Introduction: When to Seek Diagnostic Testing
Women who notice any unusual changes in their vulvar area should consider seeking medical evaluation. The vulva includes all the external parts of the female genitals, such as the inner and outer lips surrounding the vagina, the clitoris, the opening where urine exits, and the skin between the vagina and anus. Any persistent changes in this area deserve attention from a healthcare provider.[1]
Diagnostic testing becomes advisable when certain symptoms appear and do not go away on their own. These symptoms include lumps or growths that resemble warts, open sores that fail to heal, persistent itching or burning sensations that do not improve with treatment, changes in skin color or texture, unexplained bleeding unrelated to menstruation, and tenderness or pain in the vulvar area. Some women may experience discomfort during sexual activity or while urinating.[1][2]
It is important to understand that many of these symptoms can also occur with noncancerous conditions. Skin irritation, infections, and other benign problems can cause similar changes in the vulvar area. However, because vulvar cancer symptoms often do not appear in the early stages, seeking evaluation as soon as changes are noticed increases the chances of catching any serious condition early.[2]
Women at higher risk should be particularly vigilant about seeking diagnostic evaluation. Risk factors include increasing age, infection with certain types of human papillomavirus (a virus spread through sexual contact, abbreviated as HPV), smoking, chronic inflammatory conditions of the vulva such as lichen sclerosus (a skin condition causing white patches and itching), previous radiation treatment to the pelvic area, and conditions that weaken the immune system.[2][8]
Waiting for symptoms to worsen or hoping they will disappear on their own can delay diagnosis. Since vulvar cancer is highly curable when detected early, especially when it has not spread beyond the vulva, prompt medical attention for any concerning changes is the best approach. Healthcare providers can distinguish between cancer and other conditions through proper diagnostic testing.[9]
Classic Diagnostic Methods
Initial Physical Examination
The diagnostic process typically begins with a thorough physical examination. A doctor, gynecologist, or other healthcare professional will first discuss your personal and family health history. This conversation includes questions about your symptoms, how long they have been present, any changes you have noticed, and whether you have any known risk factors for vulvar cancer.[10]
Following the discussion, the healthcare provider performs a pelvic examination. During this examination, the provider carefully inspects the entire vulvar area, looking for any visible abnormalities such as lumps, sores, color changes, or areas of thickened skin. The examination also includes checking the vagina and cervix. The provider may insert one or two gloved fingers into the vagina while pressing on the lower abdomen with the other hand to feel the size and position of internal organs. A similar check of the rectum may also be performed to detect any lumps or abnormal areas.[10]
Colposcopy
When a healthcare provider notices something concerning during the physical examination, they may use a special magnifying instrument called a colposcope. This device looks like a large pair of binoculars mounted on a stand. The colposcope does not touch the body but allows the provider to examine the vulvar skin closely, magnifying the area to see details not visible to the naked eye. This same instrument can also be used to examine the vagina and cervix if needed.[11]
The colposcope helps healthcare providers identify areas that may need further testing. By magnifying the tissue, providers can better assess the borders of any suspicious areas, check for unusual blood vessel patterns, and determine the best location for taking tissue samples if a biopsy becomes necessary.[11]
Biopsy
A biopsy is the only way to definitively diagnose vulvar cancer. This procedure involves removing a small sample of skin or tissue from the suspicious area so it can be examined under a microscope in a laboratory. A specialist called a pathologist looks at the cells in the tissue sample to determine whether cancer is present and, if so, what type it is.[11]
Many vulvar biopsies can be performed right in a healthcare provider’s office. The provider first numbs the area with a local anesthetic, which is medicine that prevents you from feeling pain in that specific spot. Once the area is numb, the provider removes a small piece of skin using either a surgical blade or a circular cutting tool. The discomfort is usually minimal because of the numbing medicine, though you may feel some pressure during the procedure.[11]
In some situations, the biopsy may be performed in an operating room while you are under general anesthesia. This means you receive medicine that puts you into a sleep-like state so you are not aware during the procedure. This approach might be chosen if a larger tissue sample is needed or if the suspicious area is in a location that would be difficult to biopsy in an office setting.[11]
After the biopsy, the tissue sample is sent to a laboratory where it is prepared and examined by a pathologist. The pathologist looks for abnormal cells and determines whether they are cancerous. If cancer is present, the pathologist also identifies the specific type of cancer and how abnormal the cells appear, which helps guide treatment decisions. Results typically become available within several days to a week.[15]
Staging Tests
If the biopsy confirms vulvar cancer, additional tests are performed to determine how far the cancer has spread. This process is called staging, and it is essential for planning the most appropriate treatment. Staging tests help doctors understand whether the cancer is confined to the vulva or has spread to nearby lymph nodes or other parts of the body.[11]
A more thorough pelvic examination may be conducted to look for signs that cancer has spread to nearby areas. The healthcare provider carefully examines the entire pelvic region, checking for enlarged lymph nodes or other abnormalities that might indicate cancer spread.[11]
Imaging tests create detailed pictures of the inside of the body and help doctors see whether cancer has spread beyond the vulva. Several types of imaging tests may be used. X-rays are the simplest form of imaging and may be used to check the chest for signs of cancer spread to the lungs. Computed tomography, or CT scans, use multiple X-ray images taken from different angles and combine them with computer processing to create cross-sectional images of the body. These scans can show the abdomen and pelvis in detail, helping doctors see whether cancer has spread to lymph nodes or other organs.[11]
Magnetic resonance imaging, or MRI, uses powerful magnets and radio waves instead of X-rays to create detailed images of soft tissues in the body. MRI scans are particularly good at showing the details of muscles, organs, and other soft tissues, which can help determine the extent of cancer spread. Positron emission tomography, or PET scans, involve injecting a small amount of radioactive sugar into the body. Cancer cells, which grow quickly, use more sugar than normal cells and show up as bright spots on the scan. PET scans can help identify cancer that has spread to distant parts of the body.[11]
Examination Under Anesthesia
In some cases, doctors may recommend a thorough examination while the patient is under anesthesia in an operating room. This allows the healthcare team to conduct a very careful and complete examination without causing discomfort. During this examination, the provider can assess the full extent of the cancer and take additional biopsies if needed. This is particularly helpful when the cancer is large or located in an area that would be difficult to examine thoroughly in an office setting.[15]
Diagnostics for Clinical Trial Qualification
Clinical trials are research studies that test new ways to prevent, detect, or treat diseases, including vulvar cancer. When considering participation in a clinical trial for vulvar cancer, specific diagnostic tests are used as standard criteria for determining whether a patient is eligible to enroll. These tests ensure that patients in the trial have the specific characteristics the researchers are studying.[10]
The first requirement for clinical trial enrollment is typically a confirmed tissue diagnosis through biopsy. The pathology report from the biopsy must document the presence of vulvar cancer and identify its specific type. Most clinical trials specify exactly which types of vulvar cancer they are studying, so the biopsy results must match the trial’s requirements. The pathology report also needs to include information about how the cancer cells look under the microscope, which is called the grade of the cancer.[15]
Accurate staging is another essential component of clinical trial qualification. Trials often enroll patients only at specific stages of cancer. For example, some trials might focus on early-stage vulvar cancer that has not spread beyond the vulva, while others might study advanced cancer that has spread to lymph nodes or distant organs. The complete set of staging tests, including physical examination findings, imaging test results, and surgical findings if applicable, must be documented to confirm the stage.[15]
Many clinical trials require tests to assess a patient’s overall health and organ function before enrollment. These may include blood tests to check blood cell counts, liver function, and kidney function. Healthcare providers need to know that a patient is healthy enough to tolerate the experimental treatment being studied. Blood tests measuring different components such as red blood cells, white blood cells, and platelets help determine whether the bone marrow is functioning normally. Tests of liver enzymes and kidney function ensure these organs can process medications safely.[10]
For trials involving HPV-related vulvar cancers, testing for HPV status may be required. This involves laboratory analysis of the biopsy tissue to determine whether HPV infection is present in the cancer cells. Different types of vulvar cancer arise through different pathways—some are associated with HPV infection while others develop through other mechanisms—and this distinction can be important for certain clinical trials.[2][8]
Some trials studying new treatments or diagnostic approaches may require additional specialized tests not typically performed in routine care. These might include molecular testing of the tumor tissue to look for specific genetic changes, special imaging techniques, or collection of additional blood or tissue samples for research purposes. The specific requirements vary depending on what the trial is investigating. Researchers conducting the trial will explain all required tests and procedures during the informed consent process before a patient decides whether to participate.[10]
Documentation of previous treatments, if any, is also typically required for clinical trial enrollment. This includes detailed records of any prior surgeries, radiation therapy, chemotherapy, or other treatments. Some trials specifically enroll patients who have not yet received treatment for their cancer, while others focus on patients whose cancer has returned after treatment or has not responded to standard therapies. Complete medical records help trial coordinators determine whether a patient meets the specific eligibility criteria.[10]
