Vaginal intraepithelial neoplasia (VaIN)

The main cause of VaIN is thought to be infection with the human papilloma virus (HPV).

There are over 200 types of HPV. Some types of HPV can affect the vagina. The types of HPV that cause VaIN are called high-risk HPV. In the UK, children are offered a vaccine to help protect them against these types of HPV.

HPV is very common. Most people will have HPV at some point in their life. Usually, your immune system gets rid of the virus naturally. HPV usually has no symptoms and often the virus does not cause damage. Most people do not know they have it.

But for some people, the immune system does not get rid of the infection and the virus stays in the body for longer. If the vagina is affected by HPV, the virus can cause changes in the cells. If this is left untreated, these cells can develop into VaIN over a long time.

Some factors can affect how well the immune system gets rid of HPV. This may increase the risk of VaIN. These factors include:

• smoking
• inherited conditions that affect the immune system
• medicines that suppress the immune system, such as those taken after transplant surgery
• HIV
• some rare bone marrow and blood disorders.

You may have an increased risk of developing VaIN if you have had previous pre-cancerous or cancerous conditions in the:

• cervix (CIN)
• vulva (VIN)
• anus (AIN)
• vagina.

These conditions are often linked to HPV infection which is the main cause of VaIN.

If you have had radiotherapy to the pelvic area (vagina, womb, cervix, bladder or lower bowel), you may also have a slightly increased risk of VaIN.

Your doctor will examine the area around the vagina and do an internal vaginal examination. This is called a vaginoscopy. It is used to diagnose VaIN. This test is similar to a colposcopy. It uses a microscope with a light on the end, called a colposcope, to look closely at the vagina. You usually have it in a hospital outpatient clinic.

During the vaginoscopy, the doctor may put a liquid on the lining of the vagina to help show any abnormal areas. They may then take one or more small tissue samples from the vagina. This is called a biopsy.

Before taking a sample, they will inject local anaesthetic to numb the area. Each sample of tissue is small, about the size of a peppercorn. These samples are sent to a laboratory to be examined under a microscope.

• Low-grade (VaIN 1) – you may not need treatment as the abnormal cell changes in the vagina will often return to normal naturally.
• High-grade (VaIN 2 or VaIN 3) – your doctor may talk with you about having treatment. The aim of treatment is to prevent vaginal cancer developing while keeping any side effects to a minimum.

Your treatment may depend on:

• the grade of VaIN
• the size of the affected area
• where the abnormal cells are in the vagina
• any previous treatment you have had.

Sometimes, your doctor will suggest monitoring rather than treatment. For example, if you are pregnant, the side effects of treatment may outweigh any benefit. In this situation, treatment can be postponed. You will have regular colposcopies to closely monitor the VaIN.

Surgery may be used for VaIN if:

• there is high risk that there may be undetected cancer cells in the vagina
• the VaIN has come back after other treatments.

When there is a small area of VaIN, it may be possible to remove that area of tissue and some surrounding normal tissue. This is called a wide local excision (WLE). Depending on the amount of tissue removed, it can affect the vagina. The vagina is naturally stretchy, so you may not notice any changes. But if you have difficulties with vaginal sex or internal examinations, talk to your specialist nurse or surgeon. They can discuss what may help. We have more information about pelvic changes and your sex life.

If VaIN affects a larger area, you may have the same types of surgery used for vaginal cancer. Surgery may involve removing part, or rarely all, of the vagina. This is called a partial or total vaginectomy.

A new vagina can be created using tissue from other parts of the body. This is called vaginal reconstruction. This surgery is complicated and can have several side effects. The result may not be successful. For these reasons, vaginal reconstruction is rarely available in hospitals in the UK.

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

We have more about partial and total vaginectomy in our surgery for vaginal cancer information.

Local ablation is used to treat VaIN by removing or destroying the abnormal cells in the vagina. It is normal to have slight vaginal bleeding or discharge for a few days after treatment as the vaginal tissue takes time to heal.

Your doctor or nurse will ask you not to use tampons, douches or have vaginal sex for about a month. This will give the vagina time to heal and help prevent infection.

Local ablation is usually done as an outpatient. The doctor will use a colposcope to see the affected areas. There are different types of ablation:

Sometimes VaIN is treated with a cream. The cream is applied directly to affected areas (topical treatment) for several weeks.

This is not the standard treatment for VaIN, but it may be used if:

• there is VaIN in several areas of the vagina and surgery is not possible or suitable
• VaIN has come back after other treatments.

Topical treatment may be given as part of a clinical trial.

The nurse may apply the treatments in a clinic, or you may be shown how to apply them yourself at home.

One topical treatment is imiquimod. This is applied 3 times a week. It boosts the immune system to target HPV.

Follow any advice from the nurse about using topical treatment. The nurse can advise you about methods of contraception during treatment.

The most common side effects of topical treatment are soreness or a burning feeling in the vagina.

Radiotherapy uses high-energy rays to destroy abnormal cells in the treatment area. This treatment is used less often than other treatments for VaIN. It can be effective in treating VaIN that has come back after initial treatment. It may also be used if there is VaIN in several areas of the vagina.

VaIN is usually treated with a type of internal radiotherapy called intracavity brachytherapy.

During brachytherapy, an applicator containing a radioactive substance is placed inside the vagina.

Your cancer doctor will explain more about the treatment and what to expect.

Before treatment, you will have a radiotherapy planning appointment. During this appointment you will have a vaginal examination. Your head will be on a pillow and your legs raised and placed on knee rests. The doctor or radiographer will then put a plastic treatment applicator in your vagina. The end of the applicator will have lubricating gel. You might find the feeling of pressure at the top of the vagina uncomfortable, but it should not be painful. You can ask for painkillers if this would make you more comfortable. Or a gel containing local anaesthetic can be used if needed.

Once the applicator is in place, the radiographer will lay your legs flat on the bed and you will have a CT scan or MRI scan. After this, the applicator is removed and you can go home.

During the treatment session, you will have the applicator placed in your vagina. The end that is outside your body is connected to the brachytherapy machine. The radiographer will leave the room but they can still see you and talk to you via an intercom. If the applicator is uncomfortable tell the radiographer. You can ask for painkillers if you feel that would help. Treatment takes around 15 minutes.

After treatment, the applicator is removed, and you can go home.

Depending on your situation, you usually have between 2 to 4 treatment sessions. Your doctor, treatment radiographer or nurse can explain how many sessions you will have.