well, because if you have thinning in the vagina, you'll very often have thinning of the skin of the outside of the vagina as well. We treat that with a slightly different probe or different laser, but a different probe and that can be quite uncomfortable. So when you come for the treatment, you come to mine before the treatment starts, and we give you a local anaesthetic cream to put on the outside skin and that just numbs it to take the edge off. But the laser inside the vagina is very insensitive to the laser. Thank you, Vicky.

And what you do is it? It fires off little light beams, and essentially what you do is you put the probe in. You fire it, you twist it degrees, and you get this sort of pattern of heat treatment inside the vagina and the whole process, as I said, takes about a minute, and the aim is to try to stimulate through heat treatments, not by burning, but by heat treatment, the fibrocytes that we talked about before, and on the outside with the laser that we use for that or the hand device we use for that, you get a little pocket of about these little heat treatments, which you can sometimes see for a couple of minutes as little white dots on the skin, but they go away very, very quickly. Thank you, Vicky.

We were asked about, or I should say, about the side effects, and there are very few, because this is a very low-power laser, but we have had some ladies that had some bleeding after the first, or sometimes even after the second treatment. This isn't really an issue with the laser itself. but more that we're treating very, very thin, thin skin. It does cause a little bit of inflammation and therefore, if you have inflammation, and then you're walking afterwards, you can rub that skin, and you get some bleeding because of that, and if it causes a discomfort or inflammation. You can sometimes have a discharge that is a mixture of protein and sugar. So it's not usually a smelly, infectious type. Discharge, but just a discharge almost to protect the skin and it can be a little bit tender, and certainly, if you get that tenderness, it doesn't really last very long. But you've got the tube of local anaesthetic cream that you can use if you need to, and, of course, it is by causing the inflammation, and if you're walking in your normal activities, you can also feel a little bit swollen afterwards, and because it's treating the vagina next to the bladder, very occasionally you can get a feeling of cystitis or bladder pain, especially when you pass urine, because, of course, if we go back slides, please, Vicky.

Sorry to the one with the probe in that one there, of course, just above that metal probe. That's the bladder and the wee tube, or the urethra, and because you're treating the outside, it can sometimes cause a little bit of irritation to the opening of the wee tube, so that when you pass urine, it can sometimes sting a little bit. But again, very, very few people have any problems. If we go back to again, please, Vicky.

Thank you, and of course the biggest issue is because this is something that nobody's had before. Is that worry about the treatment? And usually people say, Gosh! That was very easy, and then the second and third times. They know exactly what to expect, and it makes it much easier. Next slide, please. After the Mona Lisa. This is a bit more important because you are getting that soreness or irritation in the vagina of a vagina. That's already a little bit irritated. So we don't recommend that you exercise, especially running or swimming, for a few days afterwards, and of course the reason for that is that when you run, you're potentially rubbing the vagina inside, and that's the same with swimming, and of course, most of the time when you swim, you do the breaststroke. So you're opening the legs up, and if the vagina is sore, that can just pull on this and make it sorer, and cycling, obviously, we'll be treating the inside and outside of the vagina.

So, sitting on a bicycle seat, which aren't the most comfortable things in the world, is probably not recommended either. having intercourse afterwards again because you're irritating the vagina inside. We don't recommend that for a few days, and driving as well is absolutely fine, because you're not causing any problems. It won't cause any problems. But the first time you come for the treatment; most people come with a friend just in case they feel sore afterwards. Thank you. Vicky.

So what we'll do now is, we'll answer some questions if people have any questions, and I just like to talk very briefly about Benderson itself. There are gynaecologists that work as a team. So we're all general gynaecologists. We've got experts in the menopause. So that's me. One of the late doctors, Anna. We've got specialists in. I'm sorry that my camera is going up and down specialists in Urogynae. So that's prolapse and incontinence, and we offer many services for that. We've got a fantastic team of specialist urogynae nurses that can teach you about bladder drills and pelvic floor exercises. There's Jan pelvic floor exercises and bladder health in general and they also do some of the tests that we may have to do on the bladder before or after surgery and part of that incontinence. Treatment is bulkamid, which is like a bulking agent around the wee tube. Botox for an overactive bladder, and obviously we've also got other outpatient treatments for abnormal bleeding, including hysteroscopies, where we look inside the womb, and we also have other services like cystoscopies, where we can look inside the bladder. If you go back again, please, Vicky, thank you, and us also deal with endometriosis and pelvic pain. which is one of those disease processes that is often overlooked, and we treat everything else from ovarian cysts and minor minimal access treatments of hysterectomies and vaginal hysterectomies as well. So it's a full service, a little bit like an ordinary NHS. Hospital with experts, but we all do a little bit of everything. So I hope I've kept the time. That gives us a little bit of time to answer any questions. If people have it. So I'll leave the floor to Vicky now.

Vicky

Thank you very much. Thanks, Mr Connell, for that presentation. I'm going to take some questions. So the first one is, after treatment, do you have any advice on products or supplements to prevent symptoms from returning? Or is this inevitable? And how soon after could symptoms return?

Mr Rowan Connell

A very good question. So I'm very pro the oestrogen. HRT, but, as I said, some women either don't want to use it or can't use it. The advantage of that is it maintains, if you've got a good response from the Mona Lisa, it helps to maintain that thickness so that you don't have a withdrawal of that thickening so quickly. The women who don't or can't use the HRT. As I said, it does wear off, but again, the success rates of it are very variable. So we have some women that don't come back for months, some that come back at or after months, because they felt that the symptoms are deteriorating again, or the symptoms are worsening. So it's very much an individual response. Products-wise. I'm quite old-fashioned, and when I was a junior doctor, we used to use an awful lot of olive oil as a treatment in the vagina to keep the skin healthy. What we've moved over to in the last few years is coconut oil for cooking and use the coconut oil for cooking as a soap around the vagina and inside the vagina. It's a very good moisturiser because you never think about moisturising the vagina. It's very good as a lubricant. So when you're walking, it's not rubbing it, or when you're having intercourse, it's very good from that point of view, and also it's mildly antiseptic. So as you get older, the good bacteria in your vagina deteriorate or diminish, which allows you to have more likelihood of having infections, whether that's infection in the vagina or infection in the bladder, and so we promote that an awful lot. So that's coconut oil for cooking. putting it in the vagina as often as you can. I'm not hugely impressed with other lubricant products, mostly because they're either made from mineral oils or they're made from water-based products, or even petroleum, like Vaseline. whereas the coconut oil for cooking is a natural product, and it's got nothing added in it, and I have had some women who've been a little bit allergic to yes, or KY Jelly, or whatever, and a lot of these water-based lubricants, if you just put it in your hand and rub them together very quickly. Within a couple of minutes it'll get quite hard and sticky and tacky, whereas the oil-based products are a lot more. They're just a lot happier, and they keep the skin much healthier.

Vicky

Okay, thank you. That was helpful. We've sort of covered the next one, but it might be worth reiterating. But how soon could I return to cycling, yoga, or a spin class, please?

Mr Rowan Connell

So you're talking to a man that doesn't exercise very much but cycling we wouldn't recommend because that is It's not the forcing. It's just the seat and where it is, and it's very sore anyway. A lot of my friends who cycle a lot and are men will use Vaseline and products like that around their seat area, because it's very uncomfortable, and a lot of the women that I know will use that as well. So I just would not do anything for a week or afterwards, just to let it settle down, especially after the first treatment. But of course the aim of doing this treatment is if you're exercising, it's very uncomfortable. It's to allow you to do the things you want to do without it being uncomfortable. But I'd argue probably a week or for most exercises.

Vicky

Thank you. Next question. I have very sensitive skin. Is this a higher risk for laser treatment?

Mr Rowan Connell

It's not a high risk for the laser treatment, and obviously the question is, why is the skin? Is the skin sensitive? So if you have sensitive skin, whether that's like eczema or just generally sensitive skin, and then you have a bit of a discharge in the vagina. Sometimes because of that sensitivity. A lot of women will then use products in the vagina to keep the vagina clean and use water, and of course water is very drying and that makes the skin even more sore. So what I'd recommend is, if you're sensitive, if you think you've got sensitive skin, or it is very sensitive, not to wash the vagina out with water or soap products. Use the coconut oil as a first line, because it's very soothing and certainly after the treatment to use that again because it's very soothing. But of course we're using the Mona Lisa laser treatment for women with sensitive, sore skin. So I'd argue that's one of the reasons that I would treat the vagina. If the skin is very sensitive.

Vicky

Lovely. Hope that makes sense. Next question: I have been using VagiFem for a year. but NHS guidance says it can only be used for two years. I won't be using any other HRT, so should MonaLisa Touch® be used before the end of the use of VagiFem to get the most benefit from it?

Mr Rowan Connell

Okay. So, as I said before, I'm very pro HRT, and a lot of the stuff that's written about HRT is that everybody has slightly different opinions on it. My argument about VagiFem is that VagiFem is a very, very low dose of oestrogen. so compared to an oestrogen tablet for HRT. It's about a thousandth of a dose, so that means you could use it every day for years, and that would be the same dose as one HRT tablet so universally. We know it's a very, very safe drug to use in the vagina. I suppose the principle behind you. You must only use it for dot.is so that you see your GP; it's just not. It's just not on continuously being prescribed, and like all medicines, whether they're blood pressure tablets or whatever, you want to see a professional regularly to make sure it's the right treatment. Then I say in the old days. But we're talking years ago; there were dose regimens of VagiFem. One was micrograms, and the other was 10, and the 25 micrograms was designed for the older woman who couldn't put the VagiFem in her vagina herself, and the district nurse would come round to either her house or the nursing home to put the vaginal oestrogen in her this little tablet to put the tablet into the vagina twice a week, so that lady was getting 50 micrograms a week. The micrograms were used every day by women who were more dexterous. So that woman was getting 70 micrograms every week. What we've now done is they've stopped making the 25. So you only have 10, and a lot of the GPSs and pharmacists will say you must only use it twice a week. So those women now are only getting 20 micrograms a week rather than 50 from the more infirm women or the 70 from the more dexterous women. So again, that to me seems a bit of nonsense, and common sense says it's not the right thing to do. The one thing I would say about VagiFem. Is that a lot of the time people will prescribe it every night for two weeks and then twice a week after that, and I don't do that? I use it twice a week to start with because you can get a bit of a reaction to using it so often straight away. So I tend to say twice a week for weeks. Three, four, or five times a week for the next two weeks, and then every night after that, and you can use it long term. So I'd argue to use it forever and ever. But just check with your GP. That he's happy to carry on with that, bearing in mind that HRT. Which is a two thousand times higher dose of oestrogen. I've got women in their eighties and nineties on it. So you can use that at a much higher dose for longer. So I would argue that two years is not ideal. But you must see somebody, because if you're using it for a sore vagina and it's not helping, then you need to check to make sure there's nothing else going on that can be treated, like lichen, sclerosis, or other things, I think, in a very roundabout way. I've probably answered that Vicky ever.

Vicky

I think so, yes, very comprehensive. Thank you. Next question. I have recently had surgery to remove fibroids. Should I wait before having the MonaLisa Touch®? And if so, how long?

So there are ways of having the fibroids removed. One is through a cut in the tummy or keyhole to take them out that way, and the other is through the vagina, using a hysteroscope to cut them away. So, for both of those, the answer is probably the same in that the VagiFem makes no difference, and the Mona Lisa makes no difference. The only thing I would say is that if you're still bleeding, then you mustn't have the laser treatment, because blood shields the inside of the vagina and almost acts like a mirror. So whenever we see women who are bleeding, we need to clean the vagina out very gently, so no, I'd wait until you were recovered. It should have no effect on well, it sorry. I'll rephrase that it has no effect on fibroid treatments. It has no effect on anything else in theory, although we would never do it because it's so safe you could use it even during pregnancy. Of course we wouldn't do that, but it's very, very safe. So I would just say, get over the operation till you feel happy and then have the treatment. If you want to.

Vicky

Thank you. Next question is from Diane, and she asks, I have an HRT. implant because I don't have ovaries or a uterus." Would this treatment be suitable for me, as I'm plagued with UTIs?

Mr Rowan Connell

Okay. So the implant is usually a little pellet of oestrogen that goes underneath the skin. So it just gives you a continuous amount of oestrogen, a little bit like the patches, so it's through the skin, slightly different from the gel and the spray. But the same sort of treatments. What was the second part of the question? Sorry, I was on a roll then.

Vicky

Would it be suitable for me, as I'm plagued with UTIs?

Mr Rowan Connell

Yeah, UTIs. That's right. So, so what I would do, first of all, rather than leaping into the Mona Lisa, would be to think about having the hormones in the vagina. because again, for the same reason, I said before that you're the VagiFem, and the Mona Lisa will thicken up the skin in the vagina. It'll thicken up the fat in the vagina, and it'll help to close and protect the wee tube, because obviously the wee tube, as you get older, shortens and opens slightly because you're losing the fat in the vagina. What I would say for that woman to Diane is that again very much. I would use the coconut oil for cooking because coconut oil for cooking is mildly antiseptic, and for the women with recurrent infections. As long as you've had the bladder checked to make sure there's no stones or anything else in the bladder. What I recommend for that is that before and after you go to pass urine, you put a little bit of coconut oil into the vagina around your wee tube, because when women stop peeing, they suck up a little bit at the end. So what you're then doing is you're sucking up a little bit of the antiseptic coconut oil for cooking, and that reduces the risk of infections and UTIs. So that's the first thing I would do. But of course the Vagin, the hormones in the vagina, and the MonaLisa Touch® help with urinary tract infections because it thickens the skin in the bladder, thickens the skin in the vagina, and thickens the skin around the wee tube, so definitely. But you need the extra rather than just the HRT. Because of the HRT. You're getting a tablet, a patch, an implant, a spray, or whatever is never enough to get into the vagina to help with the vaginal problems. So they're separate things.

Vicky

Okay, lovely. That makes sense. So Delvina has asked something similar about chronic UTIs. So I think we've answered that. But she's also asked, How long does the treatment last? But there are bits that question.

Mr Rowan Connell

So I guess the treatment itself. When you come in last, about min for each session. How long it lasts before you need a top-up is very much dependent on the person.

So, as I said, most women have an improvement. All women have improvements, but, as I say, it may be that much, or it could be this much, and again, how long it lasts is again dependent on the late on the women herself. Since I've only had about or women who've come earlier than months. We've had quite a lot that come between and months, but the majority is over months coming back for their top-up. Of course, the women where it hasn't worked at all or not worked as well as they wanted it to presumably haven't come back at all.

Vicky

I hope that's helped, Delvina, and the next question is, are there many alternatives to MonaLisa Touch®, and how do they compare with symptoms and improvement?

Mr Rowan Connell

This is where we get into lasers in the vagina. And, as I said, this is fraught with a little bit of controversy, because the MonaLisa Touch® is a laser, and the way it works is it essentially causes the heat because it goes on to red blood cells of blood in the skin, and as it's so low powered, that's how it heats it up. But there are lots of other lasers out there, but they're much higher power, and they work on, for example, the bladder incontinence by causing scarring and burning. I suppose the easiest way to think about that is that when you have an egg, an uncooked egg, if you heat it up, it turns white because you're denaturing the proteins, and the high-power lasers work by doing that. There are a couple of other lasers around that, again, are very low power. I don't know very much about those, but certainly, if the data is there. There's no particular reason why you can't have that done. But we looked at several in, and again we looked at them again for Bennington in, and we just thought the Mona Lisa data was far better. So I would encourage people to think about Mona Lisa more rather than the other treatments, and of course other people have done a similar thing, which is why there are more centres for Mona Lisa than there are for the other lasers, because the data is there.

Vicky

Okay, lovely. Thank you very much. Next question. This attendee says, I'm post-surgical menopause after a hysterectomy years ago. Would I be suitable for treatment?

Mr Rowan Connell

Yes, if the trouble with surgery. Surgical menopause is, even if you have a hysterectomy and they don't take the ovaries, the ovaries tend to only last about, on average, and again, it's very difficult to prove this about years. So if you're having a hysterectomy in your early forties, you're likely to go into a proper menopause in your mid-forties. The average age to go through the menopause naturally is about so that lady will then be having or years more menopause than a contemporary of hers. But of course, the average age means that some women go into menopause naturally and some go in naturally. It's all about symptoms. It's not about age. So whether you're with breast cancer treatment or with the perimenopause. or with thinning of the skin. It doesn't matter. It's not about the age. It's about symptoms.

Vicky

Lovely, and kind of carrying on from that, somebody's asked, who would MonaLisa Touch® not be suitable for?

Mr Rowan Connell

I guess the answer is almost nobody. I think it can be suitable for everybody. Sometimes, if you've got a lot of scarring in the vagina, and we have had some ladies who've had lots of surgical treatments for prolapse, for example, where there's a lot of scarring, we sometimes use the Mona Lisa to try to soften that if the hormones don't work. women who've had radiotherapy in the vagina, for example, for cervical cancer. The responses to that are much less good than the young women who are on breast cancer treatment. But again, I would use it for those lasers as well, because, you know, if it's that sore, anything is going to help. So I would say almost nobody is excluded. There are no contraindications for anybody. We don't use it in pregnancy because there's no data, and obviously women who are pregnant have lots of hormones going around. Therefore, the vagina isn't sore. So I didn't mean that in a flippant way, but it is very, very safe, but we wouldn't use it for pregnancy, but that's probably the only way we wouldn't. We wouldn't do it.

Vicky

Lovely. I have a couple more questions. So Deborah asks, What about if you have Nabothian cysts within the lining of the vagina? Is this treatment still okay?

Mr Rowan Connell

So if it's a cyst, it's a little inclusion cyst on the cervix, and of course it's absolutely fine for that; you can get lots of little cysts in the vagina itself, because the vagina is full of little glands that produce various products, whether that's thick mucus or thin mucus to keep the vagina healthy. So, having lots of little cysts in the vagina is not an exclusion for the Mona Lisa and the bovine cysts on the cervix. Certainly, it doesn't affect those in the slightest.

Vicky

That's great to hear. Hope that's helpful, Deborah, and the last question we've got is from Delvina again. She asks, after the top-ups. Are you ever cured?

Mr Rowan Connell

Oh, I never use the term cure for anything. All we do is we make symptoms better. So the answer is, you have the vaginal atrophy for a reason. So usually, that's because of the hormones going down or the hormones being non-existent in the menopause. So of course when you thicken it up and make it better. Unless you're getting more hormones to keep it thick, it'll just start thinning out over time, and, as I said. It varies between people how quickly that happens. So no, you're never cured. It doesn't reverse it. Sorry, it doesn't cure it. It just reverses it to some extent and slowly, with time, it reverts back to pretreatment, and that's why you have the top up. I would just encourage that if it does work for you, it is not to wait until it gets really, really bad again. Because if you wait, I don't know, or years, and it's really bad. Again, we tend to do the treatments again. So the ideal is when the soreness, although it's very, very difficult to measure when the soreness is sort of between and % of how good it was. Have the top up, then, to just give it a little boost up. But no, you never cure. It only makes the symptoms better.

Vicky

Lovely. Thank you for that. I think we've covered all of the questions, so I just included a slide here. I don't know if you want to say something about this slide, Mr Connell?

Mr Rowan Connell

Oh, yes, this was from before. This was just understanding the risk of breast cancer, because some women were very concerned about the use of vaginal oestrogen, and bear in mind that we talked about the fact that it's about a thousandth of the dose of systemic HRT, so essentially just a pictorial example of risks of breast cancer based on various things. So the normal population, as I said, is, we're calling it 23. So it's about one in 20. Women will develop breast cancer if you have the combined. HRT, so that's oestrogen and progesterone tablets. You have 4 extra cases. If you're on Eastern alone, HRT, you have 4 fewer cases of HRT and you have to have progesterone. If you've got a womb, you need to protect the lining of the womb with the progesterone. So a woman who's had a hysterectomy who goes on Eastern alone, HRT. Will have less chance of developing it and that's similar with the combined oral contraceptive pill. Because, of course, that's Eastern and progesterone tablets. The one the next one is about. If you're having more than 2 units of alcohol per day, because alcohol does increase the risk of all cancers, and it does increase the risk of breast cancer as well. Smoking, of course, causes cancer everywhere. So there are another 3 additional cases. If you're a smoker and the biggest risk is BMI over 30 and we know that being overweight causes risks for everybody. So the woman who exercises, and, as I said, it says, at least and a half hours of moderate exercise every week, who has a normal BMI, so normal weight. Who is on oestrogen alone? HRT then that significantly lowers the risk of breast cancer. But the woman who smokes and drinks excessively is on the pill or on the bad form of HRT. Which is the oestrogen-progesterone tablet, and who's overweight, has a significantly increased risk. But of course this is based on oestrogen and progesterone tablets and the data for the gel and the spray, because it's a much lower dose that isn't there yet, but just to give an idea, because a couple of ladies wanted to know about it, and with the VagiFem, which again, is the very, very low dose of oestrogen in the vagina that is oestrogen on its own. So, of course, the third one down, which is for fewer cases in women on Eastern alone. HRT, vanity fem is Eastern alone. HRT. So even if it did have an effect, it would be lowering your risk of breast cancer in that woman so hopefully. That makes some sense.

Vicky

Great, lovely. Thank you very much for explaining that.

So that's all we've got time for tonight. So as a thank you for joining this session, we're offering 50% off the value of your initial MonaLisa Touch® consultation. This is available for days. A call back from your dedicated private patient advisor, an email with recording and treatment information, and a loyalty scheme reward points, and updates on news and future events as well, and we'd be grateful if you could complete the survey at the end of this session, and this helps us to shape future events. If you'd like to discuss or book your consultation, our private patient team can take your call until 8pm this evening, or between 8AM and 6PM, Monday to Friday, and that's using the number on the screen. So we've got more events and webinars coming up in the New Year on orthopaedics and urology, and you can sign up for any of these on our website. So on behalf of Mr Connell and our expert teams here at Benenden Hospital, I'd like to say thank you for joining us today, and we hope to hear from you very soon. Thank you, and goodbye. That's everything. Thanks, Vicky.