Ivo Havlik, M. D.
Private Gynaecology-Obstetrical Practice, Hlucin, CZ

Introduction

A tendency to implement non-medicamentous ways of treatment, including physical therapy, aimed at reaching analgetic, anti-inflammatory and biostimulative effects, has been followed lately in gynaecological-obstetrical routine. LLLT is one of these methods. The author`s endeavour is to provide basic information on this particular kind of treatment in above mentioned disciplines. In relation to the issue it is also necessary to notice basic attributes of laser beam, as well as to mention some of the recent findings of biological effects about laser on a living tissue.

Laser beam is strictly monochromatic, it contains no color shades, and emitted light oscillates in one direction only - it is polarized. Organization of light cycles in time and space - its coherence -is quite a unique feature of a laser. Light particles hit irradiated area in rhythmical pulses which increase biological effect of laser irradiation.

All these characteristics result in analgetic effect of laser. Partial pressure of oxygen is increased in the area of incidence of laser. Laser irradiation regulates the bio-tonus of tissue through change of activity of electrical potential on neuro-muscular discs, as well as through change of polarization of Na+ and K+ on membranes of neuro-muscular funiculi. Pass of electrical activity on synopses is regulated by thin funiculi, resulting thus in muscle relaxation and analgetic effect. 

Anti-inflammatory effect. Activation of monocytes and macrofags, increased phagocytosis and accelerated proliferation of lymphocytes in the area of inflammation has been proven. Level of E2 prostaglandine is lowered. G+ bacteria and herpes zoster virus types are sensitive to laser irradiation, HPV seems to be sensitive, too.

Biostimulative effect. This effect is proven by higher number of cells in irradiated tissue, by increased replication of mitochondrial DNA in organellae, and by increased synthesis of DNA by up to 50 - 60 per cent. Laser irradiation brings stimulation of collagen, increased vascularization, quicker regeneration of vessels and maturation of epithelium.

What device to use? In our case we will talk only about low power lasers. These devices usually work with output between 5 - 40 mW. The laser source is either helium-neon (He-Ne) tube or a laser diode. Choosing the right wavelength is also important. A He-Ne laser works in the range of red light - 632.8 nm. It is suitable for superficial irradiation of tissue. A diode semiconductor laser reaches into the infrared area in the range between 670 - 904 nm. It is utilized for irradiation of deeper structures (joints etc.). In gynaecology it is possible to use both. Special vaginal lightguides are another important part of accessories.

What else must a doctor know? Especially, it is proper energy density in J/cm2. Usually it reaches from 0.2 to 2.0 J/cm2. In general, there is a rule that acute states require lower density whilst chronic deseases are treated with higher ones.

What is the irradiation mode, continuous or pulsed? We prefer pulsed mode for depth of penetration of pulsed light in tissue is more than double with the same intensity.

What modulation of the emission? Frequencies by E. Nogiér are deemed classical. Thus most devices work with 10 Hertz frequency. Nowadays manufacturers provide their devices with the possibility to adjust two or three various frequencies, besides of built-in software according to individual diagnoses where required parameters need not be calculated for it is possible to choose a particular diagnosis on the display of the device. In general, with frequency up to 5 Hz stimulative effect is expected, up to 8 Hz anti-oedematic effect, up to 10 Hz analgetic, and up to 25 Hz germicidal and viricidal effects come.

As far as the time of exposure is concerned, in general it can be said that irradiation time up to 5 minutes has stimulative effect, over this time the effect fades or even can be inhibitory.

Technique of Treatment and Modus Operandi

The main condition is a cleansed irradiation area, or a drained cavity (absces, haematoma). However, we have good experience also with opposite cases, where a quicker colliquation can be seen (and thus easier incision and depletion), or furunculi resorb in such a way that surgical intervention is not necessary. The same applies to haematoma (posttraumatic or postoperative). We recommend application of laser in the first (proliferous) phasis of the cycle (however teratogenic effects of laser irradiation have not been reported). Frequency and number of applications depend on the kind of disease, usually once a day (in acute stages - exfoliative alergic vulgovaginitis - even twice a day), followed by 5 to 7 applications every second day. Usually we finish with no more than 10 applications alltogether.

INDICATIONS IN GYNAECOLOGY

CERVICITIS, COLPITIS
Energy Density: 0.5 - 2.0 J/cm2 
Frequency Modulation: acute forms up to 3 Hz, chronic forms up to 10 Hz
Applications: Intravaginal, daily, 5 times

ABSCESS, FURUNCULUS OF VULVA
Energy Density: 0.5 - 2.0 J/cm2 
Frequency Modulation: 3 Hz to 10 Hz
Applications: Externally before or after drainage of cavity, in acute forms
twice a day, afterwards 6 or 7 times once a day

HERPES SIMPLEX, ZOSTER, HPV
Energy Density: 0.5 - 2.0 J/cm2 
Frequency Modulation: 5 - 10 Hz
Applications: Externally, intravaginally, 1 - 2 times a day, on HPV
infections repeatedly for 3 months in the first half of the cycle. If gravidity excluded, shorten the interval between irradiations to 14 days.

ECTROPIUM, TRANSFORMATION ZONE
(after coagulations, excisions, conizations)
Energy Density: 2.4 J/cm2 
Frequency Modulation: 5 Hz
Applications: Intravaginally, 5 - 7 times every second day, the main purpose
is to utilize immediate effect on tissue, when quicker healing of wounds can be noticed and thus shortening of period of unpleasant increased exudation. General prerequisite is to exclude clinical or suspective form of malignity.

DYSTROPHIA, CRAUROSIS VULVAE
Energy Density: 0.5 - 2.0 J/cm2 
Frequency Modulation: acute cases to 3 Hz, chronic cases up to 9 Hz
Applications: Once a day 5 times, followed by 2 times a week and further on
once a week till 12th - 15th irradiation. The method is accepted by patients very well thanks to extinction of unpleasant pruritus (usually after the third application). Objectively there appears "softening and increased elasticity" of the whole area which has a positive impact also on sexual activity. Malignity must be excluded, too. Good results can be expected with allergic contact disorders in the area of outer genitals, where we become usually helpless due to aetiology.

POSTOPERATIONAL WOUNDS
Energy Density: 0.1 - 2.0 J/cm2 
Frequency Modulation: 5 - 10 Hz
Applications: Individual points on the edge of the wound, central area later.
On larger areas meandring (about 10 sec. per sq. cm) every day. We prefer starting the first day after operation. Practically - after return from hospitalization, we do not hesitate to start. Patients appreciate analgetic and anti oedemative effects. Biostimulation results in consequential shortening of recovery. LLLT is utilized on clean as well as on infected and decayed wounds. Even in these cases we can expect good results, usually in combination with other therapies (we presume a good toilet, depletion of wound area, ATB treatment according to infectious agent etc.). Same applies to EPIZIOTOMIES. Here we can reach good analgetic and biostimulative effects in a short time. Scars become plain and elastic, we can see importance for sexual life and further deliveries. 

STIMULATION OF HEALING OF RHAGADES AFTER BREAST FEEDING, MASTITIS PUERP.
Energy Density: 0.5 - 2.0 J/cm2 
Frequency Modulation: up to 3 Hz
Applications: Once or twice a day, max. 5 irradiations sufficient

SKIN STRIAE, SCARS
Energy Density: 0.5 - 1.0 J/cm2 
Frequency Modulation: 50 - 100 Hz
Applications: 2x - 3x a week, continued with up to 30 applications. Therapy 
is complemented by applications of ointments, creams, silicon stripes. Interesting paper presented by Kimplova mentions applications on jelly-fish burns, previously treated for a long time with no effect (4 J/cm2, 10 - 25 Hz).

LEES FREQUENT INDICATIONS

STRESS INCONTINENCE
Energy Density: 0.5 - 0.7 J/cm2 
Frequency Modulation: 5 - 10 Hz
Applications: frontal wall of vagina in the area of trigon, every second day
up to ten applications.

IRRITATED URINARY BLADDER
Energy Density: 0.5 - 0.7 J/cm2 
Frequency Modulation: 10 Hz and more
Applications: frontal vaginal wall complemented by point irradiation of 
fossa of sacrum. 
HYPOTALAMIC-HYPOPHYSEAL DYSFUNCTION
Energy Density: 0.5 - 1.0 J/cm2 
Frequency Modulation: 3 Hz
Applications: intravaginally, two to three times. Rather quick haemostatic
effect is reported, thanks to reflexive stimulation of FSH and increased production of ovarial oestradiol. However, we have no direct experience.

In which cases it is not possible to use laser? Quite recently the list of contra-indications has been significantly reduced. According to Navratil the contra-indications can be divided as follows:

- Justified: applications close to the eye, malignant disease in the area of application, irradiation of neck in case of hyperthyroidism, irradiation of belly of gravid women till the sixth month, epilepsia, caution with applications of matters containing photosenzibilizing components.
- Justified in certain cases: febricity, disorders in haematogenesis, applications in the area of gonads (however, no teratogenic and/or mutagenic effects have been reported).
- Disputable: patients with implanted pacemakers, states of exhaustion, cachexia, drugs addiction, children with aggravated expressive or grasping ability.

CONCLUSION

On the basis of its analgetic, anti-inflammatory and biostimulative effects therapy with low power laser (LLLT) appears to be a prospective physical therapy. It has been more and more utilized in gynaecology, provided that all hygienic and security regulations are duly observed and adhered to.


Pictures:

Eczema contactum alergicum (alergy on sanitary pads with wings)
Dose: 1.5 J/cm2, frequency modulation: 4.3 Hz, power: 30 mW
Improvement after 3 applications in 3 days

Literature with the author