The study will examine the effects of fractional/pixel CO2 laser treatment in vaginal atrophy and in vulvar lichen sclerosus by means of histological and immuno-histochemical characterization of the epithelial layers and markers of tissue aging. The tissue characterization will be performed by biopsies of the vaginal or vulvar tissue at three different points of time: prior to treatment, two weeks after the third and last treatment, and one year after the last treatment.

Many studies have been published recently describing the use of a fractional/pixel CO2 laser for the treatment of various disorders of the vulva and the vagina, such as atrophy due to estrogen deficiency, urinary stress incontinence, skin diseases (lichen sclerosus) and more.

The results of the studies that investigated this technology in relation to vaginal atrophy and urinary stress incontinence have shown improvement in symptoms after a series of only 3 treatments.

The proposed effect of the fractional CO2 laser is based on studies performed on non-genital tissues [Daffon, Capon], which demonstrated changes in the connective tissue and proliferation of fibroblasts, as well as formation of collagen and elastic fibers. The suggested explanation is based on the theory that heat shock proteins are involved in the process and arise due to thermal tissue damage, and this in turn activate tissue cytokines, growth factors and fibroblasts. These theories have not been proven for vulvar and vaginal tissues, and except for the demonstration of histologic and morphologic changes in the irradiated tissues [Salvatore, Menopause 2015], the cellular mechanism of action and the nature of the process mediating the changes in uro-genital tissues has not yet been examined.

The technology known as fractional CO2 has been used for many years in dermatology and plastic surgery. In this method, the laser beam splits while passing through a lens to 81 dots (9 x 9 pixels) onto approximately 1 cm2. The laser beam penetrates the tissue and causes minimal evaporation around each spot of the fractionated beams and release of heat only at the desired tissue depth. The method of energy transfer to tissues in tiny dots leads to the creation of various thermal effects in the focus of the beam, around the focus, and in the areas between these heat foci. Following the tissue irradiation, different processes occur: epithelial cell proliferation and thickening of the epithelial layer, migration and proliferation of endothelial cells, creation of neo-vasculature in the lamina propria, creation of collagen and elastic fibers, and accumulation of glycogen in the cells [Salvatore, Menopause 2015]. The result of these processes is improved tissue elasticity and plasticity as well as regeneration of the epidermis layer. Previous studies demonstrated that the effect of this treatment on the atrophic vagina is identical to long-term local estrogen treatment, with improved cytological index, improved lubrication, alteration of the vaginal flora, and reduced acidity to the level of "estrogenic" levels (approx. pH 4 -4.5) [Salvatore, Menopause, 2015;Perino; Gasper; Salvatore, Climacteric, 2015].

Considering the multitude of recently published articles presenting impressive clinical results, the investigators decided to examine the effects of the treatment with a fractional CO2 laser on the vaginal and vulvar tissue at a cellular level for two conditions: vaginal atrophy due to estrogen deficiency and lichen sclerosus. These two conditions were chosen due to the magnitude of recent publications dealing with clinical and histological improvement in these two pathological conditions following laser treatment. Understanding the cytological processes will enable the foundation of knowledge about the basic mechanism of action, and propose methods to improve the current therapeutic protocols. It will also enable the observation of the duration of the treatment effect, and the assessment of whether these changes are associated with undesired events, such as increased risk of malignant tissue transformation.

Patients The investigators intend to recruit 10 women for each group (10 women with atrophy and 10 with lichen sclerosus). Considering the availability of efficient and safe medical treatment, most women diagnosed with lichen sclerosus or vaginal atrophy are treated with medical preparations to their satisfaction. Therefore, the investigators will recruit the following types of patients for the trial: women with low compliance for the medical treatment, women who have developed intolerance to the treatment (such as chronic candida vulvovaginitis under long-term estrogen treatment, hypersensitivity reactions to the steroid ointment or estrogen preparation, or drug allergy) or women with only partial response to treatment, for whom there is no satisfactory therapeutic alternative.

The study includes 6 appointments:

T0-recruitment: ascertain eligibility, sign informed consent form, complete a questionnaire including epidemiologic and clinical details, gynecological examination, cytological smear (maturation index), determination of the acidity level of the vaginal secretions (pH), determination of vaginal health index score [Bachmann].

A punch biopsy will be taken from the mid-third of the vagina (in vaginal atrophy) or the vulva (in lichen sclerosus).

T1-Visit 2 (2-4 weeks from recruitment) The treatment protocol includes a series of three laser treatments, 4-6 weeks apart.

The first laser treatment will be performed during Visit 2. In the vagina, the treatment is performed by a special vaginal transducer enabling 360° treatment; the irradiation of the vagina is performed in adjacent "squares" along the entire vaginal circumference, by turning the handle while slowly withdrawing the transducer from the vaginal canal. The duration of treatment is 5-7 minutes. The vaginal treatment is not associated with pain. The treatment of the introitus will be performed by a transducer enabling treatment around 360° named FemiLift.

The treatment will be performed by a fractional micro-ablative CO2 laser system manufactured by Alma Laser in accordance with the accepted protocol (laser mode: pulse, energy: 40-80 mj/pulse).

For lichen sclerosus, a handgrip of the FemiLift transducer will be used, which transmits the "pixel print" directly and not under a 90° angle. Since the vulvar skin is pain sensitive, it will be treated prior to the laser application, with EMLA anesthetic cream. The duration of treatment is 3-7 minutes and it is performed by the same device with energy levels of 20-60 mj/pulse.

During Visit 3 (T2) and Visit 4 (T3), identical treatment to that described above will be performed.

In the framework of the study, the below follow-up procedures will be performed:

1. Biopsy - three biopsies will be taken from the lateral mid-third of the vagina: prior to treatment (T0), two weeks after the third and final treatment (T4) and one year after the completion of the treatment series (T5). The biopsy will be a punch biopsy with a 5 mm diameter. The biopsies will be performed under local anesthesia with 2% lidocaine.

2. In the course of each of the follow-up examinations (T 0 - 5), the following will be performed (In vaginal atrophy):

   • Gynecological examination with speculum
   • Smear taken from the mid-third of the vagina with a cotton tip applicator, which will be used for a cytological smear and to determine the acidity level of the vaginal secretions.
   • The vaginal health index score will be determined, including the evaluation of 5 parameters: elasticity, pH, integrity of the epithelium, moisture and fluid volume. Each parameter is scored on a scale of 1 to 5, and if the total score is lower than 15, the vagina is considered atrophic [Bachmann].
   • The patient will be requested to grade symptoms (dryness, itching, burning, discomfort, dyspareunia, dysuria) on a VAS (visual analog scale) with "very disturbing" and "not disturbing at all" at its limits.
   • The patient will be requested to grade the extent of her satisfaction with the treatment results (very satisfied. satisfied, not sure, not satisfied, very unsatisfied).
   • The patient will be requested to report side effects.

In lichen sclerosus patients:

- External examination of the vulva and a photograph of the results for follow-up.

The biopsies will be sent to the Institute of Pathology at Hadassah Hospital, where the following examinations will be performed:

1. Routine hematoxylin-eosin staining.
2. Immunohistochemistry staining for P16 protein.
3. Immunohistochemistry staining for the KI-67 protein.
4. Immunohistochemistry staining for the p63 protein,\.
5. Staining for alpha and beta estrogen receptors and progesterone receptors.

Vaginal Atrophy - Inclusion Criteria

• Menopause for more than one year
• One or more of the following symptoms: sensation of dryness, itch, irritation, burning, discomfort, dysuria, dyspareunia
• Characteristic atrophic changes on gynecological examination
• Laboratory workup: pH >4.5, characteristic microscopic smear (increased number of para-basal cells)
• Normal Pap-smear within 12 months
• Negative vaginal culture for fungi or relevant bacteria
• Negative test for STD pathogens (chlamydia, gonorrhea, genital mycoplasma and trichomonas)

Exclusion Criteria

• Genital skin disease
• Active infection
• Pelvic organs prolapse above grade 2
• Previous surgery for pelvic organs prolapse
• Use of systemic or local hormonal preparations during 6 months preceding the study treatment
• History of malignant diseases
• Undiagnosed vaginal bleeding
• Use of analgesics or antidepressants
• Use of anticoagulants

Lichen Sclerosus Inclusion Criteria

• Age 18-80
• Biopsy demonstrates characteristic changes for lichen sclerosus
• One or more of the following symptoms: sensation of dryness, itch, irritation, burning, discomfort.
• Characteristic changes for lichen sclerosus on gynecological examination
• Negative vaginal culture for fungi or relevant bacteria
• Negative test for STD pathogens (chlamydia, gonorrhea, genital mycoplasma and trichomonas)

Exclusion Criteria

• Use of steroid-containing creams for the vulvar region two months preceding recruitment
• Additional genital skin disease
• Active infection
• History of malignant diseases
• Use of analgesics or antidepressants
• Use of anticoagulants
• Pregnancy or planning pregnancy during the study
• Systemic treatment with immuno-modulatory drugs