Vulvar Dysplasia

Vulvar dysplasia involves abnormal changes in the skin cells of the vulva that can develop into cancer over time if left untreated, but with proper care and monitoring, most cases can be successfully managed before they ever become cancerous.

Table of contents

• What is Vulvar Dysplasia?
• Types of Vulvar Dysplasia
• What Causes Vulvar Dysplasia?
• Risk Factors
• Symptoms and Appearance
• How is it Diagnosed?
• Treatment Options
• Follow-up After Treatment
• Prevention

Vulvar intraepithelial neoplasia, VIN, Squamous intraepithelial lesion

• Vulva
• Labia majora
• Labia minora
• Clitoris

What is Vulvar Dysplasia?

Vulvar dysplasia, also called vulvar intraepithelial neoplasia (VIN), refers to abnormal changes that occur in the skin cells of the vulva. The vulva is the external part of the female genitals, including the outer and inner lips, clitoris, and the opening to the vagina. When you have vulvar dysplasia, the cells on the surface of your vulvar skin become atypical, meaning they don’t look or behave like normal, healthy cells.^[1][2]

It’s important to understand that vulvar dysplasia is not cancer. However, it is considered a precancerous condition, which means that without treatment, these abnormal cells could eventually develop into vulvar cancer over several years. The good news is that most cases of vulvar dysplasia can be cured with proper treatment and follow-up care.^[1][3]

Although vulvar cancer itself is rare, accounting for about 6% of cancers of the female genital system, vulvar dysplasia has become increasingly common. According to U.S. health surveillance programs, vulvar dysplasia is now four times more common than it was in the 1970s. This condition is most often seen in women in their 40s and 50s, though it can occur at other ages as well.^[1][3]

Types of Vulvar Dysplasia

Vulvar dysplasia is divided into different categories based on how the abnormal cells look under a microscope and what causes them. Understanding these types helps doctors determine the best treatment approach and assess how quickly the condition might progress.^[2][4]

The main classification system recognizes two major types of vulvar dysplasia that can become cancer. The first is usual type VIN (uVIN), also called high-grade squamous intraepithelial lesion (HSIL). This is the most common form, accounting for the majority of vulvar dysplasia cases. It is strongly associated with infection by the human papillomavirus (HPV), particularly high-risk types of the virus that can cause normal cells to transform into cancer cells. Women with this type are typically diagnosed in their 40s.^[2][4]

The second type is differentiated VIN (dVIN), which accounts for only about 5% of all vulvar dysplasia cases. This type is most common in women aged 60 and older and is not related to HPV infection. Instead, it develops alongside chronic inflammatory skin conditions, particularly lichen sclerosus, a condition that causes inflammation and white, scaly patches on the vulvar skin. Differentiated VIN tends to progress to cancer more quickly than the usual type, typically within two to three years compared to six to seven years for HPV-related dysplasia.^[2][4]

There is also a category called low-grade squamous intraepithelial lesion (LSIL), which is associated with low-risk forms of HPV. These low-risk types can cause warts in the genital area but rarely become cancerous. LSIL often goes away without treatment and is not considered a true precancerous condition.^[2][6]

What Causes Vulvar Dysplasia?

The exact cause of vulvar dysplasia has not been fully established, but researchers have identified two main pathways through which it develops. The most common cause is infection with high-risk types of human papillomavirus. HPV is a sexually transmitted infection that spreads through skin-to-skin contact during various forms of sexual activity, not just intercourse. This means the virus can be transmitted through intimate touching as well.^[2][5]

HPV is found in 72% to 100% of cases of vulvar dysplasia. Among the many types of HPV, certain strains are considered high-risk because they can cause cells to become abnormal. The most common high-risk strain associated with vulvar dysplasia is HPV-16, though types 18 and 33 are also linked to the condition. When these viruses infect vulvar skin cells, they can interfere with the normal cell growth process, leading to the development of dysplasia over time.^[2][8]

The second pathway involves chronic inflammation rather than viral infection. In these cases, vulvar dysplasia develops in association with long-standing inflammatory skin conditions, particularly lichen sclerosus. This condition causes the vulvar skin to become thin, white, and wrinkled, and it may be related to the body’s immune system mistakenly attacking its own tissues. Less commonly, vulvar dysplasia has been linked to chronic vulvar irritation, genital herpes simplex virus, and other conditions that cause ongoing inflammation of the vulvar area.^[2][5]

Risk Factors

Several factors can increase your likelihood of developing vulvar dysplasia. Understanding these risk factors can help you take preventive measures and recognize when you should pay closer attention to changes in your vulvar health.^[1][2]

Human papillomavirus infection is the strongest risk factor for vulvar dysplasia. Because HPV is sexually transmitted, factors that increase your exposure to the virus also raise your risk. These include having multiple sexual partners and beginning sexual activity at an early age.^[2]

Cigarette smoking is another significant risk factor. Smoking appears to weaken the body’s ability to fight off HPV infections and may contribute to the progression of abnormal cells. Women who smoke are not only more likely to develop vulvar dysplasia but also face higher rates of recurrence after treatment.^[1][4]

Having a weakened immune system increases your vulnerability to vulvar dysplasia. This includes women with HIV (human immunodeficiency virus) infection, those taking medications that suppress the immune system, and anyone whose immune system is compromised for other reasons. A healthy immune system normally helps control HPV infections and prevents abnormal cell growth, so when immune function is impaired, these protective mechanisms don’t work as well.^[1][2]

Lichen sclerosus of the vulva is an important risk factor, particularly for the differentiated type of vulvar dysplasia. This chronic inflammatory condition requires ongoing medical monitoring because of its association with dysplasia development.^[1][2]

Women with a history of abnormal Pap smears or previous genital cancers, including cervical cancer, also face increased risk. This is because the same risk factors, particularly HPV infection, can affect multiple areas of the genital tract.^[1]

Symptoms and Appearance

Many women with vulvar dysplasia do not experience any symptoms at all, which is why the condition is often discovered during routine gynecologic examinations. However, when symptoms do occur, they can significantly affect your comfort and quality of life.^[1][2]

The most common symptom is chronic itching of the vulva, which can be persistent and bothersome. You might also experience burning sensations, tingling, or soreness in the vulvar area. Some women report pain during sexual intercourse. These symptoms are general and can be caused by many different conditions, which is why it’s important to see your doctor for proper evaluation rather than trying to diagnose yourself.^[1][5]

Vulvar dysplasia can appear in many different ways, making visual identification challenging without medical expertise. The condition may show up as visible changes in skin color, with affected areas appearing white, gray, pink, reddish, or dark brown. The skin might look thickened or you might notice new growths that resemble warts. In some cases, you may see cracks or ulcerations in the vulvar skin.^[1][2]

The appearance of vulvar dysplasia varies considerably from person to person. Affected areas might be raised or flat. The color changes can range from white to red to pink to gray-brown or black. The abnormal areas might appear on just one part of the vulva or spread across multiple areas. Some lesions look like slightly raised patches, while others may appear darkened like a mole or freckle, or as flat gray areas.^[2][5]

Because vulvar dysplasia can look very different in different women and can resemble other vulvar conditions, the only way to know for certain if you have dysplasia is through a biopsy, where a small tissue sample is examined under a microscope.^[1]

How is it Diagnosed?

Unlike cervical cancer, there are no routine screening tests for vulvar dysplasia. Detection depends on visual examination and confirmation through tissue biopsy. This is why it’s important to bring any unusual symptoms or changes to your doctor’s attention during your regular gynecologic visits.^[1][5]

During a regular pelvic exam, your doctor examines your vulva for any abnormal-looking areas. If you’ve noticed symptoms like itching, burning, or skin changes, make sure to mention them. Your doctor will look for areas of discoloration, unusual growths, thickened skin, or other changes that might suggest dysplasia.^[1][2]

If your doctor sees abnormal areas, they may use a special magnifying instrument called a colposcope to examine your vulva more closely. This device, which is commonly used to examine the cervix, allows the doctor to see details that aren’t visible to the naked eye and helps identify lesions that might not be clearly visible otherwise. The colposcope doesn’t touch your body; it simply provides magnification and lighting to help the doctor see better.^[1][5]

The definitive way to diagnose vulvar dysplasia is through a biopsy. During this procedure, your doctor removes a small sample of tissue from the abnormal-looking area. First, the area is numbed with a local anesthetic so you won’t feel pain during the biopsy. The tissue sample is then sent to a laboratory where a specialist called a pathologist examines it under a microscope, looking for abnormal cells.^[1][2]

The biopsy results tell your doctor exactly what type of dysplasia you have and how severe it is. This information is crucial for determining the best course of treatment. You typically return to the clinic about two weeks later to get your biopsy results and discuss next steps with your doctor.^[1]

Doctors should maintain a low threshold for performing biopsies on vulvar lesions. Any lesion that is persistent, rapidly changing, or displays unusual features should be biopsied. Suspected genital warts in postmenopausal women and any lesions that haven’t responded to topical treatments should also be biopsied to rule out dysplasia or cancer.^[4]

Treatment Options

Treatment is recommended for all women with moderate to severe vulvar dysplasia because the condition’s course cannot be predicted and it may progress to invasive cancer over time. The good news is that most cases can be cured with proper treatment. Your doctor will help you choose the best treatment approach based on several factors, including the size, location, and number of affected areas, as well as whether there’s any suspicion of cancer.^[4][5]

Surgical removal through wide local excision is one of the main treatment options. During this procedure, the doctor surgically removes the dysplastic area along with a margin of normal-looking tissue around it. The removed specimen is sent to a pathology laboratory for microscopic examination to ensure all abnormal cells were removed and to check for any signs of hidden cancer. When cancer is suspected, wide local excision is the preferred approach because it allows complete examination of the tissue. The surgeon takes care to avoid injury to surrounding structures like the clitoris, urethra, and anus.^[4][5]

Laser ablation is another treatment option when cancer is not suspected. This procedure uses a focused laser beam to vaporize the dysplastic tissue. Laser treatment can be used for single lesions, multiple spots, or areas where lesions run together. Before the procedure, your doctor may use a colposcope to carefully identify the margins of the abnormal area. The laser destroys cells through the entire thickness of the skin surface, approximately two millimeters deep in non-hair-bearing areas. For large lesions in hair-bearing regions of the vulva, surgical excision is generally preferred because dysplasia can extend deeper into hair follicles beneath the skin surface.^[4][5]

A non-surgical option involves using a topical cream called imiquimod 5%. This medication can be applied at home, though it’s used off-label for vulvar dysplasia, meaning it hasn’t received specific approval from regulatory authorities for this particular use. Topical treatment with imiquimod may be particularly helpful for patients with numerous or widespread lesions when cancer is not suspected, or for those who cannot tolerate the conditions required for surgical treatments.^[4][5]

Using imiquimod requires significant commitment from the patient. Treatment typically involves applying the cream three times weekly for 12 to 20 weeks, with monthly visits to the doctor for examination of the treated areas. Lesions that don’t respond to the topical treatment will need surgical excision instead. Some women experience vulvar irritation or pain from the medication, which may require stopping treatment early. Despite these challenges, topical therapy can be an ideal approach for women unable to undergo surgical procedures.^[4]

The choice of treatment should be individualized based on your specific situation, preferences, and medical circumstances. Your doctor will discuss the benefits and potential drawbacks of each option to help you make an informed decision.^[4]

Follow-up After Treatment

Even after successful treatment, ongoing monitoring is essential because vulvar dysplasia can come back. Women who have had vulvar dysplasia remain at risk for recurrence and progression to vulvar cancer for the remainder of their lives. This doesn’t mean you will definitely develop problems again, but it does mean regular follow-up is important for early detection if dysplasia returns.^[4][5]

Recurrence rates after treatment range from 9% to 50% with all treatment methods. Several factors affect your risk of recurrence. If the tissue removed during excision shows dysplastic cells at the edges (called positive margins), the risk of recurrence is higher. Having more than one dysplastic lesion also increases recurrence risk. Cigarette smoking is associated with higher recurrence rates, providing another important reason to quit if you smoke.^[4][5]

After treatment, you should examine your own vulva regularly for any new changes or symptoms. Your doctor will also want to see you for follow-up examinations. Following successful treatment, if you have no new lesions at your 6-month and 12-month follow-up visits, you can typically be monitored annually thereafter through visual inspection of the vulva. However, if you notice any signs or symptoms of recurrence between scheduled visits, contact your doctor promptly rather than waiting for your next appointment.^[4][5]

The relatively slow rate of progression from dysplasia to cancer means that with regular monitoring and prompt attention to any changes, problems can usually be caught and treated early. Your healthcare provider will give you specific instructions about how often you need to be seen and what warning signs to watch for.^[4]

Prevention

While not all cases of vulvar dysplasia can be prevented, there are several important steps you can take to reduce your risk and protect your vulvar health.^[1][7]

Vaccination against HPV is one of the most effective preventive measures. The HPV vaccine protects against the high-risk virus types most strongly associated with vulvar dysplasia, including HPV types 16, 18, and others. Current vaccines are recommended for girls aged 11 to 12 years, with catch-up vaccination available through age 26 for those not previously vaccinated. Studies have shown that HPV vaccination decreases the risk of developing vulvar high-grade dysplasia.^[7]

Stopping cigarette smoking is another crucial step if you smoke. Smoking not only increases your risk of developing vulvar dysplasia but also raises the likelihood that it will come back after treatment. Quitting smoking benefits your overall health in many ways, and protecting your vulvar health is one more reason to stop.^[1]

Getting regular gynecologic examinations is important for early detection. While there’s no specific screening test for vulvar dysplasia, routine pelvic exams allow your doctor to identify suspicious changes early when they’re most treatable. Don’t hesitate to bring up any unusual symptoms or concerns about your vulvar health during these visits.^[1]

If you have risk factors for vulvar dysplasia, such as HPV infection, lichen sclerosus, or a weakened immune system, you should perform vulvar self-examinations and see your doctor promptly if you notice any worrisome changes. Learning what’s normal for your body helps you recognize when something has changed.^[1]

Managing chronic vulvar conditions like lichen sclerosus with appropriate treatment can help reduce your risk of developing dysplasia. If you have such a condition, follow your doctor’s treatment recommendations carefully and keep all scheduled follow-up appointments.^[1]