Cancer of the vulva, the outer part of the female genitalia, is rare. Vulvar cancer most often occurs in women between the ages of 55 and 85, although it can also occur in women who are younger than 40.
More than 90 percent of vulvar cancers are squamous cell carcinomas — a type of skin cancer — that develop slowly over years and are preceded by precancerous changes in the surface of your skin. A small percentage of vulvar cancers begin as melanoma. Rarely, vulvar cancers may develop in the mucus-producing glands located on the sides of the vaginal opening. The exact cause isn't known. Human papillomavirus (HPV), a sexually transmitted infection, may play a role.
Getting regular gynecologic exams may increase your chance of early detection of vulvar cancer, which means a better chance of successful treatment. You may also be able to prevent vulvar cancer by engaging in safe sexual practices to reduce your risk of contracting HPV infection, and you may be able to control other risk factors as well.
Recognizing possible signs and symptoms of vulvar cancer may help you detect the disease early, before it reaches an advanced stage. This may give you a better chance for successful treatment and long-term recovery. If you experience any of the following vulvar signs or symptoms, see your doctor:
The exact cause of vulvar cancer isn't known. Most vulvar cancers occur in women between the ages of 55 and 85 who have a mutation or defect in the p53 tumor suppressor gene — a gene that plays a role in keeping cells from becoming cancerous. These women also often have lichen sclerosus — a condition that causes the vulvar skin to become thin and itchy.
The remaining 30 percent to 50 percent of vulvar cancers occur in younger women who have the sexually transmitted infection HPV, which appears to play a key role. It may take years or decades for vulvar cancer to develop after infection with HPV. Many times these women have a precancerous skin condition called vulvar intraepithelial neoplasia in multiple areas of the vulva, and they typically are smokers.
Although the exact cause of vulvar cancer isn't known, certain factors appear to increase your risk of the disease. These factors include:
Because an early diagnosis of vulvar cancer increases the likelihood of successful treatment, it's important that you see your doctor if you experience any of the signs and symptoms of vulvar cancer.
If you have been treated for vulvar cancer, be sure to see your doctor for regular follow-up exams. Your doctor will monitor you to guard against recurrence of the cancer.
To check for vulvar cancer, your doctor will first conduct a physical examination, including a pelvic exam. If your doctor finds any irregularities, you'll likely need further testing.
Biopsy
Because signs and symptoms of vulvar cancer can also suggest a noncancerous condition, your doctor will need to confirm a diagnosis by removing a small sample of tissue (biopsy) from the irregular area for analysis under a microscope.
To select the best tissue to sample, your doctor may swab a blue dye across your vulva. This dye will react with certain diseased areas, including those affected by a precancerous condition or by vulvar cancer, causing them to turn blue.
Your doctor might also use a special lighted microscope called a colposcope. The colposcope magnifies the surface, helping your doctor identify areas of abnormal cell growth that can't be seen by the naked eye. Your doctor may also swab the area with a weak acetic acid solution (similar to vinegar), which can cause areas affected by a precancerous condition or by vulvar cancer to turn white, making them even more visible.
Once your doctor determines which area to biopsy, he or she may choose one of two types of biopsies:
Staging tests
Staging tests help determine the size and location of your cancer and whether it has spread. They also help your doctor determine the best treatment for you. To gather this information, your doctor may use the following tests:
Imaging tests also can help determine if your cancer has spread. These tests may include:
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
The more advanced a vulvar cancer is, the more tissue that may need to be surgically removed. Options include:
Vulvectomy. Several types of vulvectomy exist. A skinning vulvectomy removes only the top layer of skin where the cancer is. Your doctor may graft skin from another part of your body to cover this area. A simple vulvectomy involves removing the entire vulva. These types of vulvectomies are performed in people with noninvasive vulvar cancer. In a radical vulvectomy, your doctor removes either the cancer and the deep surrounding tissue (partial vulvectomy) or the cancer and the entire vulva, clitoris and nearby tissue (complete radical vulvectomy).
Removing large areas of skin and tissue in the vulva may create problems with healing, infection, and the ability of the skin grafts to take. The risk of such complications rises with greater tissue removal.
Lymph node removal. Vulvar cancer often spreads to the lymph nodes in the groin, so your doctor may remove these lymph nodes. Your doctor may also tie off a major vein, the saphenous vein. Some doctors will try to avoid closing this vein to prevent additional risk of leg swelling that can occur with this procedure. After the procedure, you'll need a suction drain in the incision for several weeks.
Removing lymph nodes can cause problems with fluid retention, leg swelling and an increased risk of infection of the lymph vessels (lymphangitis), a condition called lymphedema. If you develop this complication, your doctor may give you compression devices or support stockings to help ease the symptoms. You'll also need to avoid scratches, sunburn and other injury to your legs.
Other complications from vulvar cancer surgery may include the development of cysts near the wounds (lymphoceles), blood clots, urinary infections, loss of sexual desire or pleasure, and painful irritation.
Radiation therapy
Radiation therapy uses high-energy X-rays to kill cancer cells. The radiation is given outside the body and is usually used only to treat the lymph nodes in the groin and pelvis, not the vulva itself. Sometimes it's used to shrink a large tumor so that it can later be removed with less extensive surgery. The skin in the treated areas may look and feel sunburned for six to 12 months. Also, if radiation is used on the pelvis area, you may experience problems with premature menopause and urination.
Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. You may take these drugs through a vein, by mouth or through your skin (topically). Vulvar cancers that have spread tend to be resistant to chemotherapy.
The side effects of chemotherapy may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow — as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control some of them.
Reconstructive surgery
Treatment of vulvar cancer often involves removal of some skin from your vulva. The wound or area left behind can usually be closed without grafting skin from another area of your body. However, depending on how widespread the cancer is and how much tissue your doctor needs to remove, your doctor may perform reconstructive surgery — grafting skin from another part of your body to cover this area.
You can help prevent vulvar cancer by avoiding sexual behaviors that put you at risk of sexually transmitted diseases such as HPV and HIV, both conditions that increase your risk of vulvar cancer. Not smoking may also reduce your risk of vulvar cancer.
You can help prevent invasive vulvar cancer by being aware of the signs and symptoms of vulvar cancer and having regular gynecologic exams to monitor for precancerous changes that may lead to vulvar cancer. When vulvar cancer is detected early, it's highly curable. According to the American Cancer Society, the overall five-year survival rate is 90 percent when the lymph nodes aren't involved. The overall five-year survival rate drops to 50 percent to 70 percent if cancer has spread to the lymph nodes.
In addition, a new vaccine against HPV, which was approved by the Food and Drug Administration in 2006, is effective in preventing vulvar cancer as well as cervical cancer.
Living with cancer is challenging. But dealing with the physical effects of vulvar cancer and its treatment can be especially difficult. In particular, if your treatment involved vulvectomy, lymph node removal or pelvic exteneration, you may wonder how the changes in your body will affect your normal activities, your relationships and your sexuality.
It may be difficult to come to terms psychologically with the physical changes you've experienced. Although there are no easy answers for coping with vulvar cancer, the following suggestions may help:
Share your concerns with others. When you feel ready, consider talking to someone you trust about your concerns. This might be a friend, a family member, your doctor, a social worker, a spiritual adviser or a counselor. You may also find it helpful to talk to other people with vulvar cancer. They can tell you how they've coped with problems similar to the ones you're facing.
One of the best ways to do that is to join a support group for people with vulvar or gynecologic cancers. Although support groups aren't for everyone, they can sometimes be a good resource for practical information about your disease. You may also find strength and encouragement in being with people who are facing the same challenges you are.
If you're interested in learning more about support groups, talk to a doctor, nurse, social worker or psychologist. They may be able to put you in touch with a group in your area. Or check your local phone book, library or cancer organization. The National Cancer Institute also can provide a list of support groups. So can the American Cancer Society at 800-ACS-2345, or 800-227-2345, or CancerCare at 800-813-HOPE, or 800-813-4673.
After deciding to participate in a group, try it out a few times. If it doesn't seem useful or comfortable, you don't have to continue.
Don't be afraid of intimacy. Your natural reaction to changes in your body may be to avoid intimacy. Although it may not be easy, it's vitally important to discuss these feelings with your partner. For example, a light touch and use of lubricant may help you avoid painful irritation. You may also find it helpful to talk to a therapist, either on your own or together. Remember that you can express your sexuality in many ways. Touching, holding, hugging and caressing may become far more important to you and your partner. In fact, the closeness you develop may produce greater intimacy than you've ever had.
Intimacy issues may be even harder to address if you're not currently in a committed relationship. You may worry that no one will ever find you attractive or desirable. In that case, the advice and understanding of a medical social worker or other therapist who is knowledgeable about vulvar cancer can be a tremendous help. Your doctor may be able to recommend a qualified counselor. Or call the National Cancer Institute's toll-free information line, called the Cancer Information Service. It provides access to trained counselors and accurate, up-to-date information on all aspects of living with cancer. You can reach the Cancer Information Service 24 hours a day at 800-4-CANCER, or 800-422-6237.
July 11, 2006