Vulval cancer

The vulva is everything on the outside: the outer and inner lips, the clitoris, the entrance to the vagina and the skin of the perineum. Vulval cancer is uncommon, far rarer than cervical cancer, and it is found mainly in older women, although it can occur at any age. Almost always it is a squamous cell cancer arising from the skin; melanoma, basal cell cancer and other forms are much less frequent. What makes this tumour unusual is that it sits in plain sight and can be examined, so in theory it ought to be caught very early. In practice the diagnosis comes late — not because the disease hides, but because its first signs look so much like ordinary irritation and get treated for years with the wrong thing.

What shows up on the vulva

Changes usually appear in one place: on the inner or outer surface of the lips, less often near the clitoris or at the vaginal opening. Anything that does not go away deserves attention.

• Itching or burning that persists for weeks and months and does not settle with the usual remedies.
• A thickening, a nodule or a lump you can feel under your fingers.
• A sore or a fissure that has not healed for more than three weeks.
• A growth resembling a wart or a cauliflower.
• An area of skin that has changed colour: whitish, bright red, brown or almost black. Such patches are harder to spot on darker skin.
• A thickened, rough or raised area standing out from the surrounding skin.
• A mole that has changed shape or colour, started to grow, or bled.
• Spotting between periods and, after the menopause, any bleeding at all.
• Pain, soreness or stinging when urine passes over the damaged area.
• A firm, enlarged node in the groin.

None of these on its own means cancer: far more often the cause is a fungal infection, eczema, lichen sclerosus, a reaction to a hygiene product, or the changes the tissue undergoes with age. But telling one from another is only possible by looking, and the sooner someone looks, the simpler the treatment turns out to be.

Why the diagnosis comes so late

The commonest route to a late diagnosis is persistent itching treated for years with thrush creams. A woman buys an antifungal, the itch quietens for a while, then returns; another tube is bought, and then another. A year goes by, then three, then five. Yet the rule is simple: vulval itching that does not clear with treatment calls for an examination, not for the next course of cream. If two courses in a row have not given a lasting result, the next person to look should be a doctor, not a pharmacy shelf.

The second reason for delay is embarrassment. Showing this part of the body to a stranger is uncomfortable for almost everyone, and women put the appointment off for months hoping it will "sort itself out", or feel awkward saying exactly where the itch is. That postponement is the single biggest cause of late diagnosis in vulval cancer. It is worth remembering that for a gynaecologist this examination is routine: they do it dozens of times a week and will remember neither you nor what your vulva looks like. The only thing that matters is whether you came in time.

There is a third trap, and it is age. After the menopause many women stop seeing a gynaecologist altogether, reasoning that with no periods there is no reason to go. Yet those are exactly the years in which vulval cancer is most common.

What the examination involves

There is nothing complicated or painful about it. The doctor will ask how long the symptoms have been there, what you have already tried, whether you have any skin conditions, then ask you to undress from the waist down behind a screen and offer you something to cover yourself with. You are entitled to ask for a female doctor when booking, and to ask for someone else to be in the room, whether a person you trust or a nurse.

The examination itself means looking carefully at the skin of the vulva, feeling it with gloved hands, checking the groin for enlarged nodes, and usually examining the vagina and cervix with a speculum. It may be uncomfortable but it should not hurt; if it does, say so at once, because the examination can be stopped at any moment. It helps to prepare: remember when the itching started, which creams you used and for how long, and whether relatives have had anything similar. If the change is only visible in a certain position, or comes and goes, take a photograph beforehand.

Pre-cancerous change and lichen sclerosus

Vulval cancer almost never appears suddenly on healthy skin. It is usually preceded by changes that can be found and treated long before they become a tumour. They are called vulval intraepithelial neoplasia: the skin cells are already abnormal but have not spread beyond the surface layer. It shows itself as persistent itching with whitish, reddish or dark patches and areas of thickening. Such changes are treated with topical medicines, laser or a small excision, and the woman is then kept under review.

Lichen sclerosus deserves separate mention. It is a chronic inflammatory condition of vulval skin that makes it thin, white and inelastic, causes itching and easy splitting, and over time flattens out the shape of the lips. It is not a cancer, but it clearly raises the risk: roughly one woman in twenty to fifty eventually develops a tumour. So the diagnosis carries two consequences. First, it needs treating, usually with courses of potent topical steroids, which not only relieve the itch but lower the risk of malignant change; stopping as soon as things feel better is a mistake. Second, it needs regular review, along with your own watchfulness for any new lump, sore or crack that will not heal. Vulval lichen planus is followed in much the same way.

HPV, smoking and other risk factors

Vulval cancer develops along two different routes. One is linked to human papillomavirus: certain types live in skin cells for years and gradually produce pre-cancerous change. This route accounts for more of the cases in younger women. The other runs through chronic inflammation of the skin, above all lichen sclerosus, and belongs to older age.

HPV is a very common virus, passed on through any skin contact in the genital area, not only through penetrative sex. In most people the immune system clears it unaided, but in some the infection persists for years. Besides HPV, the risk is raised by smoking, which both weakens local defences and is itself carcinogenic; by a weakened immune system, whether from HIV, after a transplant or on medicines that suppress immunity; and by previous pre-cancerous change or cervical cancer, which shows the virus has already done damage.

What genuinely lowers the risk is HPV vaccination, which protects against the virus types responsible for most HPV-related tumours. It is given to teenagers before they become sexually active, and several countries offer it to adults as well; the exact ages and schedules differ from one country to another, so check your national programme. After that come stopping smoking, treating vulval skin conditions instead of enduring them, using condoms, which reduce though do not abolish transmission, and getting into the habit of a monthly look with a mirror so that any change is noticed early.

Tests: vulvoscopy and biopsy

If the doctor sees a suspicious area, the next step is to look at it under magnification. The skin is examined through a colposcope, an instrument with powerful optics that stays outside and puts nothing in; sometimes a solution is applied that makes altered areas stand out.

Only a biopsy gives the final answer. The doctor numbs the area with a local anaesthetic and takes a piece of tissue a few millimetres across; occasionally a single stitch is needed. It takes only minutes, and afterwards there is soreness and slight spotting for a few days. Results usually come back in one to three weeks. A long wait does not mean something bad has been found — the sample simply goes through several stages of processing.

If cancer is confirmed, further tests establish the size of the tumour and whether it has spread: blood tests, CT, MRI and sometimes PET. The groin nodes are assessed separately, and as a rule the sentinel node — the first one the tumour drains to — is removed and examined during surgery. All of this determines how extensive the treatment needs to be. From that point a specialist team looks after you, and it usually includes a nurse who acts as your point of contact between appointments.

How it is treated

Vulval cancer found early responds well, and that is the strongest argument for not putting off the examination. The main treatment is surgery. A small tumour is removed together with a rim of healthy tissue around it, and the vulva looks much as it did before. With wider spread, part of the vulva or all of it is removed, sometimes along with the groin nodes. After extensive surgery the shape is rebuilt using the patient's own tissue; plastic surgeons do this work, and the result is worth discussing before the operation rather than after.

Radiotherapy is used to shrink the tumour before surgery, to lower the chance of it returning afterwards, and where surgery is not possible. Chemotherapy is given alongside radiotherapy or on its own, including in advanced disease. The exact plan depends on the type of tumour, its size and site, and the state of the lymph nodes, and in most cases it is agreed by a multidisciplinary team.

Worth asking in advance: how passing urine and sensation will change, how long the wound takes to heal, what happens to sex life, whether physiotherapy will be needed, and who to contact if a leg swells, which can happen after the groin nodes are removed. If the disease is found late and cannot be cured, treatment aims at holding the tumour back and controlling pain; that is the work of the palliative care team, and there is every reason to involve them early rather than at the very end.

Online consultation

A remote appointment suits this subject particularly well as a first step, precisely because so many women find it hard to go in person. You can describe calmly what is wrong and for how long, say what you have already tried, and get a clear answer to the main question: is this ordinary irritation or a situation that needs looking at? You can send a photograph of the affected area, go through the result of a biopsy already taken, work out how to use the ointment properly for lichen sclerosus and how often to be reviewed, and ask about HPV vaccination or what to do about the itch while you wait for an appointment.

There is one limitation, and it is a real one: neither a photograph nor a description replaces an examination, still less a biopsy. Vulval cancer is diagnosed only on a piece of tissue. So if the doctor says you need to be seen in person, that is not over-caution. And do not put off getting help if there is bleeding from the vulva, a lump that is growing quickly, a sore that has not healed in more than three weeks, or an enlarged node in the groin.

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