Menopause is defined as the absence of menstruation for more than a year and occurs around 51 years old in industrialized countries [[1], [2], [3]]. It is the consequence of a clear reduction in circulating estrogen levels, caused by severe alteration of the ovarian follicle stock [4].

Most of the female urogenital structures comes from the same embryological origin, which explains why estrogen receptors are found in the vagina, vulva, urethra, and bladder trigone [5]. It is therefore natural that the significant drop in circulating estrogen levels that occurs at the time of menopause, combined with the natural age-related aging of tissues, can have structural and functional consequences in this anatomical region. Decreased oestrogen affect the renewal and maturation of the vaginal epithelium as well as the vagina's biomechanical properties such as elasticity and strength [4,[6], [7], [8]]. Macroscopically, tissues appear pale and thinned, and the diameter and depth of the vagina narrow [4,7]. In the vulvar region, these histological alterations lead to an atrophic appearance of the labia minora and majora, loss of hymenal elasticity and sometimes fibrosis of the clitoris [[9], [10], [11]]. These structural changes are likely to lead to uncomfortable or painful intercourse and can cause symptoms of daily discomfort. All the consequences of estrogen deficiency on the genitourinary region are grouped together under the term "Genitourinary Syndrome of Menopause" (GSM) defined in 2014 by the Society for the Study of Women's Sexual Health (ISSWSH) and the North American Menopause Society (NAMS) [12].

It is estimated that 40–60 % of menopausal women are affected by at least one symptom of GSM [13]. With the increase in life expectancy linked to improved living conditions, women now spend almost a third of their lives in menopause. Management of GSM is therefore a major public health issue.

The first step is to manage the various factors that can potentially aggravate symptoms (smoking withdrawal, reduction in alcohol consumption, weight loss, etc.) [5]. As a first-line treatment, the CNGOF (Collège National des Gynécologues-Obstétriciens Français) recommends the use of local vaginal treatments (recommendation Grade A). Non-hormonal topicals remain less effective than local hormonal treatments [14], but their application has shown benefits in patients with moderate symptoms [15,16]. However, local hormonal treatments present a major limitation in patients being monitored for hormone-dependent cancer, including patients with a history of breast cancer [17]. To date, there is no effective long-term treatment for GSM. Local treatments provide only a transitory solution and require strictly daily applications. On the other hand, systemic treatment such as hormone replacement therapy is not recommended in the absence of associated climacteric syndrome, and while it has shown notable improvements in the symptoms of vulvovaginal atrophy, it has numerous contraindications and potential side effects.

CO2 fractional laser has been used for the past 10 years in dermatological esthetic medicine for its ability to induce neocollagenogenesis in tissue [18,19]. Given that collagen fiber deficiency and disorganization partly explain symptoms of GSM, the laser has been explored by gynecologists as a potential treatment. Two recent meta-analyses showed that CO2 fractional laser therapy was significantly effective in improving GSM symptoms with the Female Sexual Function Index (FSFI) sexual health score and the Short Form 12 (SF-12) quality of life score with an average of 3 sessions spaced one month apart. No significant adverse effects have been reported [18,20]. However, the vast majority of studies have assessed the effects of CO2 fractional laser therapy over short follow-up periods (1–3 months) after treatment. Data are therefore lacking on the long-term (over 12 months) efficacy of vaginal laser treatment on GSM. Our center published in 2020 the results of a study on the efficacy of the Mona Lisa CO2 fractional laser at 3 months after treatment, showing an overall improvement in various symptoms of GSM, as well as better lubrication and greater satisfaction among patients with their sex life in general [21]. We present here the results of a long-term re-evaluation of patients who underwent vaginal laser treatment for GSM symptoms in our center.