Published: March 04, 2009 08:31 am      

The facts about cancer of the vulva

Dear Dr. Mona: For weeks, I have been having itching and seem to have a painful growth on the outside of my private area. What can I do? — Ellie

Dear Ellie: Go visit your doctor right away. It is important to make sure that you don’t have any major problem in the vulva. Chronic vulvar itching, lumps or wart-like symptoms, bleeding that is not menstrual bleeding, pain does not go away and skin color changes are signs of vulvar disease (cancer). Early detection improves the outcome and provides a better outlook for long-term recovery. Don’t be alarmed however, because all women with itching do not have vulvar cancer.

The exact cause of vulvar cancer is not clear, but you may have predisposing factors if you are a smoker, have been diagnosed with lichen sclerosis, have had a human papilloma virus infection, or have a history of melanoma. Lichen sclerosis is a condition in which the skin in the vulva is thinned; about 4 percent of patients with this condition progress to vulvar cancer. An HIV infection also predisposes women to vulvar cancer.

Vulvar cancer is more prevalent in aging women. Half of patients with vulvar cancer are older than 70; however, 18 percent of patients are under age 40, suggesting that this condition is not limited to old age.

At your medical visit, your doctor will evaluate the area that is causing the pain. In order to do this properly, the area is coated with a blue dye; the abnormal areas can then be detected. Alternatively, the vulva can be painted with vinegar and evaluated with a special lighted microscope called a colposcope. That allows us to identify the abnormal cells and biopsy them. When tissues are biopsied, the area is numbed, some of the affected tissues are removed and the skin is closed with stitches.

The biopsied tissues are sent to a lab for evaluation in order to determine how extensive the tissue involvement is. This allows us to “stage” this cancer, which will determine the treatment method. Other tests may be required as well, such as cystoscopy (looking in the bladder and ensuring that no cancer had spread to the bladder) and possibly examination under anesthesia to estimate the degree of the involvement of the cancer. Finally, when vulvar cancer has been identified, it is important to determine whether it has spread to other areas by performing a chest X-ray, CT scan of the pelvic area or MRI or PET scans.

Treatment options for vulvar cancer depend on the type and stage of cancer and include surgical removal of the tumor, radiation therapy, chemotherapy or a combination of these. Surgery can be done with laser, removing the affected area with a wide margin to ensure clear cancer-free margins (usually 1 to 2 inches around the affected area). Removal of the vulva known as vulvectomy can be simply removal of the skin or removal of the entire vulva (simple vulvectomy).

If the cancer has spread outside the vulva, areas of the surrounding organs are removed in an extensive operation called pelvic exenteration. This may involve removal of the cervix and the uterus, ovaries, lymph nodes, bladder and the rectum and parts of the colon. Lymph nodes in the groin are the first area where the vulvar cancer spreads and are removed in the process of staging. However, lymph node dissection may lead to leg swelling, and unacceptable side effects; therefore we are able to perform selective evaluation of the lymph nodes similar to what is done in breast cancer, in which the tumor is injected with a blue dye or a radioactive material a day before surgery and the tissues are selectively removed and tested. Adjacent lymph nodes are also removed to ensure complete removal of the tissues. Once the cancer is removed, treatment may be followed with chemotherapy, radiation therapy or a combination therapy.

Following cancer treatment, close followup is required because 10 percent of women with vulvar cancer have a recurrence. So self-examination at home as well as visiting the doctor at given intervals is very important.

Reading this is frightening, but this type of cancer can be prevented by avoiding the risk factors. Improve your immune system, stop smoking, and get vaccinated with Gardisil, a vaccine approved to give protection against two types of HPV that cause vulvar infections and the two types of HPV viruses that lead to cervical dysplasia.

This vaccine is approved for women and young girls between the ages of 9 to 26 years. Regular physical examinations are also important.

So please get to your doctor and have this area checked; hopefully, it is a simple thing and your doctor will have some options to treat that itching and biopsy this area and then you can put your mind at ease.



Dr. Mona Alqulali is a board certified OB-GYN.