Vaginal intraepithelial neoplasia (VAIN)

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

There are over 100 types of HPV. Each type is known by a number. Some types of HPV can affect the vagina. The types that cause VAIN are called high-risk. In the UK, children are now offered a vaccine against these types of HPV at school.

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. There are no symptoms and often the virus does not cause damage. Most people do not know they have it.

In 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 may cause damage that can develop into VAIN over a long time. This risk may be increased in people with HPV who smoke.

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 immunity problems
• some medicines, such as those taken after transplant surgery
• HIV
• some rare bone marrow and blood disorders.

If you have had previous pre-cancerous or cancerous conditions in the cervix or vagina, you may have a slightly increased risk of developing VAIN.

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

A test called a colposcopy is used to diagnose VAIN. This test uses a microscope called a colposcope to look closely at the vagina. You usually have it at a hospital outpatient clinic.

During the colposcopy, the doctor or nurse may take one or more small samples (biopsies) of skin from the vagina. They will inject local anaesthetic to numb the area first. They then take a sample of tissue about the size of a peppercorn. The samples are sent to a laboratory to be looked at under a microscope.

If VAIN is low-grade (VAIN 1), you may not need treatment 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 2 to 5 in 100 of women with VAIN (2 to 5%) may develop vaginal cancer after treatment.

Surgery may be used:

• if there is high risk that there may be undetected cancer cells in the vagina
• if VAIN comes back after other treatments.

When a small area of the 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 the vagina shorter. The vagina is naturally stretchy, so you may not notice any changes. But if you have difficulties with penetrative 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 bigger area, surgery may involve removing part or all of the vagina. This is called a partial or total vaginectomy. A new vagina may be created during the operation or at a second operation, using tissue from other parts of the body. This is called vaginal reconstruction. 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.

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 takes time to heal after treatment. Your doctor or nurse will ask you not to use tampons or douches, and not to have vaginal sex for about a month.

Local ablation is usually done as an outpatient. It can be done in 2 ways.

Sometimes VAIN is treated with 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. Or it may be used if you are not well enough to have the surgery. This treatment may be given as part of a clinical trial.

Drugs that may be applied as a cream include:

• imiquimod
• fluorouracil (5FU).

The cream may be applied in the clinic, or you might apply it yourself at home after being shown how. You usually apply imiquimod 3 times a week. It can help to boost the immune cells in the vagina to target HPV and abnormal cells. Fluorouracil (5FU) cream is a type of chemotherapy drug that you usually have once a week.

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

Radiotherapy uses high-energy rays (radiation) 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 to treat more widespread VAIN. Your cancer doctor will explain more about the treatment and what to expect.

VAIN is usually treated with internal radiotherapy (brachytherapy). During brachytherapy, an applicator containing a radioactive substance is placed inside the 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.

We want everyone affected by cancer to feel our information is written for them.

We want our information to be as clear as possible. To do this, we try to:

• use plain English
• explain medical words
• use short sentences
• use illustrations to explain text
• structure the information clearly
• make sure important points are clear.

We use gender-inclusive language and talk to our readers as ‘you’ so that everyone feels included. Where clinically necessary we use the terms ‘men’ and ‘women’ or ‘male’ and ‘female’. For example, we do so when talking about parts of the body or mentioning statistics or research about who is affected.

You can read more about how we produce our information here.