Hyaluronic acid used in the female genital area: technique proposal

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Elisabetta Garavaglia
Giacomo Dell’Antonio
Eleonora Bellani
Antonello Tateo


hyaluronic acid, genitourinary syndrome, vulvovaginal atrophy, labia majora augmentation, genital biostimulation


Background: external female genitalia lose elasticity and volume with age due to a deficiency of oestrogen leading to hormonal and anatomical changes in the genitourinary tract, with vaginal dryness, dyspareunia, and reduced lubrication. Most of these symptoms can be attributed to a syndrome called genitourinary syndrome (GS) which affects approximately 27% to 84% of postmenopausal women; GS is associated to vulvo-vaginal atrophy (VVA) impairing health, sexual function, and quality of life. The primary goal of the treatment of VVA is to relive all these symptoms. The First-line treatment consists of non-hormonal therapies such as lubricants, while hormonal therapy is generally considered the “gold standard’’, although some women may experience side effects. Newer therapeutic approaches with hyaluronic acid can be employed as alternative options to achieve faster results and without any side effects, but further research is required to standardize techniques and to investigate the scope of their implementation in a daily clinical practice.

Aim: to report the description of two specific techniques regarding: 1) the labia majora augmentation, using the cross-linked hyaluronic acid with an aesthetic goal and 2) the vulvo-vaginal bio-stimulation, using an injection of high and low molecular weight HA (HCC), as a treatment of the genito-urinary syndrome pre- and post-menopause.


Materials and methods: cross-linked hyaluronic acid injections have been performed into the fibrous tunic using a 25 G (70 mm) nano-cannula with 2 ml of product for each side. HCC injections, however, have been administered around the vulvar vestibule, following a linear retrograde technique: one injection at the anterior (0.3 mL), one at the posterior entries (0.5 mL), and two injections into each of the lateral sides (0.3 mL) using a 29 G 13 mm long needle (Picture 7). The outcome assessment included genital examination images and histological biopsies.

Results: cross-linked hyaluronic acid is an effective treatment for women who wish to seek a youthful genital appearance; in addition, genital examination images and histological biopsies show the ability of HCC to increase thickness in the epithelial layer and dermo-epidermal junctions, decreasing the infiltration of T lymphocytes.

Conclusions: HCC injections in the vaginal-vestibular area are associated with tissue regeneration of atrophic tissues in pre and post-menopausal women, with moderate-to-severe symptoms associated with vulvo-vaginal atrophy (VVA).

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1. Keen MA. Hyaluronic Acid in Dermatology. Skinmed. 2017; 15(6):441-448.
2. Stellavato A, Corsuto L, D’Agostino A, et al. Hyaluronan Hybrid Cooperative Complexes as a Novel Frontier for Cellular Bioprocesses Re-Activation. PLoS ONE. 2016; 11(10):e0163510.
3. D'Agostino A, Stellavato A, Busico T, et al. In vitro analysis of the effects on wound healing of high- and low-molecular weight chains of hyaluronan and their hybrid H-HA/-HA complex. BMC Cell Biol. 2015; 16:19.
4. Stellavato A, La Noce M, Corsuto L, et al. Hybrid Complexes of High and Low Molecular Weight Hyaluronans Highly Enhance HASCs. Differentiation: Implication for Facial Bioremodelling. Cell Physiol Biochem. 2017; 44(3):1078-1092.
5. Stellavato A, Abate L, Vassallo V, Donniacuo M, Rinaldi B, Schiraldi C. An in vitro study to assess the effect of hyaluronan-based gels on muscle-derived cells: Highlighting a new perspective in regenerative medicine. PLoS One. 2020; 15(8):e0236164.
6. Bukhari SNA, Roswandi NL, Waqas M, et al. Hyaluronic acid, a promising skin rejuvenating biomedicine: A review of recent updates and pre-clinical and clinical investigations on cosmetic and nutricosmetic effects. Int J Biol Macromol. 2018; 120(Pt B):1682-1695.
7. Hong L, Shen M, Fang J, et al. Hyaluronic acid (HA)-based hydrogels for full-thickness wound repairing and skin regeneration. J Mater Sci Mater Med. 2018; 29(9):150.
8. Laurino C, Palmieri B, Coacci A. Efficacy, Safety, and Tolerance of a New Injection Technique for High- and Low-Molecular-Weight Hyaluronic Acid Hybrid Complexes. Eplasty. 2015; 15:e46.
9. Alessio N, Stellavato A, Squillaro T, et al. Hybrid complexes of high and low molecular weight hyaluronan delay in vitro replicative senescence of mesenchymal stromal cells: a pilot study for future therapeutic application. Aging (Albany NY). 2018; 10(7):1575-1585.
10. Kagan R, Kellogg-Spadt S, Parish SJ. Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs Aging. 2019; 36(10):897-908.
11. Angelucci M, Frascani F, Franceschelli A, Lusi A, Garo ML. Efficacy of intradermal hyaluronic acid plus polynucleotides in vulvovaginal atrophy: a pilot study. Climacteric. 2022: 25(5):490-496.
12. Prestia VM, Bertozzi E, Radice M. Low-molecular weight hyaluronic acid for the treatment of vulvovaginal atrophy: an innovative clinical practice. IJMDAT. 2020; 3:e260.
13. Garavaglia E, Sala C, Busato M, Bellia G, Tamburlin N, Massirone A. First use of thermal stabilized hyaluronic acid injection in one-year follow-up patients with genitourinary syndrome. Med Devices (Auckl). 2020; 13:399–410.
14. Gonzalez IP, Leibaschoff G, Esposito C, et al. Genitourinary syndrome of menopause and the role of biostimulation with non- cross-linked injectable hyaluronic acid plus calcium hydroxyapatite. J Biol Regul Homeost Agents. 2019; 33(6):1961–1966.
15. Palmieri IP, Raichi M. Biorevitalization of postmenopausal labia majora, the polynucleotide/hyaluronic acid option, Available from: www.oatext.com.
16. Hersant B, SidAhmed-Mezi M, Belkacemi Y, et al. Efficacy of injecting platelet concentrate combined with hyaluronic acid for the treatment of vulvovaginal atrophy in postmenopausal women with history of breast cancer: a phase 2 pilot study. Menopause. 2018; 25(10):1124-1130.
17. Yeung J, Pauls RN. Anatomy of the Vulva and the Female Sexual Response. Obstet Gynecol Clin North Am. 2016; 43(1):27-44.
18. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med. 1988; 18(4):1007- 19.
19. Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996; 34(3):220- 33.
20. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000; 26(2):191-208.
21. Litwiniuk M, Krejner A, Speyrer MS, Gauto AR, Grzela T. Hyaluronic Acid in Inflammation and Tissue Regeneration. Wounds. 2016; 28(3):78-88.
22. Park HJ, Jung KH, Kim SY, Lee JH, Jeong JY, Kim JH. Hyaluronic acid pulmonary embolism: a critical consequence of an illegal cosmetic vaginal procedure. Thorax. 2010; 65(4):360-1.
23. Han SW, Park MJ, Lee SH. Hyaluronic acid-induced diffuse alveolar hemorrhage: unknown complication induced by a well-known injectable agent. Ann Transl Med. 2019; 7(1):13.

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