Vaginal intra-epithelial neoplasia (VAIN)

This information is about a skin condition called vaginal intra-epithelial neoplasia (or VAIN) which can affect the vagina and, in some women, may develop into cancer after many years.

VAIN

The term VAIN refers to changes that can occur in the skin of the vagina. VAIN is not cancer and in some women it disappears without treatment. However, if the changes become more severe, there is a chance that cancer might develop after many years and so it is referred to as a pre-cancerous condition.

VAIN can occur in just one area of the vagina, but more often it affects several different areas at once (multifocal). If only one area is affected, this is most often the upper third of the vagina, towards the neck of the womb (the cervix).

Although cases of VAIN used to be rare, it is now recognised and diagnosed more frequently. It can affect women of any age but is more common in women aged over 50. Occasionally, women may have abnormal changes that affect other areas in addition to the vagina, such as the cervix, vulva and anus.

Causes

HPV

It is not fully understood what causes VAIN but infection in the skin of the vagina, caused by certain types of human papilloma virus (HPV), may be a factor.

HPV (often known as the wart virus) is a very common infection. There are over 100 types of HPV. Some types affect the genital area including the cervix, vagina and anus.

Genital HPV infection is spread by direct skin-to-skin contact during sex with someone who has the infection. HPV is so common that most sexually active women are exposed to it at some time in their life. For most women, their immune system gets rid of the HPV naturally, without them ever knowing they had the infection. Sometimes women will notice genital warts. However, not all types of HPV cause warts.

HPV infection alone will not cause VAIN. Other factors that depress the body’s immune system also need to be present, such as: particular medicines (for example those taken after transplant surgery); smoking; inherited immunity problems; and some rare bone marrow and blood disorders.

Other Factors

• VAIN is more common in women following a hysterectomy for cervical cancer.
• Women who have had previous pre-cancerous or cancerous conditions in the vagina or cervix, or who have been treated with radiotherapy to the pelvic area (vagina, womb, cervix, bladder), may have a slightly increased risk of developing VAIN.
• Women whose mothers were prescribed the drug diethylstilboestrol (DES) during their pregnancy may have an increased risk of developing VAIN.

Symptoms

VAIN does not cause any symptoms. Most women are diagnosed with it while having medical tests for other reasons. For example, VAIN may be first detected by a cervical smear test, or by a smear taken from the top of the vagina (vaginal vault) following a hysterectomy.

Some women are diagnosed following investigations for vaginal discharge, but any discharge is usually caused by an infection (not the VAIN itself).

How it is diagnosed

VAIN cannot be detected by the naked eye. If VAIN is suspected, a test that inspects the vagina more closely, called a colposcopy, is needed. A colposcopy uses a specially adapted type of microscope (colposcope) which acts like a magnifying glass.

Colposcopy

A nurse will help you to position yourself on the couch. When you are lying comfortably, the doctor (or nurse colposcopist) will use a speculum to hold your vagina open. The walls of your vagina may then be painted with a liquid that makes the abnormal areas show up more clearly. A light is shone on to the affected area and the doctor looks through a colposcope (which stays outside your body) to examine the surface of your vagina in more detail. The cervix, vulva and skin around your anus are also examined.

During the colposcopy a small sample of cells (a biopsy) may be taken for examination under a microscope. Before the biospy is taken, a local anaesthetic cream is usually used to numb the vaginal area, and this takes effect in about 20 minutes. Liquid anaesthetic is then injected into the area, using a small needle. Sometimes a general anaesthetic may be given. A sample of tissue (about the size of a peppercorn) is taken from the vagina.

A cervical smear test or liquid-based cytology test may be done at the same time to check for any changes in the cells of the cervix.

The grades of VAIN

VAIN is divided into grades. These describe how deeply the abnormal cells are embedded in the surface layer of the vagina:

• VAIN 1 (low-grade VAIN) One-third of the thickness of the surface layer of the vagina is affected.
• VAIN 2 (high-grade VAIN) Two-thirds of the thickness of the surface layer of the vagina is affected.
• VAIN 3 (high-grade VAIN or carcinoma in situ) The full thickness of the surface layer of the vagina is affected.

VAIN 3 is also known as carcinoma in situ. Although this sounds like cancer, VAIN 3 is not cancer of the vagina.

With all three grades of VAIN, only a small area of the vagina may be affected by abnormal changes, or there may be several areas of the vagina affected by a mixture of grades of VAIN.

Treatment

VAIN is not cancer, but it does cause some cells of the vagina to change. If the cell changes are mild (VAIN1), treatment may not be needed as this will often return to normal. You will have the area checked regularly by your doctor.

If changes are more severe (VAIN 2 or VAIN 3) you may be advised to have treatment. The aim of treatment is to prevent cancer developing, while keeping unwanted effects to a minimum.

The type of treatment that is most appropriate for you will depend on a number of factors including:

• how abnormal the cells are (the estimated risk of cancer developing)
• the size of the affected area
• the location of the abnormal cells in the vagina
• your age
• any previous treatment that you may have had.

In certain situations (for example if you are pregnant), the side effects of treatment may outweigh any benefit, and treatment can be postponed. In this situation, you will have regular colposcopies to closely monitor the VAIN.

Types of treatment

Local ablation (conservative treatment)

Local ablation treats VAIN by removing or destroying the abnormal cells in the vagina. This can be done in two ways:

• Carbon dioxide (CO2) laser treatment  This is the most common method of local ablation. A colposcope (magnifying lens) enables the doctor to see the affected areas. A very fine beam of light (laser) is then directed at the abnormal cells and destroys them. This procedure is usually carried out under a general anaesthetic (while you are asleep) although occasionally, if only a very small area is affected, it may be done using a local anaesthetic. If several areas of your vagina are affected, or if your doctor feels that there is a high risk that the disease may return, all of your vagina may be treated with CO2 laser therapy.

• Loop diathermy or LEEP  Sometimes a loop diathermy or loop electro excision procedure (LEEP) is used to remove the cells. A thin wire uses an electric current to cut away the affected area. After laser or loop diathermy treatment it is usual to have slight bleeding or discharge for a few days. The vaginal tissue will take some time to heal after treatment. So you will be asked not to use tampons, douches or have sexual intercourse for about a month.

Surgery

Surgery may be recommended if there is any possibility of there being undetected cancer in your vagina. It may also be used if VAIN comes back after previous treatment.

When just a small area of your vagina is affected it may be possible to remove that area of tissue, together with some surrounding normal tissue (wide local excision). Depending on the amount removed, your remaining vaginal tissue may be stretched so that you are still able to have sexual intercourse.

If VAIN is more widespread, surgery may involve removing part, or all, of your vagina (partial or total vaginectomy). A new vagina may be created during the operation, using tissue from other parts of the body.

Your surgeon and specialist nurse will make sure you receive information and support to help you prepare for surgery.

Radiotherapy

Radiotherapy can be effective in treating VAIN that has come back after initial treatment. It may also be used to treat more widespread VAIN.

Radiotherapy uses high-energy rays (radiation) that destroy the abnormal cells, while doing as little harm as possible to normal cells.

VAIN may be treated with internal radiotherapy (brachytherapy). An applicator (similar to a tampon) containing a radioactive substance is placed in your vagina. The applicator may stay in for several hours or a few days. If your specialist recommends this treatment, you may find it helpful to ask the staff in the radiotherapy department to explain what will happen and to show you the equipment beforehand.

Follow-up

After treatment you will be seen regularly by your specialist, as the VAIN may return in some women. Your doctor will check for any further changes that may need to be treated.

How your sex-life might be affected

How your sex life is affected physically will depend upon the treatment you have. For most women, treatments such as laser and loop diathermy do not have any long-term effect on their sex lives.

If you have a vaginal reconstruction you may not be able to have a vaginal orgasm. However, surgery to the vagina will not affect your clitoris so you will still be able to have an orgasm through oral sex and masturbation.

If you have radiotherapy, it will cause your vagina to become tender in the early stages and for a few weeks afterwards. This irritation may leave scarring, and will make your vagina narrower and less flexible. A specialist gynaecology nurse will advise you on the use of vaginal dilators which can help to lessen these effects.

Your feelings

Many women feel frightened when they are first told that they have VAIN, and worry that they may develop cancer. You may find the treatments embarrassing and frightening, and may feel tense, tearful, or withdrawn. At times these feelings can be overwhelming and hard to control.

Everyone has their own ways of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation, such as a specialist nurse or counsellor. Others prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it. It is important to give yourself, and your partner, time to deal with the emotions and feelings that you experience.

CancerBACUP has information on the emotional effects of cancer, which discusses the feelings and emotions that you may have, and advises on support services that can help.

References

This section has been compiled using information from a number of reliable sources, including:

• Evidence-based Oncology ed C Williams. BMJ Publishing Group, 2003.
• Oxford Textbook of Oncology (2nd edition). Souhami et al. Oxford University Press, 2002.
• Gynaecological Oncology: A guide to clinical management. Ed P Blake et al. Oxford University Press, 1998 (reprinted 2004).
• Cancer and its Management (5th edition). Souhami and Tobias. Oxford Blackwell Scientific Publications, 2005.
• Principles & Practice of Gynaecologic Oncology (3rd edition). Hoskins et al. Lippincott, Williams and Wilkins, 2000.

For further references, please see the general bibliography.