Platelet-Rich Plasma: an innovation in gynaecology

Cosmetic gynaecology has become one of the fastest-growing subspecialties in women’s health, pooling interest around the world from specialists in gynaecology, uro-gynecology, urology, and plastic surgery.

The field includes non-surgical and surgical cosmetic procedures to enhance the aesthetic appearance of the vulva/vaginal region and can involve the functional repair of the vagina to enhance or help restore sexual function. A variety of new methods like hormones, platelet rich plasma (PRP), hyaluronic acid (HA), adipose tissue, laser, and radio-frequency devices are now being used to treat vulva/vagina deformity, scars, tenderness, atrophy, prolapses (when organs fall down or slip out of place), and incontinence, as well as to enhance sexual pleasure. 

According to the World Health Organization (WHO), 22 percent of women suffer from dyspareunia, or vaginal pain during intercourse, but are hesitant to express their concerns. Seventy percent of women experience stress incontinence and prolapse in their lifetime, with 30–40 percent being symptomatic and requiring treatment to improve their quality of life.

Pelvic floor exercises have been the simplest method of prevention and treatment for urine incontinence, prolapses, or vaginal laxity. Hormonal therapy is useful as well, but patients need to weigh the pros and cons of different types, forms, and benefits, as well as potential risks. Therefore, case selection, customisation, discussion, and counselling are particularly important steps for achieving a fair result.

Ring pessary insertion is another option to support vaginal or organ prolapse. While giving the mechanical support at the vagina tract, ring pessary can also cause ulceration, bleeding, foul smelling discharge, or infection due to its compressive effect at the vaginal wall area. Pelvic floor surgery with or without surgical mesh is currently the most common treatment. However, recent mesh controversies have resulted in the US FDA and Australian Therapeutic Goods Administration removing many transvaginal implants for prolapse and incontinence.

All of this has created a challenge for researchers and doctors to come up with more holistic and comprehensive approaches to minimally invasive management. Platelet-rich Plasma (PRP) cell therapy has become one of the most promising, minimal invasive treatment options with no major complications. In simple terms, PRP is a concentrate of platelet-rich plasma protein obtained from the patient that, when injected into her own body, can accelerate healing.

PRP therapy became popular in regenerative medicine and other specialities in the 1980s and 1990s. After its initial usage in maxillofacial surgery, PRP spread to various applications around the world, including sports medicine, orthopaedics, cardiovascular surgery, aesthetic medicine, maxillofacial surgery, plastic surgery, ophthalmology, and gynaecology.

PRP therapy mimics the biological healing process after injury by removing the red and white blood cells that delay the healing process. Blood samples obtained from the patient are centrifuged to separate the plasma from blood cells. However, the large variability in PRP preparations increases the

difficulty in drawing conclusions from studies to guide PRP preparation and use. To overcome these issues, RegenLab, which is one of the prominent contributors in the field, developed its own PRP separation system and protocols to produce a plasma PRP with high platelet recovery (>80%), a low level of white blood cells, and virtually no red blood cells.

One of the PRP injection sites

Autologous PRP (using the patient’s own plasma) shortens the different phases of natural healing and avoids immune system reaction and transmission of infections. It stimulates cell proliferation, builds up the frame, and enhances cell migration through its multiple growth factors. Several in vitro studies have also suggested that PRP may have antimicrobial effects against pathogens like Staphylococcus aureus and Escherichia coli. However, PRP was also associated with certain risks like hematoma formation, infection, nerve damage, vasovagal reaction, syncope, fainting, bleeding, and pain at the blood sampling site.

The most important platelet-released growth factors and their biological activities.

Despite the risks, PRP treatment has been shown to improve women’s quality of life and sexual function as well as symptoms of lichen sclerosus (LS), an inflammatory autoimmune dermatosis which is relatively common but underestimated. LS usually occurs at the anogenital area. While continuous usage of topical corticosteroids is the mainstay of treatment, PRP injections at the affected areas have been reported to result in regeneration of normal skin and were shown to be a potential treatment. PRP treatments have also been shown to reduce vaginal atrophy in menopause and dyspareunia.

Furthermore, PRP or PRP gel could be used as a new alternative method to overcome vaginal mesh exposure or complications, resulting in mesh resection with complete healing. The goal is the complete removal of exposed mesh and saving as much vaginal tissue as possible to avoid a subsequent shortened and narrowed vagina. Three cases underwent endoscopic bipolar PlasmaKinetic resection of exposed mesh and PRP gel was delivered in the surgical site to cover the gap left by the resection. The surgery was uneventful in all cases with recovered sexual function and no relapsed pelvic organ prolapses at the one-year follow up.

Besides using PRP as a therapy for various types of incontinence, it can also be combined with vaginal laser treatment with minimal side effects, good safety, and efficacy.

Recent evidence has also shown that PRP can improve the quality of atrophic acne scars when combined with ablative fractional CO2 laser, while decreasing the duration of laser-related side effects like edema and erythema. PRP also may improve wound and surgical scar healing. Incorporation of PRP with fat-grafting procedures and non-ablative, fractional laser can give  better wound healing and a significant improvement in texture, color, and contour in traumatic scar resurfacing. However, there is a need for high-level studies to support PRP usage in the management of keloid scars, but, overall, PRP is showing a promising adjunct in scar management practice.

Stretch marks are another quite common, asymptomatic, skin condition frequently seen in females postnatally or in obesity or ageing. From the evidence presented, it appears that fractional laser and fractional MNRF should be the first line of treatment, although high costs are a limiting factor. Alternatively, peels or derma rollers with PRP may be a cheaper option. It should be made clear that none of the treatments can provide complete clearance, and multiple sessions are always needed.

Despite all the advances already made, we are just at the beginning of a new journey. Women’s perceptions and perspectives towards the quality of their lives have advanced to a higher level. Therefore, more ideas and methods will need to arise to meet their demands. Instead of living a life, as a gynaecologist, we shall work together with women to savour the flavour of life.

Dr Quek Yek Song is a consultant obstetrician and gynaecologist at Columbia Asia Hospital – Iskandar Puteri in Johor Bahru, Malaysia. He’s the founder and president of the Malaysia Gynecological Cosmetic Society (MAGICS).