Louise King

Good evening everyone. I hope you're well and welcome to our webinar on MonaLisa Touch®. My name is Louise, and I’m your host. Our expert presenter this evening is Mr Rowan Connell, Consultant Gynaecologist at Benenden Hospital.

His presentation will be followed by a Q&A session. If you'd like to ask a question, then please do so via the Q&A icon at the bottom of the screen. You can do this with or without including your name. Just to remind you, this webinar is being recorded so if you don't want to be part of the recording just ensure that you don't include your name within the Q&A.

I’ll now hand over to Mr Connell and you'll hear from me again shortly for the questions and answers. Thank you.

Mr Rowan Connell

Thank you very much and welcome to everybody. My name is Rowan Connell. I’m a Consultant Gynaecologist at Benenden Hospital and I’m going to be talking to you about the MonaLisa Touch®.

So, a little bit about me. I started off my medical training going down the route of general surgery and concentrated quite a lot on breast surgery and breast cancer in particular. And I trained in London and the southeast mostly.

Around the time that I was training, keyhole surgery started coming in more and more as a profession and I met up with quite a key gynaecologist at the time who was using laser keyhole surgery for hysterectomies. I thought this was a fantastic advance in surgery because of recovery etc. and moved over from general surgery to that - to gynaecology - at the time and laparoscopic surgery specifically.

In 2003, I was a Consultant in the southeast of England and initially really specialised in keyhole surgery but also moved into urogynaecology which is essentially incontinence, vaginal prolapse and pelvic floor reconstruction. And then the story continues that because of that, because those conditions tend to affect the older women and menopausal women, I also developed an interest in menopause.

MonaLisa Touch® was first developed really in Milan with Stefano Salvatore who I worked with at Kings a long, long time ago and had lots of dealings with him over those first few years in the research. And I brought it to Benenden Hospital in 2017 or I should say that Benenden had a lot of foresight about where this treatment could lead for the benefit of women.

The problem in a lot of healthcare, of course, is that we don't prevent things. We tend to have a knee-jerk reaction to treatment of problems, so I put the prevention in brackets, but essentially the MonaLisa Touch® is for women who have uncomfortable vaginal symptoms or vaginal dryness. And initially it was thought this would be in the menopause, because we know that about 40% or more of menopausal women will have these symptoms. We quite quickly found that, actually, we were tending to see women who were more perimenopausal so, around the time of the menopause (the menopause being approximately 52).

And those women were 45 to 60 with all these terrible symptoms. And I think there is a subgroup of women who are very sensitive to the hormones going down as they get closer to the menopause. And, of course, this condition - I think - is very similar to impotence in men in that it's very, very much an unspoken disease or condition because women don't want to talk about their sore vaginas or pain with intercourse in the same way that men don't want to talk about their impotence and not having erections.

And of course, we had a huge increase in the number of people coming forward when Davina McCall had her recent television program about menopause, and she talked about soreness in the vagina for a few minutes then.

And, of course, because it's a condition of lowering of oestrogen you do see this in a number of women after they've had their babies, where they're breastfeeding where the oestrogen levels go down. And especially we see it in women who have breast cancer treatment - and I’ll talk about that in a minute.

So, you may have looked it up on the internet as the genitourinary symptom of the menopause – or GSM. I tend to call it laser vaginal rejuvenation but essentially, it’s vaginal dryness, itchiness and that burning and pain with intercourse.

On websites, they'll talk about vaginal laxity and I’ll talk about that a bit later on. But the vaginal laxity - we don't use this as a prolapse procedure, we use this as a thickening of the vagina. So obviously, if you've got a feeling of laxity in the vagina, we can thicken it, then that feeling will go down.

There's also a lot of sales pitch (not from me) but from the company about mild bladder issues or incontinence; and certainly we’ve found that every woman that we've treated who has mild urinary incontinence or bladder issues have improved, but I’ve still kept it in a bracket.

And then there's a condition called lichen sclerosis which an awful lot of women also have. That's a condition of – again - lack of oestrogen. So you see it in in eight-year-old children or eight-year-old girls and in the menopause and we've noticed that when we treat the outside of the vagina for this that also does improve, but again I don't sell it as a treatment of that that everybody has improved.

Interestingly it was really developed for scars on the face, so it's a carbon dioxide laser and Stefano - who works in Milan - had a poor lady who'd had an awful delivery and terrible scarring after birth. And he tried everything to try to make that scarring better and - almost in desperation - he used this low powered laser on the woman's vagina and noticed a huge improvement. And from there he's developed the research and researched into it, got data and he started using it properly from 2012. And as I said, we used it in 2017.

We initially just used it inside the vagina but, as I said, I now use it inside the vagina and on the outside in every woman because – obviously - if you've got thin skin in the vagina you very often have thin skin on the outside, so you treat the two together. As I said, it's a condition you see with decreasing oestrogen levels and it's the only non-hormonal treatment for vaginal atrophy that we can use.

Just very briefly about breast cancer. Women who have oestrogen-positive breast tumours are very often very, very nervous about using any oestrogen at all. One of the things we use in vaginal atrophy is either Vagifem or oestrogen cream. Vagifem is the little pessaries that you use. These are very, very low-dose hormones and they’re approximately a thousandth of the dose of HRT tablets. And there's a lot of data to show that there's no problems at all with breast cancer and using Vagifem, but still a lot of women who are being treated for breast cancer will not use the treatment - and that's one of the first things that I would use is oestrogen in the vagina rather than leaping in and doing the laser.

One of the treatments we used to use called Tamoxifen is a very good treatment of breast cancer and actually it's quite good in the vagina as well, because it has oestrogenic effects in the vagina. The newer treatments like Letrozole so on are very, very good at treating breast cancer but they’re absolutely awful in the vagina because they really can make it incredibly sore. So, a lot of the patients that we see who have sore vaginas after breast cancer treatment find the MonaLisa Touch® treatment very, very good indeed when they don't want to or they can't use oestrogen.

What the MonaLisa Touch® is not is for vaginal tightening. So, there are some lasers out there - which are high power lasers - which essentially use scarring for mild prolapse or incontinence to scar it and tighten it up but the MonaLisa Touch® certainly isn't that. As I said, it does improve the feeling of laxity but that's because it thickens it up and plumps up the vagina, rather than tightening, and certainly Stefano's data from Milan has shown that - and this is now patients in their thousands, because this is a treatment now which we use all over the world and certainly at Benenden and we've trained a lot of people from the east and west coast of America who've gone on to use it in in the States - but the data now is certainly getting much better. And I would say now it's a proven procedure because of the data.

A bit a little bit of science, I guess. It's all about collagen. The fibrocytes are just cells inside the skin of the vagina and essentially what it does is it rejuvenates the collagen into a different type of collagen which is much more elastic and thicker to give you that feeling inside. And I won't go on about the other things.

What do you expect when you come to the clinic? Well if you feel that MonaLisa Touch® would be an option for the treatment of your symptoms you come and see me, I’m the only gynaecologist at the moment who's doing the MonaLisa Touch® in Benenden. I’ll see you, take a history and then obviously examine you very carefully and gently.

The basic treatment, essentially what I use if people are willing is - as I said - the hormone pessaries in the vagina. I quite like the Vagifem because they're little tiny pellets, little lozenges, that go in the vagina and slowly dissolve overnight. I use lubricants.

Some of the lubricants you can buy are quite artificial with a lot of colour and preservatives and other things in it, which sometimes can cause an awful lot of burning in the skin of the vagina - which is obviously exactly what we don't want. So for the last few years I’ve been using either olive oil or - more recently - coconut oil in the vagina and you can use that as a soap, as a moisturiser it protects the skin very, very well and - because it's an oil - when you're walking you get much better lubrication and it also is mildly antiseptic. So, I use that as a conservative management first. If people aren't doing well with that and they still have symptoms, then they'll come in for the treatment.

The vagina itself is quite insensitive to the laser treatment but, because we now treat the outside in almost every woman, then you come 10 or 20 minutes before the clinic appointments for the treatments and we give you some local anaesthetic cream to put on the outside of the vagina - especially around the clitoris, around your wee tube - so that's just inside the vagina and in the skin between the vagina and the rectum because those are very sensitive areas.

We use a very specialised room, which is very private. I put ‘all female’ because of course, I’m not female, so you have to put up with me because I’ll do the treatment but there are three nurses to manage the laser equipment, to talk you through and make sure you're okay. And then somebody will test your urine and do all the normal pre-operative tests. It's a procedure, it's not an operation, and the whole thing takes about five or ten minutes.

Most people are very nervous because they don't know what to expect with the first treatment, so they tend to come with somebody. But when they realise how easy it is for the second and third treatments, they usually come on their own.

There are three treatments and they’re six weeks apart. That's important and - as I said - it's if you get pain after it or discomfort after you have the local anaesthetic cream just to use. We put these pictures on; essentially, the device is on the right-hand side. It's about the same size as your thumb and it fits inside the vagina (so you can see that in the middle picture) and it goes into the top of the vagina or near the cervix. The machine itself is on the left. It's like a very small filing cabinet so it's not very intimidating. The procedure is done a little bit like you see in American films with your legs up in stirrups - but that's only so that you can relax, and there's a lot of privacy. We put the device in and then we treat.

Those little notches on it are the measurements so, depending on the length for the vagina, you might have 20 treatments. So, you put it in, you gradually withdraw it for each treatment - those little markings - and what you essentially get is little dots inside the vagina. But remember it's not exactly like that but they're very low power lasers so it's a heat treatment but in a way it's a very mild burn and of course you can't feel it inside the vagina. But that's how it works by causing that collagen to change.

The biggest side effects we always quote are bleeding or discharge. So, if you've got a very, very sensitive vagina then this treatment can occasionally cause a little bit of bleeding for a few hours or a couple of days after the treatment because it is causing a very mild burn. Your body then will react by having a bit of a discharge, but it's almost never infection - just a discharge - and you can occasionally get some tenderness and that's why you go home with that local anaesthetic cream. But very few people have that. And because it's causing a reaction, you'll feel the swelling inside the vagina. If we're treating near the wee tube (because the patient has urinary symptoms) and very occasionally because of the irritation you can get some discomfort or pain when you pass urine for the first few times.

Just before the treatment, we don't recommend that people do an awful lot of exercise - especially running. We don't like you to have sex two or three days before it or use any lubrication or the Vagifem or the coconut oil. And that's because that can put a barrier inside the skin of the vagina and reduce the efficacy of the laser. Afterwards, again, because the swelling and sometimes a bit of soreness, we again don't recommend that you have any exercise - especially swimming, running, cycling etc - for three or four days afterwards. Again, because of the discomfort, we don't recommend sex for a week or two afterwards and driving, of course, is absolutely fine usually - unless we've done a lot of treatment on the outside because of lichen sclerosis, it can be a bit little bit sore.

So, results. Well I do claim that everybody has improved, but some people - and I’ll say some people - improve that much and some people it's this much because the results are somewhat variable. We do give three treatments and that's important, so you can have an awful lot of improvements after the first and then less after the second and third - or very little after the first and second treatments and an awful lot after the third. So, it's important you complete those three treatments six weeks apart. Everybody that we've seen with any bladder dysfunction have all improved, but again we don't sell it as a treatment, but that's just something that has happened.

I like the oestrogen because essentially if the oestrogen in the Vagifem or whatever before the treatment hasn't helped, very often when you start the thickening of the skin in the vagina it will then absorb more of the oestrogen and you'll get a fantastic improvement because of the oestrogen. And if you carry on using that in the vagina, instead of there being an annual top-up where you come for one treatment, you very often don't have to come every year, maybe 18 months. And we've had a couple of ladies that have taken more than two years before they've needed their annual top-up.

So that's essentially all I wanted to say, just as a very basic introduction to MonaLisa Touch®. There's lots on our website as well. Some people have asked about what other things we do at Benenden. So, we're a group of general gynaecologists; we concentrate quite a lot on the urogynae - whether that's prolapse or incontinence. We do a lot of keyhole surgery and treat pelvic pain and endometriosis and obviously ovarian cysts and hysterectomies if needed. Because of two of our interests, we also deal a lot with menopausal ladies and obviously the MonaLisa Touch®. But we've got a very good multi-disciplinary team of the gynaecologists, continence care advisors, physiotherapists and theatre nurses who very often will go through your whole process and look after you.

If you’re a Benenden (Health) patient, you can come straight through to the physiotherapist via Benenden (Health) for pelvic floor assessment and exercise etc. But they don't just do pelvic floor exercises. They do bladder health and bladder training and we are one of one of the centres in Kent who deal with Bulkamid and Botox® for bladder incontinence and we've got a hysteroscopy clinic for outpatient procedures.

So, I think that's where we shall pause for a moment and if there's any questions, I think please feed them through and I will be questioned on them!

Louise King

Thank you, Mr Connell, that was really interesting. We do have a few questions. I will just go through them now. So, the first one is: are there any health risks during or after treatment?

Mr Connell

Good question. The trouble with a lot of these treatments that we do - because it's a laser - everybody thinks of very high-powered lasers. The best way of thinking about it is more of a heat treatment. So, it's like you'll very often feel a warmth inside the vagina, rather than it being anything else. So, there are no health risks for it because it's just like warming.

As I said, the complications - I think I said – am I allowed to go backwards? Those are the sort of side effects that we have which is occasionally a bit of bleeding and discharge and some tenderness, but there's no risks of it. It's not a hormonal treatment, it's literally a stimulation of the skin cells to make them swell up and grow to reduce the symptoms that you've got from your problems.

Louise King

Okay thank you. Another question: are other lasers used for this type of treatment?

Mr Connell

I should have probably said that! There are three or four different types of lasers that have been used and we looked at YAG lasers and so on. The problem I’ve personally got with some of these lasers is they're quite high-power lasers. So there's a couple that I don't use but there are a couple that are used for urinary incontinence and mild prolapse and - as I said - they essentially work by burning and scarring the vagina and congealing that collagen to give you the effect.

One of them you can have one treatment and that's for laser rejuvenation as well. I don't like the data on that particularly and I prefer the sort of slowly, slowly treatments, so the three treatments on low power. There are two others and I’ve forgotten the name (I’m terrible with names) there's another laser that is exclusively used for incontinence, but again that causes burning underneath the wee tube to lift up the wee tube to reduce incontinence.

So yes, there are other things out there but myself and Salvatore were not particularly impressed with it. Obviously, I love this and I’m going to promote it, and certainly I’ve got two colleagues in London that have two lasers, but again they use it for slightly different reasons. But I’m not particularly impressed with the others; that's my own personal view.

Louise King

Okay thank you. I’ve had quite a few more questions but I’ve got two via the chat. One says: good evening, Mr Connell. Are there any limitations as to how well it works for vaginal atrophy, post partial hysterectomy please? Literally I had this just last week. Thank you.

Mr Connell

When you've had a hysterectomy there's no difference, particularly in the vagina, so a partial hysterectomy – I presume that means leaving the cervix behind, so that's the subtotal - so if you have a subtotal hysterectomy the vagina is going to be exactly the same. All you're doing is you're taking away the womb or the uterus because of bleeding fibroids or whatever it is. If you take away the ovaries then, obviously, if you're a 40-year-old you'll instantly go into the menopause and you may develop this condition of genitourinary symptoms of the menopause. But the laser can be used whether you've got a womb or not. If you've got a large prolapse - it's a big lump in the vagina or collapsing of the vagina - then we don't tend to do that because it doesn't help that and actually can get in the way a little bit.

So, if you've got all the symptoms that we've talked about, and a large prolapse, we would deal with the prolapse before we did the MonaLisa Touch®

Louise King

Okay thank you. Another question via chat. I’ve had an operation as I had skin growing over which was unsuccessful. I’ve been unable to have sex for three years, due to dryness and pain. Would this help? I’m on HRT patches.

Mr Connell

Okay so that's five questions! So, the HRT patches are interesting because HRT - I love HRT, whether it's tablets, patches, gel - but HRT is very good for your body, but it's not enough to get into the vagina. So, if a lady is on HRT, no matter what the dose, I would give the Vagifem in the vagina on top of that. So the Vagifem in the vagina will do nothing for the rest of the body but does an awful lot of good in the vagina and the bladder, whereas the tablets or the treatment for the body isn't enough to get into the vagina.

So, I'd always use that anyway. If this is like a skin bridge, and I sort of liken it so - if you can see that little bit of skin here - so there's a growth of skin at the bottom of the vagina. Obviously if that's a very thin, tight, somewhat scarred piece of skin the MonaLisa Touch® will thicken it up. But again, I don't tend to do that first. So, what you would normally do first is use my coconut oil to massage the back, the bottom of that dip to try to soften it first.

If it's a very tight bit of skin, so the actual opening of the vagina is too small to let a penis in during intercourse, then sometimes we have to make a little nick in the skin just to open it a little bit before we do anything else. So sometimes, if it's just a little bit of skin we'll do the MonaLisa Touch®. If it's a big bit of skin covering it, then we'll make the nick and just open it first and if there's still a problem we then do the MonaLisa Touch®. But always the massaging, always using the hormones that's what I like to do if you can.

Louise King

Okay, I think that relates to another question we had which was: please can you explain why you suggest using coconut oil?

Mr Connell

So 100 years ago, when I was a baby Doctor, I had this fantastic lady with similar problems to this and she said that she had used olive oil to keep the vaginal skin healthy and she'd used it on her children when they were in nappies because it reduces nappy rash. So, since I was quite junior, I’ve always said use some olive oil. Gently massage it if you have an operation in the vagina or after childbirth, use it inside the vagina to help. But olive oil itself is a bit gloppy and smelly and people don't like it very much - and now of course you can get coconut oil an awful lot everywhere.

And the great thing about coconut oil, sorry, is at autumn room temperatures (not summer room temperatures) it's fairly solid and so you can put it on like you put your face cream on in the morning, rather than being a liquid. And nobody's ever allergic to it; it's a fantastic soap, because soap is very drying in the vagina, but you can use it as a soap because it's oil-based it's then therefore very good at moisturising the skin. It's a very good lubricant and - as I said it's - a mild antiseptic, so it does help to get your normal bugs healthy again, the sort of friendly bacteria, which is one of the symptoms you can get with this condition. If you're getting recurrent infections, so bladder infections or infections afterwards of course, and you've got coconut oil, which is a mild antiseptic, it can also help with that irritation when you go to pass urine.

I think that's all the questions, wasn't it?

Louise King

Yes, that's great. Thank you. And we have several more questions and one is: please can you explain more about the oestrogen cream or the pessaries?

Mr Connell

So, there's two ways you can put oestrogen in the vagina. One is cream; and it usually comes on a little soft plastic syringe and you fill the syringe up, put it in the vagina and you squeeze it and the cream comes out. The lozenges, the Vagifem, which is an awful name, is a little lozenge, again that comes on a little pencil so you can gently put it in the vagina. You push the end and it comes off at the top of the vagina.

Personally, I’ve had some patients who've reacted to the cream because the cream has preservatives in it, colouring and so forth and very few people have reacted to the Vagifem because it's almost like a very thick Vaseline. And - as I said - because they're very low dose oestrogen, you don't tend to get any problems with it, although a woman who has this condition the GP or Pharmacy will say you take it every day for two weeks or every night for two weeks and then twice a week after that. But if you're doing that with a very sore vagina that can be quite a high dose first of all, so what I tend to do is: you take it twice a week for two weeks and then gradually build it up.

As I said, because it's a thousandth of the dose - roughly a thousandth of the dose - of an HRT tablet, you'd have to take three years’ worth every night to have the same dose as one HRT tablet, so the side effects are non-existent apart from the - as I said - the irritation sometimes with the cream. And the cream also is, you know, to me it's a bit messy. It's a cream going into the vagina rather than this nice little lump of hard or soft Vaseline. So that that's just a personal preference.

Louise King

Okay, thank you. We have another related question. A lady says: I have used Vagifem and, yes, lube quite a long time with no improvement. I bleed after intercourse. Will MonaLisa Touch® be suitable? My GP has just put me back on Oestragel HRT.

Mr Connell

So, the problem is the water-based gels really shouldn't be used because they could be very, very drying. It's either KY Jelly or water based. There is another thing, which are oil-based, and they tend to be quite mineral content and some people can have a reaction to it. So that's why, you know, again I go back to my coconut oil.

The oestrogen gel? Fantastic for the for the body but not enough to get in the vagina and - as I said - if you've got a very thin skin in the vagina, it just sits there and doesn't do anything and therefore when you put the oestrogen in, it doesn't absorb enough of the oestrogen to thicken it up. So that woman, if she had MonaLisa Touch® and if it worked well, she'd then get a much thicker vagina which would then start absorbing the oestrogen much better - so she may not need any further laser treatment because she'll maintain the thickness of the vagina with the oestrogen cream or gel.

So her question was whether it would be good for her? Well, yes, because if you're splitting the skin inside because it's so sore and you can thicken it by whichever means, and you use the coconut oil as lubrication then yes, that might be perfect for you.

Louise King

That sounds sensible, thank you, I had a quick question, which I can answer actually is where to buy coconut oil. Most health food shops will sell that!

Mr Connell

Yeah everywhere! It's very cool, they come in little jars like the dipping stuff you get for tacos and they're now so relatively cheap. When we first started using it 5, 10, 15 years ago you couldn't get it anywhere and it was incredibly expensive, but you just buy anywhere. It's a cooking oil so, theoretically, it's a healthy cooking oil but I’ve got patients use it for their hair, their skin, their vaginas, their nappy rash for the kids. I don't use it on my hair!

Louise King

Yes, I use it for cooking! A lady says: what should I expect during the recovery?

Mr Connell

I presume recovery means after the procedure is done? There isn't really a recovery because most people are - especially after the first treatment - they're so amazed about how easy it was. The only thing, I suppose is - if you're really worried - you'll have lots of adrenaline going around so, because you're on a little bed with your legs up (as I said, like in American films!) we just like let you sit there for a little bit longer just in case you feel a bit faint, because it's the worry of coming in. But the second and third treatments almost everybody is absolutely fine about it, so there isn't really a recovery.

If you mean recovery as in once the swelling settles down after three or four days and, yes that is important that you don't go off and do a marathon or have sex too early or ride bikes or ride horses because you don't want to be hurting the vagina too much. So, three or four days afterwards, everybody's usually fine.

Louise King

Thank you. If you have nerve damage from pre-cancer cell removal can this treatment help that type of pain during sex?

Mr Connell

That's an interesting one. Nerve damage from cancer treatment, so that'll be where you take pre-cancerous cells off the cervix. I don't know, to be honest. I think if you've got pain in the vagina for whatever cause, then this is not going to do you any harm. Whether it makes it better, I don't know without thinking about it. I’ve not had that question before so that's interesting.

I don't know, is the answer to that. It depends on what the cause of the pain is in the first instance. If it’s because of - unless it's radiotherapy treatment for cancer cells, where you can get terrible burning of the skin and thinning? If it's for that, where you’ve had radioactive treatment in the vagina – 100% it will help but again I can't promise how much it will help, but it will certainly and it's one of the few things you can do to thicken the skin up in that area.

Louise King

Okay, thank you. Is this procedure FDA/MHRA approved?

Mr Connell

There was a hiccup about two or three years ago with FDA approval because they put all the lasers treating the vagina in one big group. But that was lifted about 18 months ago. It's approved, I think, as well - but don't quote me on it - this month or next month NICE are going to approve it as well as a treatment, but I will double check on that.

But certainly, it's now a fairly widespread treatment across the world and most places will do that.

Louise King

Lovely, thank you. Has anything been noticed with regards to an improved libido?

Mr Connell

Yes, is the answer to that because if it hurts every time you have sex, your libido will go down. If it doesn't hurt anymore when you have sex, then your libido will inevitably go up because, if you're then enjoying it, you get happy hormones in the brain and your libido will then improve. So, 100% the answer is yes. So, if we can get it so it's less sore having intercourse your libido inevitably will go up.

Louise King

That makes sense. Just a couple of questions left. How does vaginal treatment improve bladder problems?

Mr Connell

Right. So, until the MonaLisa Touch® came along we would use the Vagifem for bladder issues. So, if you think about it, as we all age our bladders will deteriorate so whether it's a man or a woman.

The problem with women is as soon as you hit 52, or the menopause, and you lose the hormones, your bladder deteriorates much quicker than mine as a man. So - for a long time - we've been using hormones (so Vagifem or oestrogen cream) in the vagina to thicken the bladder so the bladder has less irritability but also that the muscles controlling it improve so you get less coughing and sneezing and leaking.

So, of course, if we can thicken the skin in the vagina with oestrogen or with the MonaLisa Touch® then it will thicken the skin in the bladder. So that's how it works and - as I said - that's the most likely reason for it but - as I said - it just improves all the collagen and the elasticity and the irritability by thickening it up that's the easiest way I can see why it works.

Louise King

Okay, thank you. So, our last question. It's a rather long one so I’ll try and say it slowly!

Since breast cancer chemo Tamoxifen - which brought about early menopause - I can no longer have penetrative intercourse, partly due to the symptoms mentioned but I also can no longer take anything larger than a finger and just no amount of trying to override the pain will work. Will this treatment help with what appears to be shrinkage of the vagina capacity?

Mr Connell

Okay so the first thing is if you if you can't get your finger in and the MonaLisa Touch® is the same size as my thumb, then that may be one issue. If it's because of scarring at the opening, then - as I said before - you may have to make a little nick to just open the opening.

But yeah, I mean the whole point of using Tamoxifen - as I said - is much less of a problem for this than Letrozole and newer ones. But women still get it because it's an anti-oestrogen. So, I think, without pushing you to come and see somebody you need to be examined to see exactly what the problem is. If it's the scarring on the outside, that you can't get in but inside is much better capacity, then making a little nick may help.

Of course, if you think about it, if you've got very sore skin at the opening of the vagina then having sex can split the skin. When it heals, it heals in a catabolic way rather than a young, anabolic way and that scarring gives you more scarring and more fibrosis - so you end up getting more and more scarring and a tighter vagina which is very inelastic. So sometimes you do have to make a little nick in order to open it, so you get the capacity back.

But again, the first thing I would do is - if you're not keen to have oestrogen - would be to use the coconut oil and gently massage the back end where that scar tissue could be and then, if that doesn't help, then to be examined and decide which way we're going to go with that.

Louise King

Thank you. Okay, so that's all the questions we have time to answer today and if we haven't answered your question then please do them just send it again with your name and no one else will see and then we can get back to you or email their email address with them the question and we'll get back to those.

So, thank you very much, Mr Connell it's really interesting, thank you. And after this presentation you'll receive a short survey just to gain your thoughts on what you liked and didn't like, what we can improve the next time. So please do feedback.

And why not join - as you can see on the screen - our next gynaecology webinar with Consultant Gynaecologist Mr Gupta and our Specialist Nurse, Jan Chaseley, to find out how to control your bladder specialist treatments. We also have an orthopaedic webinar on the 9th of September and if you want to join that - or you know someone that'd be interested - in hip or knee replacements.

So, on behalf of Mr Connell, myself and the team at Benenden Hospital I'd like to say thank you very much for joining us today and we look forward to seeing you again soon thank you.

Mr Connell

Thank you, bye-bye!