Vulvar Dysplasia

Vulvar dysplasia, or vulvar intrapepithelial neoplasia (VIN), is abnormal changes in the skin of the vulva. The vulva describes a women’s outside genital structures, and includes the area outside of the opening of the vagina.  The vulva has the following parts:

  • The opening of the vagina with glands that produce lubrication.
  • Two skin folds called the outer and inner lips of the vagina.  The outer lips (labia majora) is the most common site of vulvar dysplasia.  The inner lips (labia minora) are smaller and located inside of the labia majora.
  • The clitoris is a sensitive tissue at the top of the vulva where the two lips meet.
  • The mons pubis is the area in front of the pubic bone.
  • The perineum is the area between the vulva and anus.

Traditionally, vulvar dysplasia was classified as mild, moderate or high grade, depending on the severity of the abnormal changes. Although this classification system is still commonly used, the International Society for the Study of Vulvovaginal Disease (ISSVD) has officially replaced it with a new classification system. In the new classification system, only high grade vulvar dysplasia is classified as vulvar intraepithelial neoplasia (VIN). VIN is then subdivided into “usual type” VIN, also known as vulvar high grade squamous intraepithelial lesion (vulvar HSIL), and “differentiated VIN”. These two types of VIN have different risk factors.

Most cases of VIN can be cured with proper treatment and follow-up. If left untreated, VIN can sometimes progress to vulvar cancer.

Although vulvar cancer is rare, VIN is becoming more common. According to the U.S. Surveillance, Epidemiology, and End Results program, VIN is now four times more common than it was in the 1970s. VIN is usually seen in women in their 40s.

Risk factors

The two types of VIN (vulvar HSIL or “usual type” and “differentiated”) have different risk factors. Risk factors for usual type VIN include HPV infection, cigarette smoking, and having a weakened immune system. Differentiated VIN is not associated with HPV infection; it is associated with other abnormal vulvar skin conditions, such as lichen sclerosis. Although both types of VIN can progress to vulvar cancer if left untreated. Differentiated VIN has a higher risk of being associated with vulvar cancer compared to usual type VIN.

Women with any of these risk factors should examine their vulva regularly and seek medical evaluation if they detect any worrisome changes.

Prevention

Vulvar HSIL (VIN usual type) 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 VIN usual type. 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 vulvar HSIL (VIN usual type) is by smoking cessation. Quitting smoking can reduce your risk of getting vulvar HSIL, and can also reduce the risk of vulvar HSIL developing into cancer.

Differentiated VIN can be prevented by the appropriate treatment of associated vulvar skin disorders, such as lichen sclerosis. The New York Center for Lower Genital Tract Diseases provides comprehensive and personalized treatment plans for the entire spectrum of vulvar skin disorders.

Symptoms

Women with VIN often do not have any signs or symptoms. Possible signs or symptoms include:

  • Itching or burning on the vulva
  • Visible changes in the color of the skin of the vulva – areas of the vulvar skin may start to appear white, grey, pink, reddish, or dark brown.
  • You may see an area of skin that appears thicker, or there may be a new growth that looks like a wart.
  • Cracks or ulcerations in the skin of the vulva


If you have any of these symptoms, it is important that you see a doctor or other health care professional immediately. Ignoring symptoms may allow the condition to become more advanced.

Screening

There are no screening tests for the early detection of VIN. If you have any symptoms that are worrisome for VIN, it is important that you see a doctor or other health care professional immediately. Ignoring symptoms may allow the condition to become more advanced.

Diagnosis

As part of a pelvic exam, your gynecologic health care provider should perform a thorough examination of the vulva to look for VIN. 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 VIN.

Treatment

Treatment options for VIN include the following:

  • Surgical excision – surgical excision means cutting away the area of VIN along with a small (1cm) margin of normal tissue surrounding the VIN. 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. Most patients are able to go home the same day of the procedure.
  • Laser ablation – this procedure utilizes a laser beam to burn away the VIN. 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 VIN. The medications that are typically used are imiquimod or fluorouracil (5-FU). The medication is usually used for several weeks.

All treatments are potentially effective in the treatment of VIN. The American College of Obstetrics and Gynecology recommends surgical excision if there is concern that the abnormal skin changes may be harboring a vulvar cancer in addition to VIN. This occurs in about 3% of cases where the biopsy only shows VIN.

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 VIN, will depend on the type and severity of VIN. 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 VIN are at risk for the VIN to recur, or come back, throughout their lifetimes. Because there is a risk of recurrence, women who have had VIN should have close follow-up with a gynecologic health care provider who is familiar with the types of skin changes that are concerning for VIN.

Follow-up visits are typically scheduled for every 6 to 12 months after the initial treatment. It is important to report any worrisome symptoms to your gynecologic health care provider at these follow-up visits, such as itching, burning, or new skin changes.