LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)

Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

OUTLINE: » Cervical cancer is the second most common cancer among

I. INTRODUCTION women in the Philippines and in the world with high mortality
rate.”
II. ETIOLOGY: THE HPV
III. RISK FACTORS
» It is also the most preventable cancer.
IV. PRIMARY PREVENTION: HPV VACCINATION
V. SECONDARY PREVENTION
a. Cervical Cytology Testing
₪ EVERY FEMALE IS AT RISK!
b. Primary HPV Testing
c. Cervical Ca Screening Guidelines “What is important are the awareness and screening, more
d. Cervical Cytology Reporting: The Bethesda System than the treatment.
e. Atypical Squamous Cells
f. Low-grade Squamous Intraepithelial Lesion β CERVICAL CANCER
g. High-grade Squamous Intraepithelial Lesion • leading cause of cancer and cancer-related deaths
h. Atypical Glandular Cells among women worldwide
VI. COLPOSCOPY • more than 85% occur in low- and middle-income
a. Cervical Dysplasia in Pregnancy countries
b. Natural History of Cervical Intraepithelial Neoplasia
• incidence and mortality decreased approx.. 70% in
VII. MANAGEMENT OF CERVICAL DYSPLASIA 1970s due to Pap smear
a. Cervical Intraepithelial Neoplasia 1 o Pap smear – introduced in 1941
b. Cervical Intraepithelial Neoplasia 2 / 3
o Led to systematic effort to detect early cervical CA
c. Treatment of Cervical Dysplasia
and precancerous lesions
d. Follow-up after Treatment
• Preventable with vaccination and screening
VIII. CERVICAL CANCER PREVENTION
• Treatable preinvasive phase
IX. VAGINAL INTRAEPITHELIAL NEOPLASIA
X. VULVAR INTRAEPITHELIAL NEOPLASIA ETIOLOGY: THE HPV
XI. REFERENCES
XII. APPENDIX β HPV – most common STD; 80% of women will be infected with
Note: IEN – intraepithelial neoplasia HPV at some point in their life
• dsDNA virus, replicates within epithelial cells of the
cervix
• 120 types, 40 infect genital tracts of men and women
• » HPV 6 and 11 – causes 90% of anogenital warts
• HPV 16 and 18 – responsible for > 70% of cervical
INTRODUCTION cancers
• Initial infection: usually during adolescence od early
adulthood
o Majority of patients clears HPV infection
within 18-24 months
o » within few weeks to 36 months especially
if patient is immunocompetent
o 3-5% develop significant preinvasive
disease
o <1% → cancer
• Causative agent of: CA in oropharynx, anus, penis,
vulva, vagina
• Pathophysiology of neoplastic cellular changes in
high-risk HPV
o Integration of viral DNA into host cell
genome → repressor areas of viral genome
lost → expression of the viral E6 and E7
genes (oncoproteins) → inactivation of p53
and retinoblastoma tumor suppressors →
immortalization and rapid cell proliferation
→ cancer develops after a period of years
▪ However, in most cases, transformed
cells are managed by the individual’s
immune system → infection clears, IEN
regresses

₪ HIGH RISK HPV TYPES??

• 16, 18, 31, 33, 35, 45, 52, 39, 51, 56, 58, 59, 68,
73, 82
• 95% of CERVICAL CANCER
•
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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

₪ PATHOPHYSIOLOGY OF IEN IN LGT

• ₪ Over 80% HPV infections are transient,

asymptomatic & resolve spontaneously.
• ₪ PRE-CANCER LESIONS usually develop <5 years
after HPV infection; ICC takes 10-20 years; in very few
cases, 1-2 yrs

• » E1 and E2 are responsible for integration to the host

DNA
• » E2 will have uncontrolled expression, stimulating E6
and E7”
• » E6 and E7 – viral factors
Intermediate cells
β RISK FACTORS
• Mean age of dx: 48 y.o.
• Compromised immune system from any cause
• Early onset of sexual activity
Parabasal cells • Multiple sexual partners
• History of sexually transmitted infections
• OCP use
• History of vulvar or vaginal dysplasia
Immature cells: nuclei are big • smoking

β PRIMARY PREVENTION: HPV VACCINATION

• preventive vaccines as early as 12 years old
o Bivalent vaccine (Cervarix) – HPV 16 and 18
(not available anymore)
o Quadrivalent vaccine (Gardasil) – HPV 16 and
18, HPV 6 and 11 (low risk)
o Non-valent (Gardasil 9) – HPV 6, 11, 16,
18,31, 33, 45, 52, 58

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

• Do not work in existing infection or associated

preinvasive or invasive disease
• Most effective if given prior to sexual debut or exposure
to HPV
• CDC: given to both boys and girls 11 and 12 years old,
or as early as 9 years
o Catch-up vaccination for girls 13-26 years old
who have not been previously vaccinated
• Issues:
o Availability of vaccine for universal mass
vaccination program
o Whether 2 doses of vaccine provide sufficient
protection or whether booster dose is required
• Routine screening still recommended in vaccinated
women as available vaccine does not provide
protection against all cancer-associated HPV

β SECONDARY PREVENTION

β CERVICAL CYTOLOGY TESTING

• Pap test (Papanicolaou smear) – became available in

1950s
• Identification of cancer and its precursors by examining
properly-prepared and stained cellular sample from
uterine cervix
• Reduced incidence of cervical CA by 50-70%
• Most widely used in developed countries • Co-testing:
• Papanicolaou and Traut (1941) o CYTOLOGY + HPV DNA TEST
o One of sentinel breakthroughs in preventive
medicine β TIMING
o Local therapy of precancerous lesions can
prevent development of cancer
• Procedure:
o Placing speculum into the vagina
o Scraping cervical cells using spatula and
endocervical brush
o Sampled from transformation zone
▪ Area in the cervix where cervical
cancer develops
▪ Includes squamocolumnar
junction - where squamous
epithelium of ectocervix meets
columnar epithelium of endocervix.

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

β TECHNIQUE β CERVICAL CANCER SCREENING GUIDELINES

• Current guidelines recommend screening women for

cervical cancer between ages of 21 and 65
• Should not be performed in women younger than 21
y.o. regardless of age of onset of sexual activity
• Guidelines (not applicable to special populations with
additional risk factors and other complicating history)
o 21 to 29 years: Pap testing every 3 years, no
HPV testing
o 30 to 65 years: co-testing with Pap and HPV
every 5 years (preferred) or Pap testing alone
every 3 years
o Screening not recommended for women >65
years old who:
▪ Have had 3 consecutive negative Pap
tests, or
▪ 2 consecutive negative HPV tests
▪ Had no history of high-grade dysplasia
(CIN 2/3) or cancer (CIN2+) in the past
20 years
o Women presenting at age 65 years of age or
older who have not had previous screening
should undergo Pap and HPV testing
o Screening not recommended: women who
have had a hysterectomy with removal of the
cervix and who do not have a history of CIN2+

β CERVICAL CYTOLOGY REPORTING: THE BETHESDA

SYSTEM

• The Bethesda System (TBS): uniform terminology for

reporting Pap test results (Nat’l. Cancer Institute,
1988)
1. sample either satisfactory or unsatisfactory
o Unsatisfactory if there is lack of label,
loss of transport medium, scant
cellularity, contamination by foreign
material, or if a liquid-based technique

2. description of cellular material (normal or not)

o abnormalities are further divided into
squamous and glandular
o evidence of infection such as yeast or
CONVENTIONAL PAP SMEAR
bacterial vaginosis
• PSCPC RECOMMENDATION:
o Any of the two combinations:
▪ Spatula & Cytobrush OR
▪ Extended Tip Spatula & Cytobrush
o In low resource setting:
▪ Ayre’s spatula with saline dipped cotton swab
o Dipping of the cotton applicator in saline will increase
the yield of endocervical cells.

PRIMARY HPV TESTING

• Effective for cervical cancer screening

• WHO (2015): HPV testing is the preferred
screening method in countries where Pap testing
is not feasible and HPV testing is available

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

Please see Appendix for the diagrams on Management of ASC-US,

LSIL, and CIN 2/3.

β LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION

(LSIL)

• Often consistent with histology reports of low-

grade dysplasia or cervical IEN 1 (CIN 1)
• May resolve spontaneously or progress to more
severe dysplasia → managed according to the
• » when glandular cells are found during Pap ASCCP guidelines
smear → R/O ENDOMETRIAL CANCER BY o If HPV test negative → repeat both Pap
ENDOMENTRIAL BIOPSY and HPV testing in 1 year
o If no HPV test performed or HPV test is
β ATYPICAL SQUAMOUS CELLS positive → do colposcopy

• atypical squamous cells of undetermined

significance (ASC-US) – most common
squamous abnormality
o features associated with squamous
intraepithelial lesions
o 3-5% of all Pap samples
o management is based on
recommendations of American Society of
Colposcopy and Cervical Pathology
(ASCCP)
o Can undergo repeat cytology at 12
months or reflex HPV testing
▪ If HPV is positive, perform
colposcopy
▪ If negative, return to routine
screening
• ASC-H – atypical squamous cells, cannot exclude
a high-grade lesion
o 5-10% of ASC cases
o Must be evaluated with colposcopy
▪ Higher likelihood that a
significant lesion (CIN 2/3) may
be present

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

ATYPICAL GLANDULAR CELLS (AGC)

• Noted in 3 out of 1,000 Pap tests

• Risk of underlying invasive cancer: 3-17%
• Can be classified by site of origin (endometrium,
endocervix, ovary)
• All women with AGC → colposcopy with
endocervical sampling
• Endometrial sampling for women who are older
than 35 years or at risk of endometrial cancer
o Unexplained vaginal bleeding, obese,
conditions suggesting chronic
anovulation (infertility, PCOS)
o Family history of Lynch syndrome or
hereditary nonpolyposis colorectal
cancer (HNPCC)

COLPOSCOPY

• Situation: If a patient comes to you for pap smear and

then on physical examination, you saw a 0.5 x 0.5 cm
mass, will you still proceed with pap smear?
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION • Answer: no → biopsy the mass
(HSIL) • Often first step in evaluation of women with abnormal
cytology
• Indicates more severe dysplasia or CIN 2/3 → all • Colposcope – low-power binocular microscope with
must undergo colposcopy powerful light source that is used to carefully examine
o Treatment: excision or ablation the cervix
(depending on age and colposcopy and
biopsy results) o magnification is from approximately 3 to 15x
• If unmanaged, 20% will progress to cervical o adequate working distance (focal length) 250 to
cancer 300 mm
o focusing is accomplished by adjusting the
distance between the objective lens and the
woman
o Placed outside vagina after speculum is
inserted and cervix put into view, examine for
presence of lesions
o Remove any obscuring mucus with swab
o Apply 3-5% diluted acetic acid to the cervix and
examine again
▪ Acetic acid dehydrates epithelial cells
→ dysplastic cells with large nuclei will
reflect light and appear white
• Endocervical curettage (ECC)
o Scraping of mucous membrane from the
Please see Appendix for fig. 28.7. endocervical canal by a endocervical brush or
curettage
o done in case of abnormal cytology and an
unsatisfactory colposcopy
• Cervical biopsies – done in the presence of any
acetowhite lesions
o Biopsy site usually heals within a few days
o Small amount of bleeding common
▪ Controlled with ferric subsulfate
(Monsel’s solution) or silver nitrate stick

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

• Identify the TRANSFORMATION ZONE

o » area of squamous metaplasia –
transformation from columnar cells to
squamous cells to withstand the acidic
environment of the vagina during puberty
o most cases of squamous neoplasia begin
because of its rapid cell turnover
o » area between you inner (new)
squamocolumnar junction and outer (old)
squamocolumnar junction
o » remember: the transformation zone is
DIFFERENT FROM YOUR
SQUAMOCOLUMNAR JUNCTION
o » RED – squamous epithelial cells of the
ectocervix
o » BLUE – columnar epithelium of the
endocervix
o » GREEN – underwent the squamous • » Look for colposcopic abnormalities that would
metaplasia, also known as warrant cervical biopsy (histologic examination);
TRANSFORMATION ZONE allows determination of the appropriate biopsy
sites

“Satisfactory” colposcopy – thorough and complete

exam of the entire transformation zone

“Unsatisfactory” colposcopy – some portions of the

transformation zone cannot be visualized as they extend
into endocervical canal

CERVICAL PUNCH BIOPSY RESULT

• Negative
• Premalignant: cin
• Cancer

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

CIN: MANAGEMENT

• » CIN I → HPV Infection → co-test after 1 year

(cytology + HPV DNA test)
• » CIN II, III → excision (preferred / goal of
treatment)

INTERPRETATION

• » CIN I – abnormal cells at the lower 1/3 of the

cervical epithelium
• » CIN 2/3 – abnormal cells at the inner 2/3 of the
cervical epithelium
• » > CIN 2/3 – full thickness of cervical epithelium
with abnormal cells

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

CERVICAL DYSPLASIA IN PREGNANCY • These patients should undergo co-testing with cytology
and HPV testing at 12 months or repeat cytology alone
• Changes during pregnancy may be confused with at 12 months in patients 21 to 24 years old
CIN • If CIN 1 persists for more than 2 years, a definitive
o Larger cervix, increased blood supply, excisional procedure can be considered
decidual changes in epithelium
• ASCCP guidelines for management of abnormal Cervical Intraepithelial Neoplasia 1 with High-Grade Squamous
cytology in pregnancy Intraepithelial Lesion Cytology
o Colposcopy – safe in pregnancy • If the diagnosis of CIN 1 is preceded by cytology
o Biopsies should ONLY be performed if showing HSIL or AGC, there is a higher chance of
there is suspicion for invasive disease underlying CIN2/3, and more aggressive management
o Further evaluation of dysplasia may be should be considered
postponed until 6 to 8 weeks postpartum • In patients who have completed childbearing, an
o NO ECC DURING PREGNANCY excisional procedure is recommended
▪ If CIN 2/3 is seen, treatment may be • In women who desire future fertility, close follow-up
delayed until postpartum period with cytology and colposcopy at 6 months is
▪ If there is significant concern for recommended
dysplastic lesion → follow-up
colposcopy or repeat cytology is A small percentage of CIN 1 lesions progress to CIN 2 or 3, but
acceptable at intervals no more it is not possible to determine which lesions have this potential,
frequent than every 12 weeks so continued follow-up is recommended
▪ If invasive cancer is diagnosed →
conization under anesthesia may be
performed CERVICAL INTRAEPITHELIAL NEOPLASIA 2/3
It is difficult to distinguish CIN 2 from CIN 3
pathologically, so the two diagnoses are often grouped
NATURAL HISTORY OF CERVICAL INTRAEPITHELIAL together as CIN 2/3 and managed similarly
NEOPLASIA • Approximately 40% of CIN 2 lesions and 30% of CIN 3
lesions regress spontaneously
• Cervical intraepithelial neoplasia (CIN) – • However, 22% of CIN 2 will progress to CIN 3 and 5%
precancerous lesion of the squamous epithelium will progress to cancer
of the cervix • Furthermore, 12% to 40% of CIN 3 will progress to
o Histologic diagnosis cancer
o Graded as 1, 2 or 3 • Most women with CIN 2/3 should be treated with an
ablative or excisional procedure
CIN 1 • mild dysplasia • Young women and those desiring future fertility may be
• Frequently regresses within weeks or months managed with careful observation, including cytology
CIN 2 • cellular atypia involves two thirds of thickness and colposcopy initially every 6 months with long-term
of epithelium
• process still reversible follow-up depending on findings
• 40% regress spontaneously without treatment • Pregnant women with CIN 2/3 and no evidence of
CIN 3 • Cellular atypia involves more than two thirds of invasion may be observed during the pregnancy, with
the epithelium evaluation delayed until 6 weeks postpartum
• Encompasses what was once called as severe • Women with a history of CIN 2/3 are more likely to
dysplasia and carcinoma in situ
develop another lesion in the future
• Precursor to invasive cancer
• Treatment recommends • Long-term follow-up for at least 20 years is
• 1/3 of these lesions may spontaneously recommended, even if this extends screening past age
disappear 65

MANAGEMENT OF CERVICAL DYSPLASIA TREATMENT OF CERVICAL DYSPLASIA

CERVICAL INTRAEPITHELIAL NEOPLASIA 1 • Can be accomplished by ablation or excision, with

• In almost all cases, CIN 1 is a manifestation of a these methods having first-treatment success rates of
transient HPV infection, and the regression rates are greater than 90% in properly selected patients
high. Patients with CIN 1 require follow-up to ensure • Ablative methods include:
that the lesion regresses. o Cryotherapy
Cervical Intraepithelial Neoplasia 1 with Low-Grade Squamous o CO 2 laser ablation
Intraepithelial Lesion Cytology • Excisional procedures include:
• Given the high rates of spontaneous regression, CIN 1 o the loop electrosurgical excision procedure
with LSIL cytology is usually managed with observation (LEEP)
o cold knife conization (CKC)
o CO 2 laser conization

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Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

• The choice of treatment modality depends on the CO2 Laser Ablation

availability of equipment and the experience and • A focused CO2 laser beam is directed at the cervical
expertise of the clinician epithelium, where water in the tissue absorbs the laser
• Hysterectomy is not recommended as the initial energy and the tissue is destroyed by vaporization. The
treatment of cervical dysplasia, as it is usually lesion is typically ablated to a depth of 5 mm
unnecessary for the treatment of CIN • Several safety procedures must be followed, including:
o the use of protective eyewear by all personnel
• If high-grade dysplasia is present, conization must first
in the procedure room
be performed to rule out underlying invasive cancer o the use of a blackened or brushed speculum
that may require more advanced procedures such as to avoid damage to surrounding tissues by
radical hysterectomy, radical trachelectomy, and lymph misdirected laser beams
node dissection o using wet towels and cloth drapes to prevent
• Ablative procedures treat CIN but do not provide further fire
diagnostic information • Because little devitalized tissue is left after the
• To qualify for ablative therapy, there should be no procedure, there is no prolonged vaginal discharge as
suspicion of glandular involvement or invasive cancer. there is with cryotherapy
• Specific criteria for ablative therapies include the • The success rate is similar to that for cryotherapy and
following: excisional procedures
o Satisfactory colposcopy with visualization of • The advantages of this technique are that the area of
entire cervical squamocolumnar junction tissue destruction can be minimized and there is no
o Biopsy confirming presence of CIN; abnormal prolonged vaginal discharge as there is with
cytology alone is not sufficient cryotherapy
o Lesion does not involve the endocervical • Similar to cryotherapy, there is no specimen for
canal and negative endocervical curettage (if pathologic evaluation
available) • Treatment success depends on the correct choice of
Cryotherapy laser energy delivered and proper depth and extent of
• commonly used treatment for CIN lesions that is safe, treatment
effective, and relatively simple to perform
• However, it does not provide a specimen for pathology EXCISION METHODS
review and in many high-resource settings has been • Excisional procedures have the advantage over
replaced by LEEP ablative procedures of providing a pathologic specimen
• Contraindications to cryotherapy include: for further diagnostic information
o large lesions (those covering >75% of the • The specific indications for an excisional procedure
cervix or those that cannot be covered by the over an ablative procedure include the following:
cryoprobe) o Suspected microinvasion
o lesions that extend into the endocervical o Adenocarcinoma in situ or other glandular
canal abnormalities
o In addition, if the patient had an endocervical o Unsatisfactory colposcopy in which the
curettage performed and it shows evidence of transformation zone is not fully visualized
dysplasia, cryotherapy is contraindicated o Lack of correlation between cytology and
• The procedure includes performing colposcopy to colposcopy/ biopsies
confirm that the lesion is confined to the exocervix o Unable to rule out invasive disease
1. A probe is selected that will cover the entire lesion. o Lesion extending into the endocervical canal
In most systems, N2 O is used as the refrigerant o Endocervical curettage showing CIN or a
2. The cervix will freeze quickly, but the probe must glandular abnormality
remain in place until the ice ball extends to at least o Recurrence after an ablative or previous
5 mm beyond the edge of the instrument. In most excisional procedure
cases, this takes 3 minutes
3. The refrigerant is then turned off, and the probe is Loop Electrosurgical Excision
allowed to thaw and separate from the cervix. It is • The loop electrosurgical excision procedure (LEEP),
recommended that a 3-5-3 double freeze–thaw also called large loop excision of the transformation
cycle is performed with 3 minutes of freezing, zone (LLETZ)
followed by 5 minutes of thawing and another 3 • Currently the most common method for the treatment
minutes of freezing of CIN 2/3 in the United States
• Most patients experience little discomfort during the • Involves the removal of the transformation zone of the
procedure. Because the tissue that was destroyed cervix under local anesthesia and can be performed
remains on the cervix, the patient will experience safely in the office
vaginal discharge within a few hours • The cervix is infiltrated with an
• As the tissue sloughs, the amount of discharge anesthetic/vasoconstrictor solution, and a cone-
increases and malodor is common. It may take as long shaped piece of the cervix inclusive of the
as 3 weeks for the discharge to stop transformation zone is removed
• The patient should be cautioned to place nothing in the • Utilizes a thin wire in the shape of a loop and an
vagina for at least 3 weeks after the procedure to avoid electrosurgical generator, providing a cutting current to
dislodgment of the eschar. remove the tissue

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Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

• The loops are available in a variety of shapes and • The current ASCCP recommendations for surveillance
sizes, allowing selection of a loop best fit to the following excision of CIN 2/3 with negative margins
patient’s lesion (Fig. 28.11). Bleeding areas can be consist of cotesting with cervical cytology and HPV at
cauterized with a ball electrode attached to the current 12 and 24 months
generator set to cautery. • If both co-tests are negative, the woman can return to
routine screening
• If any test is abnormal, colposcopy with endocervical
sampling is recommended.

CERVICAL CANCER PREVENTION

• Although the screening and diagnosis algorithms
described earlier are effective, they are expensive and
require high-level infrastructure and well-trained
personnel
• There is therefore a significant need for alternative
solutions, particularly in low-resource settings in the
United States and in low- and middle-income countries
(LMICs) where there is often a lack of trained
personnel, infrastructure, and pathology services
One commonly used approach in low-resource settings is:
• visual inspection with acetic acid (VIA)
o acetic acid is applied to the cervix and, if there
is whitening of the epithelium indicating a
precancerous lesion, immediate treatment
with cryotherapy is performed
o VIA and cryotherapy can be performed by
nonphysicians, such as community health
workers
o Such a program using VIA has been shown to
decrease cervical cancer mortality by more
than 30% in unscreened communities in India
o Several additional low-cost innovative
• The removed tissue is examined histologically for screening options are also under
diagnosis and evaluation of margin status development for LMICs
• Hysterectomy is rarely indicated for the treatment of
CIN, unless a repeat diagnostic procedure is VAGINAL INTRAEPITHELIAL NEOPLASIA
recommended but not feasible due to minimal • Vaginal intraepithelial neoplasia (VaIN) is similar to CIN
remaining cervix and is defined as squamous atypia without invasion
Cold Knife Conization (CKC) • It is most commonly diagnosed in women between 43
• An excisional procedure similar to a LEEP but is to 60 years of age
performed with a scalpel under anesthesia in the • Classification is similar to CIN and reflects the depth of
operating room involvement of the epithelial layer (VaIN 1, 2, and 3)
• For the evaluation of squamous lesions, CKC offers • Previous studies have shown 50% to 90% of patients
little advantage over LEEP with VaIN had prior or concurrent intraepithelial
• However, CKC is advantageous in patients with neoplasia or carcinoma of the cervix or vulva
glandular abnormalities or suspicion of invasive • Most cases of VaIN are discovered incidentally during
cancer, as CKC uses a scalpel and avoids the thermal colposcopy due to abnormal cytology
artifact sometimes seen at the margins of specimens • Presenting symptoms of postcoital discharge or
obtained by LEEP spotting are rare
• Once the specimen is removed, bleeding can be • Suspicious lesions should be biopsied to confirm the
controlled with cauterization and the application of diagnosis
ferrous subsulfate (Monsel’s solution) • The upper third of the vagina is the most common site
• Sutures to control bleeding are rarely necessary of VaIN
• Patients with VaIN 1 are followed with surveillance
FOLLOW-UP AFTER TREATMENT OF CERVICAL similar to patients with CIN 1 due to the low risk of
DYSPLASIA progression to invasive cancer
• The rate of recurrent or persistent disease following • However, it is recommended that patients with VaIN 2
excisional or ablative treatment for CIN 2/3 is 5% to or VaIN 3 undergo treatment, as the risk of progression
17%, with no significant differences in outcomes to vaginal cancer is estimated to be 2% to 5%
between the different treatment modalities • Treatment options include:
• Factors associated with recurrent/persistent disease o Excision
include the following: o Ablation
o Large lesion size o topical therapy with 5-fluorouracil or
o Endocervical gland involvement imiquimod
o Positive margins

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• There is a high recurrence rate of 20% to 30% o Topical therapies

regardless of the treatment modality used, and these • All modalities have similar effectiveness
patients should be carefully followed long term • The modality used depends on the risk of invasive
There are no standard guidelines for the follow-up of patients disease, location of the lesion, and the extent of
with VaIN 2/3, but it is reasonable to perform cytology and disease and symptoms
colposcopy every 6 to 12 months for 2 years . The role of HPV • If underlying invasive disease is suspected, patients
testing in patients with VaIN is still unknown. with VIN 2/3 should undergo wide local excision
• Other options for diffuse disease include:
o CO 2 laser ablation
VULVAR INTRAEPITHELIAL NEOPLASIA o topical therapies
▪ The most commonly used topical
• Defined as squamous atypia of the vulva (Fig. 28.12) therapy is imiquimod, a topical
immune response modifier that is
applied to vulvar lesions three times
per week for 16 weeks
▪ Small studies have shown
imiquimod to be very effective with a
complete response rate of 51%, a
partial response rate of 25% and a
recurrence rate of 16%
• Similar to VaIN, VIN recurrence rates are high
• There are no standard guidelines for the follow-up of
patients with VIN 2/3, but it is reasonable to perform
vulvoscopy every 6 to 12 months for 2 years
• The role of HPV testing in patients with VIN is
unknown.

• The incidence of VIN 3 is approximately 2.86 per

100,000 women in the United States
• VIN is classified as:
o VIN, usual type
▪ is the most common form of VIN and
is an HPV-associated condition
▪ It occurs in younger women, may be
multifocal, and is associated with
cervical and vaginal dysplasia
o VIN, differentiated type
▪ is less common and unrelated to
HPV infection, but it is associated
with chronic inflammatory conditions
such as lichen sclerosus and lichen
planus
• Symptoms of VIN include pruritus, pain, and burning;
however, many patients are asymptomatic and VIN is
incidentally discovered during a thorough pelvic exam
• Punch biopsies should be performed of any lesions
noted on the vulva, particularly those that persist or are
not responsive to therapy for other conditions
• Colposcopy of the vulva (vulvoscopy) with biopsies of
any lesions should be performed in all patients with CIN
or VaIN due to the association with these other HPV-
related conditions
• VIN 1 is a benign entity, and treatment for
asymptomatic disease is not necessary
• However, patients with VIN 2/3 should undergo
treatment due to the risks of underlying cancer and
progression of disease
• Treatment modalities include:
o Excision
o Ablation

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Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

END OF TRANSCRIPTION

REFERENCES
• Comprehensive Gynecology 7th Ed.
• Zalgiatroz Pamana Trans
• The Internet

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

APPENDIX

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

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 LECTURE 16: IEN OF THE LOWER GENITAL TRACT ( Cervix, Vulva, Vagina)
Dr. Chicanee M. Alvarina | April 22, 2021 (Async)

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