Vaginal intra-epithelial neoplasia (VAIN)
Vaginal intra-epithelial neoplasia (VAIN) is a term that describes abnormal changes of the cells that line the vagina. VAIN is not cancer. In some women, it goes away without treatment. But if the changes become more severe, there is a chance that vaginal cancer may develop after many years. Because of this, VAIN 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. If only one area is affected, it is usually the upper third of the vagina, towards the cervix.
VAIN can affect women of any age, but is more common in women over 50. Sometimes, women may have abnormal changes that affect other areas as well as the vagina, such as the cervix, vulva and anus.
Human papilloma virus (HPV)
The main cause of VAIN is thought to be the human papilloma virus (HPV).
There are over 100 types of HPV. Each type is known by a number. Types 16 and 18 are most commonly associated with VAIN. In the UK, all girls are now being offered a vaccine against these types of HPV at school.
HPV is very common. Most people are affected by it at some point. Usually, the body’s immune system gets rid of the virus naturally. There are no symptoms and often the virus does not cause damage. Most people will never know they had it.
In some people, the immune system does not clear the infection and the virus stays in the body for longer. If the vagina is affected by HPV, the virus may cause damage that can develop into VAIN over a long time.
HPV can be passed on through any type of sexual contact. It is often shared between partners. Using a condom does not always stop it passing from person to person. HPV can affect people who:
- have had one or more sexual partners
- have had sex with men or with women
- are in a long-term relationship with one person.
If you are in a sexual relationship, it is likely that your partner has already been affected by HPV. This is unlikely to cause them any harm. They do not need to be tested or treated for it.
Factors that reduce the immune system’s ability to get rid of HPV may increase the risk of VAIN. These factors include:
- inherited immunity problems
- some medicines, such as those taken after transplant surgery
- some rare bone marrow and blood disorders.
If you have had previous pre-cancerous or cancerous conditions in the vagina or cervix, you may have a slightly increased risk of developing VAIN.
If you have been treated with radiotherapy to the pelvic area (vagina, womb, cervix or bladder), you may also have a slightly increased risk.
During the colposcopy, the doctor or nurse may take one or more small samples (biopsies) of skin from the vagina. Before this, they will inject local anaesthetic into the area to numb it. They will then take a sample of tissue about the size of a peppercorn. The samples will be sent to a laboratory to be looked at under a microscope.
VAIN is divided into grades. They describe how deep into the surface layer of the vagina the abnormal cells are.
- VAIN 1 – one-third of the thickness of the surface layer (33%) of the vagina is affected.
- VAIN 2 – two-thirds of the thickness of the surface layer (66%) of the vagina is affected.
- VAIN 3 – the full thickness of the surface layer (100%) of the vagina is affected. VAIN 3 is also called carcinoma in situ, but it is not vaginal cancer.
With all 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 1 (low-grade VAIN)
VAIN 2 and VAIN 3 (high-grade VAIN)
If VAIN is low-grade (VAIN 1), treatment may not be needed as changes in the vagina will often return to normal naturally.
If VAIN is high-grade (VAIN 2 or VAIN 3), your doctor may talk with you about having treatment. The aim of treatment is to prevent 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, 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.
The exact risk of getting cancer is not known. It is thought that about 1% to 2% of (1 to 2 in 100) women with VAIN will develop vaginal cancer each year.
Types of treatment
Local ablation treats VAIN by removing or destroying the abnormal cells in the vagina. After local ablation treatment, it is normal 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.
Local ablation can be done in two ways:
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 is usually done under a general anaesthetic. Sometimes, 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 laser treatment. This may take more than one treatment.
The doctor uses a thin wire with an electric current to destroy the affected area. This is done under local anaesthetic.
Surgery may be used:
- if there is high risk there may be undetected cancer cells in the vagina
- if VAIN comes back after other treatments.
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 a wide local excision. Depending on the amount of tissue removed, it may make your vagina shorter. The vagina is naturally stretchy, so this may not be noticeable to you. But if you have difficulties with penetrative sex, talk to your specialist nurse or surgeon. They can discuss what may help. We have more information about female pelvic changes and your sex life.
If 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 (vaginal reconstruction) during the operation or at a second 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. This treatment can be effective in treating VAIN that has come back after initial treatment. It may also be used to treat more widespread VAIN.
VAIN is most likely to be treated with internal radiotherapy (brachytherapy). A tube-like applicator containing a radioactive substance is placed in your vagina. The applicator may stay in for several hours or a few days.
If the treatment is given over a few hours, you will usually need about 3 to 4 treatments over 1 to 2 weeks. You can go home between treatments.
A few women may be offered treatment as a cream. This is applied directly to affected areas (topical). This is not a standard treatment for VAIN. But it may be used if there is VAIN in several areas of the vagina and surgery is not possible. Some women have this treatment as part of a clinical trial.
Drugs that may be applied as a cream include:
- imiquimod, which can help to boost the immune cells in the vagina to target HPV and abnormal cells
- fluorouracil (5FU), a chemotherapy drug.
The most common side effects of topical treatments are soreness and a burning feeling in the vagina.
Any physical changes to your sex life will depend on the treatment you have. For most women, treatments such as laser and diathermy do not have any long-term effect on their sex lives.
If you have vaginal reconstruction surgery, you may be unable to have vaginal orgasms. But surgery to the vagina will not affect your clitoris, so you will 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. You may be referred to see a specialist health professional to advise you on how to use vaginal dilators, which can help lessen these effects.
You may have many different emotions, including anger, resentment, guilt, anxiety and fear. These are all normal reactions and are part of the process many people go through in trying to come to terms with their condition.
Everyone has their own way of coping with difficult situations. Some people find it helpful to talk to family or friends, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is there if you need it.