To determine the efficacy of ablative carbon dioxide laser in the treatment of the signs and symptoms of vulvovaginal atrophy (VVA) or genitourinary syndrome of menopause (GSM) in women with breast cancer.

LAAVA 2 is a double blinded randomised placebo/sham-controlled trial assessing whether fractional ablative carbon dioxide is beneficial in improving symptoms in women with a history of early breast cancer. Patients will be randomly assigned in a 1:1 ratio to either active laser treatment or inactive "sham" laser treatment (setting of close to zero)

Participants will receive the 3 treatments approximately 4 weeks apart. Participants will then be followed up at twelve weeks post completion of treatment and twelve months post completion of treatment. At the twelve week follow up visit, after completion of study procedures, patients will be unblinded and those who received "sham" treatment will be allowed to crossover to "active" treatment if they wish.

Inclusion Criteria:

• Women with a history of early breast cancer >18 years of age
• At baseline patients must have at least one of five symptoms rated at ≥5 on a 10cm VAS scale. Symptoms include vulvo-vaginal itch, dryness, burning, dysuria and dyspareunia.
• Three groups of patients will qualify:
• Treatment induced premature menopause ≤45 years of age (eg secondary to chemotherapy or oophorectomy) for >6 months
• Premenopausal women on GNRH (gonadotrophin releasing hormone) agonist + tamoxifen or an aromatase inhibitor
• Postmenopausal women on tamoxifen or an aromatase inhibitor
• Willingness to give written informed consent and willingness to comply with the study
• Up to date pap test / HPV (human papillomavirus) testing

Exclusion Criteria:

• Medical contraindication to the use of fractional ablative CO2 laser
• Use of oestrogen therapies (systemic or local) in the 6 weeks prior to study treatment
• Use of vaginal lubricants or moisturisers 14 days prior to the study treatment
• Active or recent genitourinary infections (<30 days)
• Genital prolapse (grade III)
• Active or symptomatic vulvo-vaginal dermatological conditions (Lichen sclerosus, lichen planus, vulval psoriasis, Chron's disease, Hidradenitis Suppurativa, vulval dermatitis, candida, chronic vulvovaginal candidiasis, vulval intraepithelial neoplasia, genital warts)
• Inability to tolerate the use of fractional ablative CO2 laser (eg vaginismus)