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Menopause: Aging Gracefully
- 1. Menopause: Aging Gracefully We want to have it all! Ann Steiner MD, CNMP, FACOG Clinical Professor of OBGYN Director Menopause Clinic, Dickens Center for Women, HUP Penn Health for Women
- 2. U.S. population aged 65 and older Jacobsen LA, Population Reference Bureau66(1),1–20(2011).
- 3. APGO Objectives Videos and teaching cases, item#47 Menopause,https://www.youtube.com/watch?v=vB6x5tDGqDE&list=PLy35JKgvOASnHHXni4mjXX9kwVA_YMDpq&index=37, accessed 10/25/2015.
- 4. What happens to us when the estrogen goes away?
- 5. Your hormones aren’t out of balance! This is maybe your new normal But you may have bothersome symptoms which need to be treated
- 8. VMS Frequency As many as 75-80% of peri/postmenopausal women in U.S. report hot flashes • Severe in 10%-15% of women • Highest occurrence during perimenopause and first 2 years of postmenopause • Typically last 5-7 years • Some persist for a lifetime but usually decrease in frequency and intensity over time • 9% after age 70 Freeman EW Climacteric 2007;10:197-214 Cray LA Menopause 2012;19:864-9; Butts L et al., Hum Reprod Update 2007; 13SF JCEM 2012;97:E1032-42 Huamd et al, 2008, Arch Int Med 168: 840-846 Dennerstein L et al., Hum Reprod Update 2007; 13:551-557
- 9. TREATMENT OF VMS Treatment based on her symptom severity, risk factors, and her personal preferences and expectations • Lifestyle changes • Non FDA approved dietary supplements and nonhormonal prescriptions • FDA approved formulations of Oral Contraceptive Pill (off label), Hormone Therapy, SSRI http://www.menopause.org/docs/professional/htcharts.pdf?sfvrsn=6
- 10. Nonhormonal management of VMS: Summary levels of evidence and recommendations POSITION STATEMENT Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society Menopause, Vol. 22, No. 11, 2015
- 12. Gabapentin for treatment of Hot Flashes (800 mg TID vs CE 0.625mg qd vs placebo) Reddy S et al. Obstet Gynecol 2006; 108:41
- 13. On the Horizon: Nitroglycerin patch
- 15. FDA Approved Nonoral vs Oral Estrogen
- 16. NAMS Recommendations • The lowest dose of HT should be used for the shortest duration needed to manage menopausal symptoms • Hormone therapy should not be prescribed for chronic disease prevention Menopause, Vol. 21, No. 10, 2014
- 17. 2 drinks a day 4-5 drinks a dayBritish Journal of Cancer (2002) 87, 1234–1245. www.bjcancer.com Published online 12 November 2002
- 19. Compounding Pharmacy Industry makes $2.6 Billion a year more.com | october 2013
- 20. • Estrogens were mostly superpotent, ranging from 95.9 to 259 percent of the prescribed Estradiol • Progesterone data showed that most samples delivered about 80 percent of the prescribed amount, although one sample contained less than 60 percent of the progesterone prescribed. more.com | october 2013
- 21. Use of compounded hormone therapy in the United States: report of The North American Menopause Society Survey Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284
- 22. Sexual function • Pain with sex • Partner • Self image • Incontinence • Sleep disturbance and fatigue • Stress • Medications such as SSRIs, Beta blockers • Substance/ETOH abuse • Low desire Flibanserin approved for hypoactive sexual desire disorder in premenopausal women -norepinephrine-dopamine disinhibitor
- 23. Vulvovaginal Atrophy (VVA) Genitourinary Syndrome of Menopause (GSM)
- 24. Nonhormonal treatment • Regular sexual activity to promote blood flow to the genital area • Vaginal lubricants and moisturizers • Practice sensible vulvar hygiene-Avoid abrasive cleaning and products such as harsh soaps etc, wear cotton
- 25. Local Vaginal Estrogen Therapies
- 28. Fractional Laser Treatment of Vulvovaginal Atrophy
- 29. Fractional Laser Treatment of Vulvovaginal Atrophy and U.S. Food and Drug Administration Clearance Position Statement The American College of Obstetricians and Gynecologists and The American Congress of Obstetricians and Gynecologists The purpose of this Position Statement is to advise obstetrician– gynecologists and patients that this technology is, in fact, neither approved nor cleared by the FDA for the specific indication of treating vulvovaginal atrophy. Approved by the Executive Board: May 2016
- 31. Remember to take care of yourself! Stress reduction Mindfulness Exercise Healthy diet and weight Eliminate unhealthy habits
- 32. The North American Menopause Society Menopause.org
- 33. Menopause and sleep Women in the menopause transition are more likely to report perceived sleep disturbance, but objective reports do not confirm an association between perimenopause/menopause and sleep disruption – Nocturnal urination – Sleep disorder i.e. sleep apnea – Pain – Mood – Stress – Night sweats
- 34. The association of acupuncture with changes in sleep disturbances in perimenopausal and postmenopausal women Chiu et al OBSTETRICS & GYNECOLOGY VOL. 127, NO. 3, MARCH 2016 pp 507-515
- 36. Weight Gain: Aging vs. Menopause Menopause menopause
- 37. Anatomy a HOT FLASH Kronenberg F Maturitas 1984;6:31-43; Freedman RR J Clin Endocrinol Metab 1995;80:2354- 8; Molnar GW J Appl Physiol 1975;38:499-503
- 38. PATHOPHYSIOLOGY OF A HOT FLASH Freedman, RF, Sem Repro,Med, 2005; 23(2): 117-125
- 39. Purthi, S et al, Current Overview of the Management of Urogenital Atrophy in Women with Breast Cancer, The Breast Journal, vol. 17, issue 4, pp. 403-408. July/August 2011
- 42. MsFlash Menopause Stratagies, Finding Lasting Answers for Symptoms and Health: Change in Hot Flash Frequency Guthrie KA, et al. Obstetric Gynecol VOL. 126, NO. 2, AUGUST 2015
- 43. New on the Horizon: Stellate ganglion block
- 46. “Natural” Hormones Producing compounded estrogen requires a minimum of 15 chemical reactions in a laboratory, yielding an end-product that is no longer ‘‘natural,’’ even if the original source is plant based. In addition, there are opportunities for unrecognized errors in production of C-HT products because FDA oversight is lacking. Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284
- 47. Use of compounded hormone therapy in the United States: report of The North American Menopause Society Survey Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284
- 48. Use of compounded hormone therapy in the United States: report of The North American Menopause Society Survey Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284
- 49. HT Summary • FDA approved HT is an appropriate treatment option for healthy women with moderate-severe VMS • HT is not indicated for primary or secondary disease prevention • Younger and recently menopausal women are the best candidates for HT when indicated • Breast cancer risk does not increase appreciably with short term use of HT • Use the lowest dose of HT for the shortest duration needed
- 50. Hormonal treatment • Estrogen has been proven to restore vaginal blood flow, decrease vaginal pH, and improve the thickness and elasticity of vulvovaginal tissue • Ospemifene (SERM) an oral agent recently approved for vaginal atrophy • If vasomotor symptom relief or osteoporosis prevention is not required, low-dose local estrogen, not systemic estrogen, is recommended NAMS Menopause 2012;19:257-71
- 51. 10
- 52. Sexual function • Libido decreases with age in both men and women • Psychosocial, interpersonal, biologic factors • Distressing sexual issues peak ages 45-64, lowest after age 65
- 53. Vaginal Laser
Editor's Notes
- We all want to live a full and complete life in good health mentally and physically How do we balance being the best that we can be with growing older?
- In the US age at menopause ranges from 40-58 years of age In 2000, there were 46 million postmenopausal women By 2020, there will be >50 million women over age 51 A woman’s life expectancy in the United States is estimated at 80.5 years Currently 1/3 to 1/2 of the lifespan of most North American women
- At puberty ovulation begins along with estrogen from the ovary, maturing us into women and allowing us to reproduce
- Dr Mitchell has told you about the effects on our bones and on our risk of fractures
- Most severe in surgical menopause May be more severe in smokers
- S equol derivitives soy isoflavones Daidzien, genistennon steroidal metabolized in the gut and activates the ERbeta receptor Genisten found in chickpeas(small amt), tofu, soymilk &flour, miso etc
- Clinical studies have shown that nitric oxide (NO) plays an important role in mediating peripheral vasodilation during hot flashes, with local cutaneous blockade of NO synthase suppressing hot flash-related vasodilation.5-7 One pharmacologic agent with direct and potent effects on NO-mediated vasodilation is nitroglycerin, an organic nitrate that is widely used to treat chest pain in patients with coronary disease. Intermittent use of nitroglycerin triggers release of NO, promotes vascular smooth muscle relaxation, and triggers vasodilation. However, continuous use of nitroglycerin rapidly leads to tolerance to the drug’s vasodilatory effects and cross-tolerance to endogenous nitrates, as a result of enhanced NO degradation.8-13 Although this tolerance limits the usefulness of nitroglycerin for chest pain, it offers a potentially innovative approach to treating hot flashes, because women who develop cross-tolerance should experience a marked reduction in hot flashes as a result suppression of NO-mediated peripheral vasodilation.
- . Individualization is important in the decision to use HT and should incorporate the woman’s personal risk factors and her quality-of-life priorities in this shared decision.
- Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19–1.45, P<0.00001) for an intake of 35–44 g per day alcohol, and 1.46 (1.33–1.61, P<0.00001) for 45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5–8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis
- Consequently, in 2002, bio identical hormones, marketed as safer than commercial HT products because they were more natural, started to take off. Prempro, the only drug used in one arm of the large-scale Women’s Health Initiative (WHI), was linked with serious medical problems—such as an increased risk of heart attack, stroke, blood clots and invasive breast cancer. Bioidentical estrogen and progesterone are made from diosgenin, a plant-derived sterol found in wild yams, and are identical in molecular structure to hormones produced in a woman’s body At this point, the safety advantages of BHT are only hypothetical. claimed that customized compounded BHT would help women regain their libidos and youthful bodies. The clincher was that BHT would do all that without making them vulnerable to the many risks described in the WHI study. claimed that customized compounded BHT would help women regain their libidos and youthful bodies. The clincher was that BHT would do all that without making them vulnerable to the many risks described in the WHI study.
- From 2001 to 2008, the number of adult women filling one or more commercial HT prescriptions annually fell, from 17.9 million to 5.8 million, a decrease of 68 percent. IN THE SPRING OF 2012, the New England Compounding Center in Framingham, Massachusetts, shipped nearly 18,000 vials of an anti-inflammatory medication used in spinal injections. Produced in a facility not subject to federal requirements for sterile conditions, the drug was contaminated with a fungus, and 749 patients became ill, over half with fungal meningitis. Sixty three died. With partial funding from the Fund for Investigative Journalism, More commissioned lab tests of bioidentical hormones produced by 12 compounding pharmacies nationwide. There are currently 7,500 compounding pharmacies in the U.S., up from about 2,000 in 2007, with sales of about $2.5 billion a year. Because the FDA is not in the picture, drugs formulated by these companies do not undergo the rigorous clinical trials required of medicines made by commercial pharmaceutical companies. Nor are compounded drugs—an estimated 3 percent of prescriptions in the U.S.—
- 1st treat vaginal atrophy in addressing libido issues Change from SSRI to bupropionmay increase libido Androgen levels do not predict sexual function, giving androgen can improve sexual function in PMP women Flibanserin between 0.5 and 1 additional sexually satisfying event per month than women taking placebo. changes the norepinephrine, dopamine and serotonin levels. You take it every day and it takes a couple weeks to really reach peak effect. Flibanserin preferentially activates 5-HT1A receptors in the prefrontal cortex, demonstrating regional selectivity, and has been found to increase dopamine and norepinephrine levels and decrease serotonin levels in the rat prefrontal cortex, actions that were determined to be mediated by activation of the 5-HT1A receptor.[14] As such, flibanserin has been described as a norepinephrine-dopamine disinhibitor (NDDI). ETOH warning
- In premenopausal women the vagina is lined with glycogen rich squamous epithelium WELL VASCULARIZED AND LUBRICATED. Estrogen is the main regulator of vag physiology. E receptors are highest in the vagina, lowest in the skin/vulva. Androgen is the opposite Loss of estrogen leads to increase in pH Vaginal atrophy describes the vaginal wall that is thin, pale,less elastic, less rugated, less blood flow dry sometimes inflamed. More likely to be traumatized. Sebaceous glands more prominent. Wet prepwbs, parabasal cells, fewer superficial cells fewer lactobacilli. Atopobium Vaginae normal postmenopause may cause false + for BV in symptomatic menopaual women Atrophic changes are immediate, change in collagen, blood flow, muscle tone later. Few sx if not SA
- Ospemifene at daily doses of 30 to 90 mg clearly had a rather strong estrogenic effect on the vaginal epithelium during a 3-month treatment period-2 studies. 1 yr study-no VTE, endometrial abnormality but sl increase in VMS (180 pts). Safety in breast CA not studied Only approved SERM for this indication in the US
- However, these observational trials do not evaluate the use of concomitant treatments, and they lack long-term follow-up (trials assessed follow-up at 12 weeks). No randomized trials or comparative effectiveness studies have been published (www.medscape.com/viewarticle/846960). Although initial data indicate potential utility, additional data clearly are needed to further assess the efficacy and safety of this procedure in treating vulvovaginal atrophy, particularly for long-term benefit. Obstetrician–gynecologists should be cognizant of the evidence regarding innovative practices, and should be wary of adopting new or innovative approaches on the basis of promotions or marketing In September 2014, the SmartXide2 CO2 laser from the Italian company DEKA, along with a CO2 laser from the American company Cynosure, were cleared by the US Food and Drug Administration (FDA) for "incision, excision, vaporization and coagulation of body soft tissues in medical specialties including aesthetic (dermatology and plastic surgery), podiatry, otolaryngology (ENT), gynaecology, neurosurgery, orthopaedics, general and thoracic surgery (including open and endoscopic), dental and oral surgery and genitourinary surgery. The use with the scanning unit is indicated for ablative skin resurfacing."[1] Subsequently, a laser system called the MonaLisa Touch for the treatment of vulvovaginal atrophy (VVA) and other symptoms of the genitourinary syndrome of menopause (GSM) has been marketed using this device. clearance for the device was as described above and not specifically indicated for use in VVA. Lasers have become a very costly option for the treatment of symptomatic VVA, without a single trial comparing active laser treatment to sham laser treatment and no information on long-term safety. In all published trials to date, only several hundred women have been studied and most studies are only 12 weeks in duration. Some companies claim that the laser, once activated, removes dried skin and revitalizes and stimulates collagen renewal. Researchers have demonstrated that the laser stimulates collagen synthesis, similarly as the technology does in plastic surgery procedures for the face. The procedure is made up of three three-minute laser sessions, each six weeks apart. It’s relatively painless and no anesthesia or painkillers are required. the laser removes the dried skin which stimulates the collagen revival
- Sleep hygiene
- In summary, the present findings show a substantial association of acupuncture with improved sleep disturbances in perimenopausal and postmenopausal women. Furthermore, we demonstrated that the association of reduction in menopause-related sleep disturbance and acupuncture was correlated . Therefore, we recommend that acupuncture should be adopted as an alternative or complementary therapy for improving sleep in addition to current conventional therapies (eg, HT) in women experiencing menopause-related sleep disturbances . Acupuncture was associated with significant elevations of the serum estradiol level with a pooled difference y. Furthermore, pooling resulted in a statistically significant difference in means of 26.75 in FSH
- The change in the hormone status at menopause is associated with an increase in body fat and in particular an increase in abdominal fat that is related to several adverse health problems. Studies have shown that aerobic or endurance exercise can counter unwanted weight gain in postmenopausal women. A lifestyle intervention program with premenopausal women aged 44 to 50 years showed better weight maintenance compared with controls over 5 years using a low-fat dietary and physical activity program. What is still unknown is how sex hormones can be manipulated to alter fat deposition for health benefits As people age, the tendency is to become more sedentary and to maintain the same caloric intake. Lean muscle decreases, and fat deposits increase. For women, muscle is the largest reservoir of estrogen receptors in the body. As estrogen declines, muscle volume and function decline. Lean muscle is a prime caloric burner and does so less effectively as this lean muscle is lost. BMI is an imperfect indicator of a person’s health- elderly can even have some protection in being overweight when the fat layer serves as an energy source in combating chronic diseaseIn the United States, 66% of women aged 40 to 59 years and more than 73% of women aged 60 years or older are overweight, defined as a body mass index (BMI) greater than 25 kg/m2 . Approximately 40% of those age groups are obese, defined as a BMI at or above 30 kg/m2 . The prevalence of obesity has been increasing over time, although it appears to have stabilized over the past 10 years at approximately 35% for adult women.6 However, there is no scientific evidence that menopause or hormone therapy is responsible for midlife weight gain. Aging is associated with slowing of the metabolism. Lean body mass decreases with age while body fat accumulates throughout adulthood. Although menopause may not be directly associated with weight gain, it may be related to changes in body composition and fat distribution. Several studies have shown that perimenopause, independent of age, is associated with increased fat in the abdomen as well as decreased lean body mass. This suggests that menopause plays a role in many midlife women’s transition from a pear-shaped body (wide hips and thighs, with more weight below the waist) to an apple-shaped body (wide waist and belly, with more weight above the waist The bottom line: you have to “run to stay in place.” Females differ with respect to distribution of adipose tissues, males tend to accrue more visceral fat, leading to the classic android body shape which has been highly correlated to increased cardiovascular risk; whereas females accrue more fat in the subcutaneous depot prior to menopause, a feature which affords protection from the negative consequences associated with obesity and the metabolic syndrome. After menopause, fat deposition and accrual shift to favor the visceral depot. This shift is accompanied by a parallel increase in metabolic risk reminiscent to that seen in men. Approximately 80% of all body fat is in the subcutaneous depot and lies just under the skin primarily around the waist, in the subscapular area, and in the gluteal and femoral (thigh) areas. Visceral fat, accounting for 10–20% of total fat, is in the abdomen primarily in the omentum and mesentery but also in perirenal, gonadal, epicardial, and retroperitoneal depots. Visceral fat accounts for a higher percentage of total fat in men than in women. In men adipose tissue preferentially accumulates in the visceral depot while fat accumulation is primarily in the subcutaneous depot in women. The magnitude of this difference is amplified from late puberty to early adulthood as men develop the typical android body shape while women a more gynoid shape. Menopause is followed by redistribution of adipose tissue to the visceral depots leading to a more central or android shape in post-menopausal women who are not hormone replaced. Estrogens protect against increased body adiposity/obesity through their effects to suppress appetite and increase energy expenditure. Estrogens also protect against weight gain by increasing energy expenditure. Many postmenopausal women gain body weight due the natural decrease in endogenous estradiol levels during menopause and reductions in energy expenditure can be prevented by estrogen replacement therapy. Premenopausal women tend to store fat on the hips, thighs and buttocks, giving them a pear shape also called gynoid, or gluteal–femoral pattern of adipose tissue distribution. Men accumulate fat predominately in the abdominal region giving them an apple shape also referred to as android, or abdominal pattern of fat accrual with rapid rises also occurring within developing countries that are associated with a decrease in physical activity and the more widespread availability of energy-rich, nutrient-poor food. The accompanying health burden threatens to overwhelm many countries as a result of obesity-related morbidities such as type 2 diabetes, cardiovascular disease and osteoarthritis. It has therefore been postulated that the current generation will be the first in living memory to have a shorter life expectancy than their parents [2]. Adult females have more total body fat, which is predominantly located within the subcutaneous, gluteal and femoral deposits, whereas males tend to possess larger central visceral fat depots. These gender dimorphic depots tend to deposit more fat during weight gain, a difference that only disappears after the female menopause [50]. After this biological transition, females are more susceptible to increased adiposity within central abdominal locations, analogous to males. In females, progesterone and estrogen appear to induce a healthier metabolic profile in WAT, an effect that may be complemented by their stimulatory effects on BAT, at least in rodents. . Basic and preclinical research shows that the disruption of E2 signaling through either genetic manipulation or surgical intervention accelerates fat accumulation, with a disproportionate increase in abdominal fat. Clinical evidence for the regulation of body composition and bioenergetics by E2 is less consistent. Evidence exists both for and against menopause as the mediator of changes in body composition. Treatment of OVX animals with E2 prevents these phenotypic changes, thereby isolating E2 as the regulatory ovarian factor, and transgenic studies indicate that the effects are mediated, in large part, through ERα. The primary system-level mechanism for the increased fat accumulation is a decrease in energy expenditure, although energy intake also increases in some species. The lower energy expenditure is the result of a marked decline in spontaneous physical activity and a decrease in resting metabolic rate. Endocrinology and Metabolism Clinics of North America Volume 44, Issue 3, September 2015, Pages 663–676 Postmenopausal HT did not increase abdominal fat loss during weight loss
- Not completely understood-skin temp rises 2/2 vasodilatation. Body temp regulated by the hypothalamus. A sudden wave of heat spreads over the the body especially the upper body and face. Heart rate and skin blood flow peak within 3 minutes of onset Related to small fluctuations in core body –the “thermoneutral zone” is vastly reduced in symptomatic women Generally lasts 1-5 minutes
- The safety and effectiveness of Brisdelle were established in two randomized, double-blind, placebo-controlled studies in a total of 1,175 postmenopausal women with moderate to severe hot flashes (a minimum of seven to eight per day or 50-60 per week). The treatment period lasted 12 weeks in one study and 24 weeks in the other study. The results showed that Brisdelle reduced hot flashes compared to placebo. The mechanism by which Brisdelle reduces hot flashes is unknown.
- for women who suffer from moderate-to-severe hot flashes (vasomotor symptoms) associated with menopause and to prevent osteoporosis after menopause. Duavee is the first FDA approved medication that combines estrogen with an estrogen agonist/antagonist (bazedoxifene). The bazedoxifene component of Duavee reduces the risk of endometrial hyperplasia Duavee is intended only for postmenopausal women who still have a uterus. Like other products containing estrogen, Duavee should be used for the shortest duration consistent with treatment goals and risks for the individual woman. When using Duavee only for the prevention of osteoporosis, such use should be limited to women who are at significant risk of osteoporosis after carefully considering alternatives that do not contain estrogen. The most common side effects observed in patients receiving Duavee were muscle spasms, nausea, diarrhea, dyspepsia, upper abdominal pain, oropharyngeal pain, dizziness, and neck pain. Because Duavee contains estrogen, it is being approved with the same Boxed Warning and other Warnings and Precautions that have been approved with estrogen products.
- If participants were uncertain about the FDA approval status of their HT, they were given the following information: ‘‘FDA approved hormones have a brand name like Premarin, Vagifem, Estrace, Vivelle dot, Prometrium, and others, while compounded hormones are identified by generic terms like estrogen, estrone, or progesterone
- REMEMBER to ASK-3% will bring it up, 19% will want to discuss if you bring it up
- In September 2014, the SmartXide2 CO2 laser from the Italian company DEKA, along with a CO2 laser from the American company Cynosure, were cleared by the US Food and Drug Administration (FDA) for "incision, excision, vaporization and coagulation of body soft tissues in medical specialties including aesthetic (dermatology and plastic surgery), podiatry, otolaryngology (ENT), gynaecology, neurosurgery, orthopaedics, general and thoracic surgery (including open and endoscopic), dental and oral surgery and genitourinary surgery. The use with the scanning unit is indicated for ablative skin resurfacing."[1] Subsequently, a laser system called the MonaLisa Touch for the treatment of vulvovaginal atrophy (VVA) and other symptoms of the genitourinary syndrome of menopause (GSM) has been marketed using this device. clearance for the device was as described above and not specifically indicated for use in VVA. Lasers have become a very costly option for the treatment of symptomatic VVA, without a single trial comparing active laser treatment to sham laser treatment and no information on long-term safety. In all published trials to date, only several hundred women have been studied and most studies are only 12 weeks in duration. Some companies claim that the laser, once activated, removes dried skin and revitalizes and stimulates collagen renewal. Researchers have demonstrated that the laser stimulates collagen synthesis, similarly as the technology does in plastic surgery procedures for the face. The procedure is made up of three three-minute laser sessions, each six weeks apart. It’s relatively painless and no anesthesia or painkillers are required. the laser removes the dried skin which stimulates the collagen revival