As the Covid-19 pandemic continues, our beloved NHS is being put under more strain than ever before. The impact that coronavirus has had on NHS staff and services is difficult for any of us to comprehend. Every aspect of the NHS has been affected by Covid-19, whether directly or indirectly. This unfortunately includes gynaecology oncology (cancer) departments. Whilst gynaecology departments are not directly related to Covid-19 (unlike A&E for example), their resources (staff, equipment and space) are becoming increasingly limited. It’s our job at The Eve Appeal to provide you with as much relevant information as we can, and for our free information service, Ask Eve, to answer your gynae-related questions and provide you with advice and support during this time of uncertainty.
Vaginal cancer is the least common gynaecological cancer, with around 250 cases diagnosed every year in the UK.
Vaginal cancer is most common in women who are over 60 and is very rare in the under 40 age group.
The main symptoms of vaginal cancer are:
- Unexpected bleeding, e.g. between periods, after menopause or after sex
- Vaginal discharge that smells or may be blood stained
- Vaginal pain during sexual intercourse
- A vaginal lump or growth that you or your doctor can feel
- A vaginal itch that won’t go away and pain when urinating
- Persistent pelvic and vaginal pain
If you are experiencing any of the symptoms of vaginal cancer, it’s important to remember that it is unlikely that you will actually have vaginal cancer as it is a very rare disease, and your symptoms will be due to something less serious than cancer, such as an infection for example. That being said, we strongly recommend reporting anything unusual to your doctor, just to be on the safe side. If you want to talk through any of your concerns with our Ask Eve team before calling your GP, please send us a message on firstname.lastname@example.org.
Reporting Symptoms to Your GP
Q: I’ve noticed that I have a brownish discharge. Is this normal?
A: Everyone will experience vaginal discharge that varies in texture and colour throughout their monthly menstrual cycle. A lot of us aren’t aware of what is ‘normal’ for us and our bodies. If this brown discharge is a very light brown/sandy colour and only enough to slightly stain your underwear, it is likely to be caused by a non-serious issue. The likelihood of certain problems being the trigger for your brown discharge varies depending on your age. For some people, a light brown/sandy coloured discharge can be because of a normal condition called vaginal atrophy. As we get older, our hormone levels decrease as the ovaries (which produce the hormones oestrogen and progesterone) gradually stop working. This process is known as the menopause, and the average age for the menopause in the UK is 51. One of many functions that oestrogen has, is to keep the vagina plump and moist. The natural reduction of oestrogen during menopause means that these properties (plumpness, moisture, elasticity) are reduced and eventually lost, making the vagina dry and the skin more fragile. This is known as vaginal atrophy and for example, can make sexual intercourse uncomfortable, causing irritation and bleeding. A light brown discharge is basically just vaginal mucus mixed in with old blood that has taken a few days to leave the vagina, hence it’s darker, less ‘new’ colour. If you are pre-menopausal, i.e. haven’t gone through the menopause yet, a change in vaginal discharge is generally not something to be concerned about. It may represent hormonal fluctuations that naturally occur throughout our menstruating lifetime, changes in the vaginal pH balance causing an infection, or it could be down to your contraception or sex life. Are you adjusting to a new form of contraception? Have you had deeper vaginal penetration recently? Are you having sex with a new partner(s) and could do with an STI check?
Q: I’ve had brown vaginal discharge for a few months. Is this my ‘new normal’ or should I see a doctor?
A: This depends on the depth of the brown colour. Very dark brown/prune colour could be due to old blood and doctors refer to it is as oxidised blood. It can come normally at the end of a period. It is not normal in the menopause and your GP would want you to report this. Light brown discharge is different. Whilst this is unlikely to be anything serious, a change in your vaginal discharge that is not going away should be reported to your GP. During Covid-19, this will be over the phone. Your GP will want to know how long you’ve had this discharge for, if there have been any changes in your contraception or sex life etc. It’s a good idea to self-examine prior to phone call if possible. What does your vagina feel like? Is there any pain? Have you noticed any lumps/changes? If you and your GP think it’s relevant, they may suggest you do an STI check. Due to Covid-19, this check-up is unlikely to happen at your GP surgery. Your GP may send you a self-testing kit, or refer you to your local sexual health service to request the test online.
If you are pre-menopause: You will probably be asked to monitor your symptoms for a little longer and call back with any changes, e.g. discharge becomes heavier, abnormal bleeding, a lump, pain etc.
If you are post-menopause: Your GP might want to see you for a face-to-face appointment if resources permit. They will want to see if the brown discharge is due to vaginal atrophy, which is a likely option for people who are post-menopausal. If your GP needs more expert advice, they will want to refer you to be seen by a specialist at a hospital. Persistent discharge after the menopause does need investigating, although please remember it is unlikely to be a sign of vaginal cancer.
Q: I can feel a lump just inside my vagina. I’m not sure how long it’s been there for. What should I do?
A: The vagina is naturally lumpy, as it is made up of folded layers of skin that normally ‘open up’ when something is inserted inside the vagina. Self-examination of the vagina for the first time can often create unnecessary worries, as what you are probably feeling is normal vaginal anatomy. That’s why checking your vagina and vulva regularly and knowing what’s ‘normal’ for you is so important, so you can identify changes and save yourself unnecessary alarm. If you have noticed a vaginal lump, we suggest monitoring this yourself for a few weeks to see if it changes, as it may well go away on its own. If the lump hasn’t gone away after a few weeks, but also hasn’t developed, it could be that this is just the normal structure of your vagina. However, if you know that this lump isn’t normal for you, or it has changed then please do phone your GP, or get in touch with Ask Eve first if you would like to talk through your worries with the team before calling your GP. Your GP would normally want to examine you, even if they lump hadn’t developed, but the impact of Covid-19 means that this is much less likely to happen at the moment. A vaginal lump that hasn’t developed over the course of a few weeks, and isn’t accompanied by other potential symptoms such as bloody/brown discharge, pain and itching is incredibly unlikely to be a vaginal cancer. Here are a few examples of things that can cause lumps in your vagina:
- Rectum pushing into the vagina – known as a posterior vaginal prolapse or rectocele.
- Bladder pushing into the vagina – known as a bladder prolapse or cystocele.
- Uterus (womb) pushing into the vagina – known as a uterine prolapse.
The rectum, bladder and uterus are all right next to the vagina with only a thin layer of tissue or muscle separating them. When this tissue/muscle becomes weaker, the rectum/bladder/uterus can begin to push into the vagina, creating a bulge/lump.
Q: My vaginal lump has gotten bigger in the last month and is becoming painful. Do I need a doctor’s appointment?
A: Yes, you do need to phone your doctor and talk them through your symptoms and changes as they will want this investigated. Depending on the resources (staff/space/equipment) in your area, this will either be with your GP in one of their limited face-to-face appointments, or the hospital’s gynaecology department. The gynae team will need to assess their hospital’s resources along with their coronavirus infection rate. Your GP will be getting in touch with them, explaining your situation and together they will decide who is best placed to see you for the initial examination.
Q: My lump/itch/discharge (delete as appropriate) has gotten worse and my GP wants to see me. What can I expect?
A: The process of having a face-to-face GP appointment has changed significantly due to Covid-19:
- When you arrive at the clinic, instead of going straight into the reception/waiting room, you will need to either wait in your car or stand outside in a queue (2m apart).
- You will need to phone the reception team inside and tell them that you have arrived. The receptionist will check with you that you don’t have any coronavirus symptoms. If you do, you will need to go home without having your appointment.
- The receptionist will phone you when they doctor/nurse is ready for you. You will be met at the doors to the clinic and directed to your room.
Expect to have a vaginal examination and to be asked about your symptoms. It’s a good idea to have everything written down, for example how long you have had the lump/itch/discharge. Your GP might suggest doing an STI check, to be as thorough as possible in this appointment, minimising the need for return visits. We can’t say whether or not after this appointment your GP will refer you to hospital for further investigation, it depends on what they see when they examine you and your medical history. Everyone is treated on an individual basis. Do contact Ask Eve after your GP appointment if you want to talk through anything.
Your Referral to the Gynae Department
Q: I’m worried. I have explained my persistent vaginal problems to my GP over the phone, and they said they will refer me to the hospital. When will this be?
A: We understand that it’s worrying to hear your GP wants to refer you to the hospital, but please try not to assume the worst. It could simply be that your hospital has more time/resources to investigate the problem. Or if your GP has seen you, it’s because they need a specialist opinion, which again, doesn’t automatically mean they suspect a cancer. Gynaecology referrals can be for anything gynae-related, and often nothing to do with cancer. Your GP will send the referral to the hospital, and the gynae team at the hospital will assess your referral, taking note of your symptoms described by your GP. They will then prioritise your appointment as either urgent or balancing your symptoms with potential Covid-19 risk and exposure in the hospital environment, decide that it’s best for you to wait for your appointment.
Q: I’m 68 and have had a bit of brown discharge and vaginal discomfort for a while now. My GP said they will refer me to the hospital. What will happen at this appointment?
A: Expect a vaginal examination and for the doctor to ask you about the length and type of symptoms you’re experiencing, along with your medical history. They may look inside the vagina using a speculum, which is the same instrument used for cervical screening (smear) tests. A sample of the discharge may be sent to the laboratory for tests. Because of Covid-19, doctors and nurses want to minimise the number of times someone has to come into the hospital, and they might not send you an appointment until the pandemic has resolved.
Q: At my hospital appointment the doctor took a biopsy. When will I get the results?
A: This is difficult to answer because there is enormous geographic variation at the moment and it depends on why the doctor took a biopsy of the vagina. Cancer limited to the vagina in a previously healthy woman is extremely rare, so it is unlikely that the doctor will find a cancer. Therefore this biopsy will not be given the same priority as a ‘more likely’ cancer. Some (but not many) hospitals are able process the sample within a few days and phone you with the result. Most hospitals require at least fortnight, then a report has to be dictated and this can take a month or longer if the secretarial team are away from work due to self-isolation.
Q: My doctor suspects that I have VAIN. What does this mean?
A: VAIN is a skin condition affecting the vagina. It is an acronym for vagina intraepithelial neoplasia. It is similar to CIN, the abnormality found on the cervix by cervical screening tests, but much rarer. The diagnosis is made by looking at a small piece of skin under the microscope. VAIN, like CIN is thought to be caused by a virus known as the human papillomavirus (HPV). This type of virus can also cause warts and affect the skin in the mouth, anus, vulva or cervix.
Q: My results show that I have VAIN. What will happen now?
A: Established VAIN may resolve spontaneously for no apparent reason. Women who are able to give up smoking have a higher chance of this happening. There is a very small risk of developing skin cancer so the skin is often monitored. Your doctor can do smears even if you have had your cervix removed or the hospital can monitor you, commonly but not always in the colposcopy clinic. Sometimes the abnormal area is removed or vaporised, often with a laser. Some doctors are experimenting with a cream called Aldara, but this is difficult to manage because it is difficult to get the cream in the correct place.
Q: If my VAIN isn’t treated, will it turn into vaginal cancer?
A: VAIN is rare and primary vagina cancer (cancer that starts in the vagina) that is not caused by cervical cancer is extremely rare. This means it is difficult to prove that VAIN can turn into cancer but doctors think it is possible, although unlikely. The condition is graded as mild, moderate and severe. The risk of severe VAIN progressing to skin cancer is not known, but most gynaecologists believe there is a risk and this means the skin should be examined regularly and smears may be taken from the vagina. Whenever there is any doubt, the doctor normally recommends that a small piece of skin is removed (a biopsy) and analysed by the laboratory. This helps diagnose any change and allows early treatment of any developing cancer.
It is important to put this into perspective. Vaginal cancer is very rare. Cancer in the vagina is usually a cancer from somewhere else, typically the cervix, occasionally from the rectum or bladder.
Q: I have a history of abnormal smears and HPV. Am I more likely to get vaginal cancer?
A: HVP is incredibly common. There are over 150 different strains of the virus and nearly everyone is exposed to it at some point in their life. Most people clear it with their immune system, but a few unfortunately find that some ‘higher risk’ strains of HPV can affect the natural growth of the skin on the cervix, vulva, mouth, throat, anus, penis and rarely the vagina. Abnormal cervical screening (smear) results are also fairly common. About 1 in 20 people will have a cervical screening test result that is abnormal, but only about 1 in 2000 will develop cervical cancer. VAIN is linked to CIN of the cervix, so anything that causes the cervix to change can cause the same change in the vagina.
If You Have Been Diagnosed with Vaginal Cancer
Q: My biopsy results have come back and I have vaginal cancer. What happens now?
A: You will need to see a specialist in vaginal cancer surgery. These doctors are known as gynaecological oncological surgeons. They will talk to you, provide nurse support, take samples to check the diagnosis and arrange scans to assess where the cancer is. They may refer you to a clinical oncologist, a doctor who specialises in radiotherapy.
Q: I understand that people who have womb cancer normally have their wombs surgically removed – can a vagina be removed if someone has vaginal cancer?
A: Yes, the standard treatment for a very early (microscopic) skin cancer of the vagina involves removing the abnormal area of skin. It is not usually necessary to remove the entire vagina for early disease. However, it is often better to treat a vaginal cancer with radiotherapy. If you are due to have surgery for vaginal cancer and begin to experience potential symptoms of Covid19, you will need to be tested. If the test is positive, you will need to wait until you have cleared the virus before having your surgery. Operating on someone with coronavirus is dangerous and puts the patient at an incredibly high risk of post-surgery complications.
Q: I have just been diagnosed with vaginal cancer. Will I have to have chemotherapy or radiotherapy?
A: Potentially. Chemotherapy or radiotherapy are options for cancer care. For people with vaginal cancer, the choice of treatment often depends on how big the cancer is and how close it is to the bladder or rectum.
Q: I am due to start my treatment for vaginal cancer next week and am scared it will be cancelled because of Covid-19. Is this likely to happen?
A: Vaginal cancer usually needs urgent treatment. Doctors know that a delay in treating some cancers makes a minimal difference to the outcome, but vaginal cancer is different. Treatment is urgent and the doctors will prioritise this over most other conditions. If you contract Covid-19 before starting your treatment for vaginal cancer, it is likely that your treatment will be postponed until you have cleared the virus. Your cancer team will discuss the options with you and work out the best plan of action taking everything into consideration.
Q: I am currently having radiotherapy for vaginal cancer. Will I be able to finish it?
A: Doctors know that completing the treatment for most vaginal cancer is urgent, and they will prioritise this over most other conditions. Unless you develop coronavirus during your treatment and become too unwell to complete the current cycle, your team will want to help you finish your radiotherapy.