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\begin{document}

\title{Letter to editor: ``Vaginal Er:YAG laser application in the menopausal
ewe model: a randomised estrogen and sham-controlled trial ``}



\author[1,2]{HSU CHENG YANG}%
\author[1,2]{Ching-Hu Wu}%
\author[1,2,3]{Cheng-Yu Long}%
\affil[1]{Kaohsiung Medical University Hospital}%
\affil[2]{Kaohsiung Medical University}%
\affil[3]{Kaohsiung Municipal Siaogang Hospital}%


\vspace{-1em}



  
  \date{June 13, 2024}


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\textbf{Letter to editor: ``Vaginal Er:YAG laser application in the
menopausal ewe model: a randomised estrogen and sham-controlled trial
``}

Cheng-Yang Hsu\textsuperscript{1}, Ching-Hu Wu\textsuperscript{1},
Cheng-Yu Long\textsuperscript{1, 2}

\textsuperscript{1} Department of Obstetrics and Gynecology, Kaohsiung
Medical University Hospital, Kaohsiung Medical University, Kaohsiung,
Taiwan

\textsuperscript{2} Department of Obstetrics and Gynecology, Kaohsiung
Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung,
Taiwan

Running head: Two prospective for this promising experiment

Words Count: 315

Corresponding Author:

Dr. Cheng-Yu Long, MD, PhD, Department of Obstetrics and Gynaecology,
Kaohsiung Medical University Hospital, Kaohsiung Medical University,
100, Shih-Chuan 1st Rd, Kaohsiung 80708, Taiwan

E-mail: urolong@yahoo.com.tw

Dear Editor-in Chief:

We read with great interest with recent publication in BJOG by Mackova
et al. (1) This study describe effects of non-ablative erbium-doped:
yttrium-aluminium-garnet (Er:YAG) laser on vaginal atrophy induced by
iatrogenic menopause in the ewe. The ewes were randomized to three
groups: vaginal Er:YAG laser application, estrogen replacement, and sham
groups.

In the estrogen replacement group of ewes, an estrogen implant was
inserted under the skin in the inguinal region. The result showed
increase in epithelia thickness in vaginal biopsies and it was
significantly higher compared with the laser application and sham
groups. In all groups, the lamina propria did not showed any significant
differences. Also the autopsy showed the uterus of estrogen-exposed ewes
weighted more.

We would like to humbly comment the vaginal estrogen use and laser
application in genitourinary syndrome of menopause.

The vaginal estrogen application was given twice a week with the cream
in currently practice of female who suffered from genitourinary syndrome
of menopause (GSM). Firstly, the vaginal estrogen application was given
twice a week with the cream in clinical practice of female who suffered
from GSM. The administration showed improvement of the symptoms while no
significant change in serum estrogen level. (2) The estrogen implant in
the ewe experiment continues to release estrogen and caused sustained
estrogen effect in the ewe and caused gaining weight of uterus, which
was very different with our clinical practice of intermittent vaginal
cream use.

Second, the application in this study is Er:YAG laser, with the the
lesser wave length: 2940 nm. While the CO\textsubscript{2}~laser had
much longer wave length 10600 nm and had deeper effect in not only
vaginal epithelium but also lamina propia. (3) Therefore the
vascularization effects of lamina propia may be obvious noticeably.

We thought these 2 flaws could be revised to make the ewe experiment
more accurate and similar to current management in women with GSM.

References

\begin{enumerate}
\tightlist
\item
  Mackova KA-OX, Mazzer AM, Mori Da Cunha MA-O, Hajkova Hympanova LA-O,
  Urbankova IA-O, Kastelein AA-O, et al. Vaginal Er:YAG laser
  application in the menopausal ewe model: a randomised estrogen and
  sham-controlled trial. BJOG . 2021 May;128(6):1087-1096.
\item
  Long CY, Liu CM, Hsu SC, Wu CH, Wang CL, Tsai EM. A randomized
  comparative study of the effects of oral and topical estrogen therapy
  on the vaginal vascularization and sexual function in hysterectomized
  postmenopausal women. Menopause . Sep-Oct 2006;13(5):737-43.
\item
  Bhide AA, Khullar V, Swift S, Digesu GA. The use of laser in
  urogynaecology. Int Urogynecol J . 2019 May;30(5):683-692.
\end{enumerate}

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