Signs and symptoms of vulvar cancers

Vulvar intraepithelial neoplasia

Most women with vulvar intraepithelial neoplasia (VIN) have no symptoms at all. When a woman with VIN does have a symptom, it most often is itching that does not go away or get better. An area of VIN may look different than normal vulvar skin. It is often thicker and lighter than the normal skin around it. However, an area of VIN can also appear red, pink, or darker than the surrounding skin.

Because these changes are often caused by other conditions that are not pre-cancerous, some women don't realize that they might have a serious condition. Some try to treat the problem themselves with over-the-counter remedies. Sometimes even doctors may not recognize the condition at first.

Invasive Squamous Cell Cancer of the Vulva

Almost all women with invasive vulvar cancers will have symptoms. The symptoms of early invasive vulvar cancer are similar to those that can be seen with VIN. As the cancer grows, a distinct tumor may be seen. The cancer may appear as a red, pink, or white bump (or bumps) with a wart-like or raw surface. The area could also appear white and feel rough.

About half of the women with vulvar cancer complain of persistent itching and a growth. Some also complain of pain, burning, painful urination, bleeding, and discharge not associated with the normal menstrual period. An open sore (ulcer) that persists for more than a month is another sign.

Verrucous carcinoma, a subtype of invasive squamous cell vulvar cancer, appears as cauliflower-like growths similar to genital warts.

Vulvar melanoma

Melanoma can appear as a darkly pigmented growth. A change in a mole that has been present for years can also indicate melanoma. The ABCD rule can help tell a normal mole from one that could be melanoma.

Asymmetry: One-half of the mole does not match the other.

Border irregularity: the edges of the mole are ragged or notched.

Color: The color over the mole is not the same. There may be differing shades of tan, brown, or black and sometimes patches of red, blue, or white.

Diameter: The mole is wider than 6 mm (about 1/4 inch).

The most important sign of melanoma is a change in size, shape, or color of a mole. Still, not all melanomas fit the ABCD rule.

Bartholin gland cancer

A distinct mass (lump) on either side of the opening to the vagina can be the sign of a Bartholin gland carcinoma. More often, however, a lump in this area is from a Bartholin gland cyst, which is much more common.

Paget disease

Soreness and a red, scaly area are symptoms of Paget disease of the vulva.

Knowing what to look for can sometimes help with early detection, but it is even better not to wait until you notice symptoms. Have a regular Pap test and pelvic examination.

Medical history and physical exam

The first step is for the doctor to take a complete medical history to check for risk factors and symptoms. Then your doctor will give you a complete physical exam, including a pelvic exam. He or she will feel your uterus, ovaries, cervix, and vagina for anything irregular. Your doctor will also look at your vagina and cervix using a speculum and will take a Pap smear.

Biopsy

Although certain signs and symptoms may strongly suggest vulvar cancer, many of them can be caused by conditions that aren't cancer. The only way to be certain that a vulvar cancer is present is to do a biopsy. In this procedure, a small piece of tissue from the suspicious area is removed and examined under the microscope. A pathologist (a doctor specializing in diagnosing diseases by laboratory tests) will look at the tissue sample under a microscope to see if cancer or a pre-cancerous condition is present and, if so, what type it is.

Rarely, to find all areas of abnormal vulvar skin and to select the best areas to take a biopsy sample from, the doctor may paint the vulva with toluidine blue dye. This dye causes skin with certain diseases to turn blue, including vulvar intraepithelial neoplasia (VIN) and vulvar cancer.

The doctor may use a colposcope, an instrument with binocular magnifying lenses, or a hand held magnifying lens, to select areas to biopsy. The skin is treated with a dilute solution of acetic acid (which is also the main ingredient in vinegar) that causes areas of VIN and cancer to turn white, making them easier to see through the colposcope.

Once the abnormal areas are found, local anesthetic is injected into the skin to make it numb. If the abnormal area is small, it may be completely removed by an excisional biopsy. For this procedure, the doctor uses a scalpel to remove a small ellipse of skin and sews the skin edges together with surgical thread.

If the abnormal area is larger, a punch biopsy is used to take a small sample. The instrument used looks like a tiny apple corer and removes a small, cylindrical piece of skin 4 mm (about 1/6 inch) across. No stitches are needed after the punch biopsy. Depending on the results of the punch biopsy, additional surgery may be necessary.

Further testing

If you have cancer, tests will be done to see how far it has spread. The results of your physical examination and certain diagnostic tests will be used to determine the size of the tumor, how deeply it has invaded tissues at the site of origin, the extent of any invasion into surrounding organs, and the extent of metastasis (spread to lymph nodes or distant organs). This is called staging (see below). The stage of your cancer is the most important factor in selecting the right treatment plan.

If your biopsy shows that you have vulvar cancer, your health care professional will refer you to a gynecologic oncologist, a specialist in female reproductive system cancers. The specialist will also look at your complete personal and family medical history to learn about related risk factors and symptoms of vulvar cancer.

The doctor will perform a complete physical examination to evaluate your general state of health. In addition, he or she will pay special attention to the lymph nodes, particularly those in the groin region, to check for signs of cancer spread. Depending on the biopsy results, several more tests may be done to determine if the vulvar cancer has spread to other areas.

Cystoscopy

This is an examination using a lighted tube to check the inside surface of the bladder. Some advanced cases of vulvar cancer can spread to the bladder, so any suspicious areas noted by this exam are removed for biopsy. This procedure can be done using a local anesthetic, but some patients may require general anesthesia. Your doctor will let you know what to expect before and after the procedure. This procedure was used more often in the past, but is no longer a standard part of the work-up of a woman with vulvar cancer.

Proctoscopy

This is a visual inspection of the rectum using a lighted tube. Some advanced cases of vulvar cancer can spread to the rectum. Any suspicious areas are biopsied. This test was used more often in the past, but is no longer a standard part of the work-up of a woman with vulvar cancer.

Examination of the pelvis under anesthesia: This permits a more thorough examination that can better evaluate how much the cancer has spread to internal organs of the pelvis.

Imaging tests

Chest x-ray

A plain x-ray of your chest may be done to check for other health problems that might make certain treatments difficult to tolerate. This x-ray can be done in any outpatient setting.

Computed tomography (CT)

The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread). The machine will take pictures of multiple slices of the part of your body that is being studied.

Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called "oral contrast." This helps outline your intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body.

The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays and you will need to lie still on a table while they are being done. Also, you might feel a bit confined by the ring-like equipment you’re in when the pictures are being taken.

A CT scan can provide information about the size, shape, and position of a tumor. and can be helpful to see if the cancer has spread to other organs. It can also help find enlarged lymph nodes that might contain cancer.

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body.

Sometimes a contrast material is injected into a vein - just as with CT scans. The contrast used for MRI is different from the one used for CT, so being allergic to CT dye doesn't mean that you are allergic to MRI contrast. MRI scans are a little more uncomfortable than CT scans. First, they take longer -- often up to an hour. Also, you have to be placed inside a tube-like piece of equipment, which is confining and can upset people with claustrophobia (a fear of close spaces). Newer, “open MRI” machines can help people with this fear. The machine also makes a thumping noise that many people find annoying. Some places will provide headphones with music to block this noise out.

MRI images are particularly useful in examining pelvic tumors. They may often detect enlarged lymph nodes in the groin. They are also helpful in detecting cancer that has spread to the brain or spinal cord.

Positron emission tomography (PET)

Positron emission tomography uses glucose (a form of sugar) that contains a radioactive atom. Because cancers use glucose (sugar) at a higher rate than normal tissues, the radioactivity tends to concentrate in the cancer. A special camera is used to detect the radioactivity. This test can be helpful for spotting small collections of cancer cells, and can be useful in seeing if the cancer has spread to lymph nodes. PET scans are also useful when your doctor thinks the cancer has spread, but doesn’t know where. PET scans can be used instead of several different x-rays because they scan your whole body. Newer devices combine a CT scan and a PET scan to even better pinpoint the tumor.

Last Medical Review: 12/30/2008
Last Revised: 05/14/2009