Vaginal intra-epithelial neoplasia (VAIN)
Vaginal intra-epithelial neoplasia, or VAIN, can affect the vagina and, in some women, may develop into cancer after many years.
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 may develop after many years, and so it's referred to as a pre-cancerous condition.
VAIN can occur in just one area of the vagina, but it more often affects several different areas at once (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 cases of 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 in addition to the vagina, such as the cervix, vulva and anus.
It's 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 is a very common infection. There are over 100 types and each 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.
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 depress the body's immune system also need to be present for VAIN to occur. These 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 following 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, or who have been treated with radiotherapy to the pelvic area (vagina, womb, cervix, bladder), may have a slightly increased risk of developing VAIN.
VAIN doesn't 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 smear test) 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).
VAIN can’t be detected by the naked eye. If your doctor suspects that you may have VAIN they will refer you for a test, which inspects the vagina more closely, called a colposcopy. A colposcopy uses a specially-adapted type of microscope (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 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. 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.
VAIN is divided into grades. They 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)
The full thickness of the surface layer of the vagina is affected.
Although VAIN 3 is also known as carcinoma in situ, it isn't 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 this will often return to normal. You will, however, 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 that you may have had.
In certain situations, for example, if you're 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.
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 magnifying lens (colposcope) 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. 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, all of your vagina may be treated with CO2 laser therapy. This may need more than one treatment.
Diathermy treatment. This treatment is sometimes used to remove the abnormal cells. It’s done under local anaesthetic. A thin wire uses an electric current to destroy the affected area.
After 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, together with some surrounding normal tissue (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 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 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) to destroy 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.
Sometimes a chemotherapy cream called 5FU is used. It can cause irritation to the vaginal skin so it's not used often. Doctors are carrying out research to find newer creams that might help.
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
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Any physical changes to your sex life will depend on the treatment you have. For most women, treatments such as laser and loop 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 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.
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 friends or family while others prefer to seek help from people outside of their situation, such as a specialist nurse or counsellor. 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.
This information has been compiled using information from a number of reliable sources, including:
H Li, 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.
Holschneider, et al. Vaginal intraepithelial neoplasia. UpToDate website. http://www.uptodate.com. (accessed October 2012).
With thanks to Professor David Luesley, Professor of Gynaecological Oncology, and the people affected by cancer who reviewed this edition. Reviewing information is just one of the ways you could help when you join our Cancer Voices network