Vaginal intra-epithelial neoplasia (VAIN)
Vaginal intra-epithelial neoplasia, or VAIN, can affect the vagina. In some women it may develop into cancer after many years.
The term VAIN refers to changes that can happen 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 may develop after many years, so it's 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 (it’s multifocal). If only one area is affected, it’s most often the upper third of the vagina, towards the neck of the womb (cervix).
Although VAIN used to be rare, it’s now recognised and diagnosed more often. It can affect women of any age, but is more common in women over 50. Occasionally, women may have abnormal changes that affect other areas as well as the vagina, such as the cervix, vulva and anus.
Human papilloma virus
One of the most common causes of VAIN is thought to be the human papilloma virus (HPV).
HPV is a very common infection. There are over 100 types and each type is known by a number. Some types affect the genital area including the cervix, vagina and anus. Types 16 and 18 are most commonly associated with VAIN. In the UK, all girls are now being vaccinated against these types at school.
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.
HPV infection alone is unlikely to cause VAIN. Other factors that reduce the body's immune system may increase the risk of VAIN. These factors include smoking, inherited immunity problems, particular medicines (for example those taken after transplant surgery), and some rare bone marrow and blood disorders.
VAIN is more common in women who have had a hysterectomy for cervical cancer or severe pre-cancerous changes (CIN).
Women who have had previous pre-cancerous or cancerous conditions in the vagina or cervix may have a slightly increased risk of developing VAIN. Women who have been treated with radiotherapy to the pelvic area (vagina, womb, cervix or bladder) may also have a slightly increased risk.
VAIN doesn't cause any symptoms. Most women are diagnosed with it while they're having 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 smear test) after a hysterectomy.
Some women are diagnosed following investigations for vaginal discharge. But any discharge is usually caused by an infection, not the VAIN itself.
VAIN can’t be seen by the naked eye. If your doctor suspects that you may have VAIN, they will refer you for a colposcopy. This is a test that looks at the vagina more closely. A colposcopy uses a specially adapted type of microscope (a colposcope) that acts like a magnifying glass.
A nurse will help you 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. The colposcope stays outside your body, and the doctor looks through it to examine the surface of your vagina in more detail. They will also look at the cervix, vulva and skin around your anus.
During the colposcopy, a small sample of cells (a biopsy) may be taken to be examined under a microscope. A local anaesthetic is injected into the area beforehand, using a fine 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 a liquid-based cytology test, may be done at the same time to check for any changes in the cells of the cervix.
VAIN is divided into grades. They indicate how much of the surface layer of the vagina is affected by abnormal cells.
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)
The full thickness of the surface layer of the vagina is affected.
Although VAIN 3 is also known as carcinoma in situ, it 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.
VAIN is not cancer, but it does cause some cells of the vagina to change. If the cell changes are mild (VAIN 1), treatment may not be needed as it will often return to normal. But 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's 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
any previous treatment you have had.
In certain situations, for example if you're pregnant, the side effects of treatment may outweigh any benefit. In this situation, treatment can be postponed and you will have regular colposcopies to closely monitor the VAIN.
The exact risk of getting cancer is not known. It’s thought that about 1–2% of women with VAIN (1–2 out of 100) will go on to develop cancer each year.
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. The doctor uses a colposcope 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 done under a general anaesthetic. 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 there is a high risk the disease may return, they may treat all of your vagina with CO2 laser treatment. This may take more than one treatment.
Diathermy treatment. This treatment is sometimes used to remove the abnormal cells. A thin wire uses an electric current to destroy the affected area. It’s done under local anaesthetic.
After CO2 laser or diathermy treatment, it's 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 or douches, and not to have sex for about a month.
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, and some surrounding normal tissue. This is called wide local excision. Depending on the amount removed, your remaining vaginal tissue may be stretched so that you're still able to have sex.
If the VAIN affects a bigger area, surgery may involve removing part or all of your vagina. This is called a partial or total vaginectomy. A new vagina may be created during the operation, using tissue from other parts of the body. This surgery is complicated and can have several side effects. Your surgeon and specialist nurse will make sure you have information and support to help you prepare for surgery.
Radiotherapy uses high-energy rays (radiation) to destroy abnormal cells, while doing as little harm as possible to normal cells. Radiotherapy is not commonly used for VAIN, as other treatments are usually successful. However, it can be effective in treating VAIN that has come back after initial treatment. It may also be used to treat more widespread VAIN.
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.
Sometimes a chemotherapy cream called 5FU is used. It can cause irritation to the vaginal skin, so it's not used often. Other creams that may be used include Imiquimod and Cidofovir. These are antiviral drugs. Doctors are doing research to find newer creams that might help.
After treatment, you will be seen regularly by your specialist as, for some women, the VAIN may return. Your doctor will check for any further changes that may need to be treated.
How your sex life might be affected
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Any physical changes to your sex life will depend on the treatment you have. For most women, treatments such as CO2 laser and diathermy don't have any long-term effect on their sex lives.
If you have vaginal reconstruction surgery you may be unable to have vaginal orgasms. However, surgery to the vagina will not affect your clitoris so you'll still be able to have an orgasm through stimulation of the clitoris.
If you have radiotherapy, it will cause your vagina to become tender during treatment 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 how to use vaginal dilators, which can help lessen these effects.
Many women feel frightened when they are first told 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.
Each person has their own way of coping with difficult situations. Some people find it helpful to talk to family or friends, while others prefer to get help from people outside their situation, such as a specialist nurse or counsellor. It may help to show your family or friends this information so they can understand what VAIN is. Some people prefer to keep their feelings to themselves. There is no right or wrong way of coping, but help is available if you need it. It is important to give yourself, and your partner if you have one, time to deal with the emotions and feelings that you experience. Our cancer support specialists can give you information about counselling in your area.
This information has been compiled using information from a number of reliable sources, including:
Holschneider, et al. Vaginal intraepithelial neoplasia. UpToDate. www.uptodate.com. January 2014. (Accessed March 2014).
Li H, et al. Risk factors for the development of vaginal intraepithelial neoplasia. April 2012. Pubmed national library of medicine.
Tobias J and Hochhauser D. Cancer and its management. 6th edition. 2010. Wiley-Blackwell.
With thanks to Dr Amanda Tristram, Senior Lecturer in Gynaecological Oncology, and the people affected by cancer who reviewed this edition.
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