Vaginal Dysplasia

Vaginal dysplasia, also known as vaginal intraepithelial neoplasia (VAIN), starts inside the vagina. It is a condition in which the skin of the vagina undergoes abnormal changes. The vagina is the muscular tube that connects the uterus (womb) to your outside genitals. It is sometimes called the birth canal. Vaginal intraepithelial neoplasia (VAIN) can range in severity from mild to severe. Women who have VAIN often do not have any symptoms. The most common symptoms are abnormal vaginal bleeding, such as bleeding after vaginal intercourse or bleeding in between periods, or an abnormal vaginal discharge. If left untreated, in some cases VAIN can progress to vaginal cancer.

VAIN is classified as low grade or high grade, depending on the severity of the abnormality. Overall, VAIN is relatively rare. It is far less common than cervical or vulvar dysplasia. It may be associated with cervical or vulvar dysplasia, meaning that it is possible to have more than one type of dysplasia at the same time. It is most common in women with a history of cervical dysplasia. It is typically found in women between the ages of 40 and 60, although it can occur at any age.

Risk Factors

Risk factors for VAIN are similar to those linked to cervical and vulvar dysplasia.  They include:

  • Exposure to the drug DES while in the mother’s womb.  DES was given to pregnant women to prevent miscarriages in the 1950s.  Women who have this exposure have an increased risk of developing a rare form of vaginal cancer called clear cell adenocarcinoma of the vagina.
  • HPV infection
  • History of cervical or vulvar dysplasia
  • History of cervical or vulvar cancer
  • Tobacco use
  • Weakened immune system from HIV or immunosuppressive medications.

Prevention

VAIN can be prevented by getting the HPV vaccine. The HPV vaccine is safe. It is effective in protecting against the most common high risk strains of HPV that can cause VAIN. The Advisory Committee on Immunization Practices (ACIP) recommends that all girls and boys get the HPV vaccine at age 11 or 12 years, although vaccination start as early as 9 years. The HPV vaccine is also recommended for females through age 26 and for males through age 21 who were not vaccinated previously. Males may also be vaccinated through age 26.

Another way to help prevent VAIN is by smoking cessation. Quitting smoking can reduce your risk of getting vulvar VAIN, and can also reduce the risk of VAIN developing into vaginal cancer.

Since VAIN is often associated with cervical dysplasia, another way to prevent VAIN is to get regular screening for cervical dysplasia and HPV infections with Pap and HPV tests.

Symptoms

Women with VAIN usually do not have any signs or symptoms.

Screening

There are no screening recommendations for the early detection of VAIN, except for women who have had a hysterectomy (womb surgically removed and they no longer have a cervix) and they have a history of cervical dysplasia.

Because women with a history of cervical dysplasia are at increased risk of developing VAIN, it is recommended that women continue to get Pap and HPV tests of the vagina to detect VAIN for 20 years after their treatment of cervical dysplasia. Women who have had a hysterectomy and do not have a history of cervical dysplasia should not get a Pap test to screen for VAIN.

Diagnosis

As part of a pelvic exam, your gynecologic health care provider should perform a thorough examination of the vagina to look for VAIN. If they see worrisome skin changes, they will perform a biopsy to confirm the diagnosis. A biopsy is performed by taking a small bite or sample of the skin with the worrisome appearance. The tissue sample is then evaluated by a pathologist to determine if there is evidence of VAIN.

A health care provider may perform a colposcopy examination to help them perform a more thorough evaluation of the vagina. A colposcopy is simply looking at your vagina with an electric magnifying instrument. Similar to a pelvic exam, the first step is for you to lie down on an examination table and put your feet in stirrups. Next, an instrument called a speculum is inserted into your vagina to hold your vaginal walls open so your healthcare provider can view the inside of the vaginal walls. Next, special solutions will be applied to the vagina to accentuate any abnormal changes. Then, your healthcare provider will look at your vagina through the colposcope, which shines a light on and magnifies the skin of the vagina.

Treatment

Many cases of low grade VAIN will regress (go away) on their own without any treatment. Healthcare providers often recommend just watching these cases closely to make sure that they don’t progress to high grade VAIN or vaginal cancer. This may mean frequent examinations with Pap tests and colposcopy every few months. If this is the management that your healthcare provider recommends, it is important not to miss any of these examinations. If the low grade VAIN gets worse or doesn’t go away on its own, your healthcare provider will likely recommend treatment. Treatment for cases of high-grade VAIN is usually started right away because high-grade VAIN is less likely to regress, and more likely to progress to vaginal cancer. Often several types of treatment are necessary.

Treatment options for VAIN include the following:

  • Laser ablation – this procedure utilizes a laser beam to burn away the VAIN. This is a minor procedure that is performed in the operating room under anesthesia. Most patients are able to go home the same day of the procedure.
  • Topical therapy – topical therapy means applying a medication to the area of VAIN. The medications that are typically used are imiquimod or fluorouracil (5-FU). The medication is usually used for several weeks. Vaginal estrogen cream is another medication that can be used to treat VAIN.
  • Surgical excision – surgical excision means cutting away the area of VAIN along with a small (1cm) margin of normal tissue surrounding the VAIN. This is a procedure that is performed in the operating room under anesthesia. The extent of the excision can vary depending on the size of the abnormal area. Surgical excision may be used if other treatments don’t work, or if there is concern that an invasive vaginal cancer may be present along with the VAIN.
  • Radiation – in some serious cases of VAIN, radiation is used for treatment. Radiation therapy uses high-energy beams to kill the abnormal cells.

The New York Center for Lower Genital Tract Diseases works with each woman to develop a treatment plan that is best suited to their particular needs and preferences, as well as deliver the most up to date and state of the art treatment. Treatment for lower genital tract diseases, including VAIN, will depend on the type and severity of VAIN. The treatment plan will also be determined based on your overall health and medical history, and your tolerance for specific procedures, medications, or therapies.

Follow-up

Women who have been treated for VAIN are at risk for the VAIN to recur, or come back, throughout their lifetimes. Because there is a risk of recurrence, women who have had VAIN should have close follow-up with a gynecologic health care provider who is familiar with the types of skin changes that are concerning for VAIN.

Follow-up visits are typically scheduled for every 6 to 12 months after the initial treatment.