Vaginal cancer

Vaginal cancer is a tumour growing in the wall of the vagina, the passage between the vulva and the neck of the womb. It is uncommon: it accounts for a very small share of all cancers of the female reproductive organs, and most cases appear after the age of sixty. Two things follow from that rarity at once. The first: if you have noticed bleeding or discomfort, the chance that it is cancer is low and another explanation is nearly always found. The second: precisely because it is rare, such symptoms are easy to wave away, both by the woman herself and by whoever she speaks to — and the tumour grows slowly and stays curable for a long time. The two ideas do not contradict each other: it needs checking, it does not need panic.

Signs worth making an appointment for

There is no screening programme aimed specifically at vaginal cancer, so it is found through symptoms. All of them are non-specific, and that is the main difficulty:

• bleeding between periods, including light spotting;
• bleeding or pain after sex;
• any bleeding after the menopause — this has a section of its own below;
• discharge unlike your usual: bloodstained, foul-smelling or watery, when it was not like that before;
• a lump, a nodule or a sore in or beside the vagina that you can feel or see;
• itching that lasts for weeks and does not settle with the usual treatment;
• pain in the pelvis or during sex;
• pain on passing urine and needing to go often; in advanced disease, constipation or swelling of one leg.

Get symptoms checked if they last longer than two or three weeks, if they keep coming back, or if this is the first time in your life they have appeared. Duration counts for more than severity here: light but persistent spotting means more than a single heavy bleed with an obvious cause.

Bleeding after the menopause always needs a doctor

This is the one rule worth taking away from the whole page. If your periods stopped a year ago or more, any appearance of blood is a reason to be seen, whatever the amount. A single spot on your underwear, a pink trace on the paper, one episode that never repeated — all of it counts. There is no need to wait and see whether it happens again, because a tumour does not politely give a second warning, and a week of waiting turns into six months.

The reason behind the rule is simple. Blood after the menopause is most often down to thinning of the lining from lack of oestrogen, which is harmless and easily dealt with. But that same symptom is the leading early sign of cancers of the womb, the cervix and the vagina, and there is no way of telling one from another without an examination. The same principle applies while you are on hormone therapy for the menopause: bleeding outside the expected pattern is discussed with a doctor rather than blamed on the treatment.

What lies behind these symptoms more often than cancer

It is worth saying this plainly so that fear does not become the reason for putting the visit off. The same complaints have far more common explanations:

• thinning of the lining after the menopause: dryness, fragile tissue, bleeding after sex or after an examination;
• infections and inflammation, including thrush, bacterial vaginosis and sexually transmitted infections;
• polyps of the cervix and the womb lining;
• fibroids and thickening of the womb lining;
• lichen sclerosus of the vulva, which causes stubborn itching and splits in the skin;
• mechanical injury, especially where there is dryness, and irritation from hygiene products;
• side effects of hormone medicines and of anticoagulants.

All of these are treatable, and most of them easily. But the list has another side to it: until it has been confirmed that this is one of them, the symptom remains unchecked. That applies above all to itching and "irritation" treated with creams for years without anyone looking.

HPV and the other risk factors

Most cases of vaginal cancer are linked to a long-standing infection with certain types of human papillomavirus. This virus is extremely common, is passed on by any skin and mucous membrane contact in the genital area, and in most people clears by itself within a year or so. The danger is not catching it but the years during which it fails to clear: over that time precancerous changes can appear in the lining, and it is those changes, if nobody finds them, that eventually turn into a tumour.

The chance is higher if:

• precancerous changes have been found before in your cervix or vagina, or you have had cervical cancer;
• your immune system is weakened — HIV, medication after a transplant, autoimmune conditions such as lupus;
• you smoke: tobacco makes it harder for the body to clear the virus and damages cells in its own right;
• you have had radiotherapy to the pelvis in the past;
• your mother took diethylstilboestrol while pregnant with you, a medicine used in the middle of the last century for threatened miscarriage; these women are followed up separately.

Two points that are often forgotten. Having had your womb removed does not remove the risk: the vagina is still there, and symptoms in it are investigated in the same way. The same holds for trans men and non-binary people who still have a vagina, in whole or in part.

What genuinely lowers the risk

Vaginal cancer cannot be prevented entirely, but two measures do work, and both involve HPV.

Vaccination against human papillomavirus. It protects against the virus types responsible for most of these tumours and, along the way, against cervical cancer. The benefit is greatest when it is given before sexual activity begins, which is why it is offered routinely in adolescence; a number of countries vaccinate boys as well as girls, and in adults it is considered case by case. Age and schedule differ from country to country — check the immunisation schedule where you live.

Regular cervical screening. Screening picks up cell changes long before they become a tumour, and along the way it finds some changes in the vagina too. That is why vaginal cancer is often prevented at an appointment a woman attended for something else entirely. The starting age and the intervals differ between countries — follow the programme running where you live and do not let the invitations lapse. After a hysterectomy for precancerous changes or for cancer, follow-up usually continues even though ordinary screening no longer applies.

What else is worth doing: stop smoking, use condoms — they lower, though they do not remove, the chance of passing the virus on — and do not put off getting a symptom checked. That last one is probably the most effective item on the list.

What the tests involve

It all starts with an ordinary gynaecological examination. The doctor looks at the vulva and the vaginal walls using a speculum and feels the pelvic organs. You can ask to be seen by a woman, bring someone with you, ask to have each step explained before it happens and stop the examination at any point: these are normal requests, not fuss.

If something looks suspicious, the next step is colposcopy — the lining examined under magnification with an instrument that stays outside the body. It takes around half an hour and is not usually painful, though nobody would call it pleasant. If needed, a small piece of tissue is taken for analysis: that is a biopsy, and only a biopsy gives the definitive answer. For a day or two afterwards you may have light spotting and period-type cramping.

Waiting for the result takes time, sometimes several weeks, and that does not mean anything bad has been found. If the diagnosis is confirmed, further tests are arranged to work out the stage: blood tests, CT, MRI, sometimes PET and, if necessary, a detailed examination under general anaesthetic. Everything that follows depends on the stage, so this step is not skipped. You will be looked after by a team — a gynaecological oncologist, a clinical oncologist, a specialist nurse. It helps to bring someone to appointments and to write your questions down in advance.

How it is treated

Vaginal cancer is often curable, and treatment is matched to the stage, the size, the position of the tumour and your general health. The mainstay is radiotherapy: external, internal (brachytherapy, with the source placed right next to the tumour), or both together. For small early tumours surgery is an option, and its extent varies widely, from removing a section of the vaginal wall to major operations in advanced disease. Chemotherapy is rarely used on its own; usually it is combined with radiotherapy. If the vagina has to be removed, reconstruction using your own tissue is discussed.

Once treatment ends, follow-up appointments are arranged, more frequent in the first years and further apart later. Between them, get in touch without waiting for your slot if you develop new bleeding, pain, swelling of a leg or anything that worries you.

Questions nobody should feel awkward asking

Treatment affects your sex life and your ability to have children, and this needs discussing with your doctors before treatment starts, not afterwards. It is not an awkward question and not a distraction from the serious business: it is part of the treatment plan, and the team expects it to be raised.

• Radiotherapy to the pelvis causes dryness, narrowing and loss of elasticity of the vagina. This is predictable and preventable: moisturisers, local treatments and vaginal dilators used regularly once the course finishes. Ask when to start and exactly how.
• In women who have not yet been through the menopause, radiotherapy and removal of the ovaries bring it on early, with all that goes with it. Ask about hormone replacement and whether it suits your situation.
• If you were planning a pregnancy, raise it at the very first appointment: some of the options for preserving fertility only work before treatment begins, and the decision has to be made quickly.
• Returning to a sex life is possible for most people, although the timing and the sensations change. Ask when you can, what helps if it hurts, and whether pelvic floor physiotherapy would be worth arranging.
• Psychological support and patient groups are not a luxury. Ask your team what is available where you are being treated.

Online consultation

An online appointment earns its place exactly where embarrassment gets in the way: describing bleeding, pain during sex or an itch that will not go away is easier from home, and it is that delay which costs the most. A doctor can work through what is most likely to be behind your symptoms, say how urgently a face-to-face examination is needed, explain which tests make sense in your situation and help you not to get lost in the referral route. Online is also a good place to go over results you already have, questions about HPV and vaccination, and how to manage the after-effects if treatment is behind you. What cannot be replaced is the examination, the colposcopy and the biopsy: any bleeding after the menopause, bleeding after sex, a sore that will not heal or a lump you can feel all need a face-to-face appointment, and preferably within days.

This material is for information only and does not replace medical advice.