Background
Topical vaginal estrogen therapy is considered the gold standard treatment for genitourinary
syndrome of menopause-associated dyspareunia, but early investigations of energy-based
devices show promise for patients with contraindications or those who are refractory
to vaginal estrogen cream therapy. Although evaluating safety, efficacy, and long-term
outcomes for novel technologies is critically important when new technologies become
available to treat unmet healthcare needs, evaluation of the costs of these new technologies
compared with existing therapies is also critically important but often understudied.
Objective
We sought to perform a cost-effectiveness analysis of 3 therapies for genitourinary
syndrome of menopause, including vaginal estrogen therapy, oral ospemifene therapy,
and vaginal CO2 laser therapy and determine if vaginal laser therapy is a cost-effective treatment
strategy for dyspareunia associated with genitourinary syndrome of menopause.
Study Design
An institutional review board–exempt cost-effectiveness analysis was performed by
constructing a decision tree using decision analysis software (TreeAge Pro; TreeAge
Software, Inc, Williamstown, MA) using integrated empirical data from the published
literature. Tornado plots and 1-way and 2-way sensitivity analyses were performed
to assess how changes in the model’s input parameters altered the overall outcome
of the cost-effectiveness analysis model.
Results
All 3 treatment methods were found to be cost-effective below the willingness-to-pay
threshold of $50,000.00 per quality-adjusted life year for moderate dyspareunia. The
incremental cost-effectiveness ratio for vaginal CO2 laser therapy was $16,372.01
and the incremental cost-effectiveness ratio for ospemifene therapy was $5711.14.
Although all 3 treatment strategies were on the efficient frontier, vaginal CO2 laser therapy was the optimal treatment strategy with the highest effectiveness.
In a 1-way sensitivity analysis of treatment adherence, vaginal CO2 laser therapy was no longer cost-effective when the adherence fell below 38.8%. Vaginal
estrogen cream and ospemifene therapies remained cost-effective treatment strategies
at all ranges of adherence. When varying the adherence to 100% for all strategies,
oral ospemifene therapy was “dominated” by both vaginal CO2 laser therapy and vaginal estrogen cream therapy. In a 2-way sensitivity analysis
of vaginal CO2 laser therapy adherence and vaginal CO2 laser therapy cost, vaginal CO2 laser therapy still remained the optimal treatment strategy at 200% of its current
cost ($5554.00) when the adherence was >55%. When the cost fell to 20% of its current
cost ($555.40), it was the optimal treatment strategy at all adherence values above
29%.
Conclusion
This study showed that vaginal fractional CO2 laser therapy is a cost-effective treatment strategy for dyspareunia associated with
GSM, as are both vaginal estrogen and oral ospemifene therapies. In our model, vaginal
CO2 laser therapy is the optimal cost-effective treatment strategy, and insurance coverage
should be considered for this treatment option if it is proven to be safe and effective
in FDA trials.
Key words
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Article Info
Publication History
Published online: June 17, 2020
Accepted:
June 10,
2020
Received in revised form:
June 2,
2020
Received:
February 5,
2020
Footnotes
This study was supported by a grant from the Foundation for Female Health Awareness.
E.R.S. reports grant funding from the National Institutes of Health , Foundation for Female Health Awareness, Cook MyoSite, Coloplast , and ACell, owns shares of stock in Pelvalon and received travel reimbursement from Contura, and also received grant funding to Stanford University from Cynosure. The other authors report no financial disclosure or conflict of interest with the manufacturers or any of the drugs or devices studied.
Cite this article as: Wallace SL, St Martin B, Lee K, et al. A cost-effectiveness analysis of vaginal carbon dioxide laser therapy compared with standard medical therapies for genitourinary syndrome of menopause-associated dyspareunia. Am J Obstet Gynecol 2020;223:890.e1-12.
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