Genitourinary syndrome of menopause (GSM) affects up to 50% of menopausal women via vulvovaginal atrophy (VVA), as well as urinary and sexual disorders, compromising quality of life (QoL) and sexual health. GSM is caused by the physiological decline in estrogen level, with reduced vascularization and blood flow and loss of vaginal tissue elasticity [1, 2].

The Italian Atrophy of the vaGina in womAn in posT (AGATA) study confirmed that a clinical diagnosis of VVA (dyspareunia, dryness, mucosal irritation, itching, and dysuria) has a prevalence of 64.7–84.2% in the first 6 years of the onset of menopause. Several studies confirmed that VVA symptoms already begin during perimenopause and early post-menopause [3].

Several therapeutic options have been proposed for the relief of GSM symptoms, including both hormonal and non-hormonal treatment. Early intervention is recommended, especially when there are severe signs and symptoms of atrophy. Furthermore, the optimal treatment course must be as personalized as possible in light of the varying clinical and social factors of menopausal women.

Non-hormonal therapies, such as vaginal moisturizers and lubricants, can be a valid first choice for the improvement of sexual activity, particularly in combating itching, burning and dyspareunia, in those patients who are fearful or skeptical about hormone therapy [4, 5]. Low doses of estrogen hormone therapy, in different formulations, remain the gold standard treatment for moderate to severe VVA and for those women who are not satisfied from the use of lubricants or moisturizers [6]. The prescription of topical estrogen is a controversial topic in women with history of breast cancer, hormone-sensitive cancer, and thromboembolism, making treatment alternatives necessary. Intra-vaginal testosterone as well as a new class of drugs, such as selective estrogen receptor modulators (SERMs), are valid alternative treatments of VVA [7]. Ospemifene 60 mg/day was the first non-estrogen therapy for women affected by vaginal atrophy and dyspareunia [8].

Over the last years, fractional CO${}_2$ laser therapy has been an emerging, effective, and safe choice for women affected by VVA. Several studies confirm the efficacy and safety of CO${}_2$ laser treatment with its improvements to blood flow in vaginal epithelium, muscle and collagen tone, and elasticity of the vaginal wall, and findings similar to a premenopausal state, restoring vaginal flora to premenopausal status with predominant lactobacilli [9, 10, 11, 12]. The combined use of local estrogen and fractional CO${}_2$ laser seems to be advantageous and effective, confirming a synergistic action [13]. Increased attention has been paid to gynecological cancer survivors, especially those who are young and/or with symptoms of VVA due to surgical or pharmacological menopause. Attention to sexual life and quality of life (QoL) is mandatory to the complete care of these cancer survivors. Breast cancer patients are the most representative; several studies confirmed the efficacy and safety of laser treatment on these cancer survivors.

For postmenopausal women under anti-estrogen therapy, the LAAVA pilot study showed a significant efficacy of three CO${}_2$ laser sessions on symptoms of VVA, such as dryness, itch, burning, dysuria, and dyspareunia [14]. A recent summary of Royal College of Obstetricians and Gynecologists (RCOG) concluded that laser treatment could be a valid non-hormonal therapeutic choice for GSM treatment; however, uncertainties remain concerning its safety and long-term efficacy. Studies focused on laser efficacy present several limitations, including small sample size and lack of randomized controlled trial and short-term follow-up. Furthermore, the efficacy of laser treatment reduces with time, reverting to the baseline situation. Due of these limitations, the RCOG concluded that vaginal estrogen remains the gold standard for treating symptoms of GSM [15].

Signs and symptoms of VVA are very common between menopausal women, worsening their QoL and sexual health; the choice of a therapy depends on a variety of factors, such as patient preference and treatment effectiveness and safety. It is critical to act expeditiously and to adapt the personalized treatment to each woman, considering not only medical history, but anxieties and fears typical of this delicate stage of life.