Abstract

Topical vaginal estrogen is considered the gold standard therapy for GSM-associated dyspareunia, but early investigations of energy-based devices show promise for patients with contraindications or who are refractory to vaginal estrogen cream. While 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 to existing therapies is also critically important, but often understudied.We sought to perform a cost-effectiveness analysis of three therapies for GSM including vaginal estrogen, oral ospemifene and vaginal CO2 laser therapy and determine if vaginal laser therapy is a cost-effective treatment for dyspareunia associated with GSM.An IRB-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, one-way and two-way sensitivity analyses were performed to assess how changes in the model's input parameters altered the overall outcome of the cost-effectiveness model.All three treatment methods were found to be cost-effective below the WTP threshold of $50,000 per QALY for moderate dyspareunia. The ICER for vaginal CO2 laser treatment of moderate dyspareunia was $16,372.01 and the ICER for ospemifene was $5,711.14. Although all three treatment strategies were on the efficient frontier, vaginal CO2 laser treatment was the optimal strategy with the highest effectiveness. In a one-way sensitivity analysis of treatment adherence, the vaginal CO2 laser was no longer cost effective when the adherence fell below 38.8%. Vaginal estrogen cream and ospemifene remained cost-effective strategies at all ranges of adherence. When varying the adherence to 100% for all strategies, oral ospemifene was "dominated" by both vaginal fractional CO2 laser therapy and vaginal estrogen cream. In a two-way sensitivity analysis of vaginal CO2 laser adherence and vaginal CO2 laser cost, vaginal CO2 laser therapy still remained the optimal strategy at 200% of its current cost ($5,554.00) if the adherence was greater than 55%. If the cost fell to 20% of its current cost ($555.40), it was the optimal strategy at all adherence values above 29%.The present study showed that the vaginal fractional CO2 laser is a cost-effective strategy for the treatment of dyspareunia associated with GSM, as are vaginal estrogen and oral ospemifene. In our model, the vaginal CO2 laser is the optimal cost-effective strategy and consideration should be made to providing insurance coverage for this treatment option.

View details for DOI 10.1016/j.ajog.2020.06.032

View details for PubMedID 32562659