Vaginal intra-epithelial neoplasia (VAIN)
Vaginal intra-epithelial neoplasia (VAIN) is a term that describes abnormal changes of the cells that line the vagina. VAIN is not cancer, but over time it can sometimes develop into cancer
Vaginal intra-epithelial neoplasia (VAIN) is abnormal changes of the cells that line the vagina. VAIN is not cancer. It may go away without treatment. But if the changes get worse, there is a chance that vaginal cancer may develop after many years. Because of this, VAIN is called a pre-cancerous condition.
VAIN can develop in just one area of the vagina, but more often it affects several different areas at once. If only one area is affected, it is usually the upper third of the vagina, towards the cervix. Sometimes, abnormal changes affect other areas as well as the vagina, such as the cervix, vulva and anus.
VAIN can affect anyone with a vagina. This includes women, trans (transgender) men and people assigned female at birth. It can affect any age group, but is more common over the age of 50.
Human papilloma virus (HPV)
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:
- inherited immunity problems
- some medicines, such as those taken after transplant surgery
- 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.
VAIN is divided into grades. They describe how deep into the surface layer of the vagina the abnormal cells are.
With all grades of VAIN, only a small area of the vagina may be affected by abnormal changes. Or there may be several areas of the vagina affected by a mixture of grades of VAIN.
VAIN 1 (low-grade VAIN)
VAIN 1 means one-third (33%) of the thickness of the surface layer of the vagina is affected. You may not need treatment. These changes often go back to normal without treatment. But a doctor will check the area regularly. If these checks show the VAIN 1 is not improving, you may be offered treatment.
VAIN 2 and VAIN 3 (high-grade VAIN)
VAIN 2 means two-thirds (66%) of the thickness of the surface layer of the vagina is affected. VAIN 3 means the full thickness (100%) of the surface layer of the vagina is affected. VAIN 3 is also called carcinoma in situ, but it is not vaginal cancer.
VAIN 2 and VAIN 3 have a higher risk of developing into vaginal cancer. You will usually be offered treatment to prevent this happening.
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.
The doctor uses a colposcope to see the affected areas. A very fine beam of light (laser) is then directed at the abnormal cells to destroy them. This is usually done under a general anaesthetic. Sometimes, if only a very small area is affected, it may be done using a local anaesthetic. If several areas of the vagina are affected, or if your doctor thinks there is a high risk the disease may come back, they may treat all of the vagina with laser treatment.
Laser treatment may take more than one treatment.
The doctor uses a thin wire with an electric current to destroy the affected area. This is done under a local anaesthetic.
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:
- 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.
After treatment, you will have regular appointments with your specialist for the rest of your life. This is because sometimes VAIN can come back. Your doctor will check for any further changes that may need to be treated.
How your sex life might be affected
Any physical changes to your sex life will depend on the treatment you have. Treatments such as laser and diathermy do not usually have any long-term effects on your sex life.
If you have vaginal reconstruction surgery, you may be unable to have vaginal orgasms. But surgery to the vagina will not affect your clitoris. You will still be able to have an orgasm through stimulation of the clitoris.
If you have radiotherapy, your vagina will become sore during treatment and for a few weeks afterwards. This may leave scarring, which may make your vagina narrower and less flexible. You may be referred to a specialist health professional who will give you advice on how to use vaginal dilators to help.
You may have many different emotions, including anger, resentment, guilt, anxiety and fear. These are all normal reactions and are part of the process many people go through in trying to come to terms with their condition.
Everyone has their own way of coping with difficult situations. Some people find it helpful to talk to family or friends, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is there if you need it.
Our cancer support specialists can give you information about counselling in your area. Call 0808 808 00 00. Our Online Community is also a good place to meet people who may be in a similar situation.
Below is a sample of the sources used in our VAIN information. If you would like more information about the sources we use, please contact us at email@example.com
Bogani et al. 2018.Treatment modalities for recurrent high-grade vaginal intraepithelial neoplasia. Journal of Gynecologic Oncology. p1-9.
Field et al. 2020. Vaginal intraepithelial neoplasia: A retrospective study of treatment and outcomes among a cohort of UK women. Journal of lower genital tract disease. Vol 24 (1), p43-47.
Gurumurthy et al. 2020. UK national survey of the management of vaginal intraepithelial neoplasia. Journal of Obstetrics and gynaecology. Vol, 40 (5) p694-698.
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Senior Medical Editor, Professor Nick Reed, Consultant Clinical Oncologist.
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