Vulvar dysplasia (atypical hyperplasia) is a change in the morphological structure of the multilayered flat epithelium of the vulva caused by a violation of the growth and development of epithelial cells. The diagnosis in gynecology is based on the results of vulvoscopy, cytological analysis of prints, biopsy of vulva tissues and their histological examination. Treatment may include vulvar ablation, excision of dysplastic areas or vulvectomy.
General information
Vulvar dysplasia – squamous vulvar intraepithelial neoplasia (VIN) – is characterized by intensive proliferation and structural rearrangement of basal and parabasal cells of the epithelial complex. With pathiology, atypical (unequal in size and shape) epithelial cells with transformed nuclei appear, the layering of the flat epithelium is disturbed.
Disease may eventually undergo spontaneous regression, remain stable, or progress to vulvar cancer. Timely treatment can prevent the development of cancer and save the patient’s life. Previously, this pathology was detected mainly in women over 40 years old, but recently the incidence among young patients has increased.
According to the degree of dysplasia, gynecology distinguishes local and diffuse forms, according to the severity of pathomorphological changes in cells – mild, moderate and severe degrees. With a mild degree (VIN 1), the changes are weakly pronounced, detected only in the lower third of the epithelial layer. With a moderate degree (VIN 2), disorders affect up to two-thirds of the multilayer flat epithelium, and with a severe degree (VIN 3), almost the entire epithelial layer is affected, and pronounced nuclear cell atypia is observed. Severe vulvar dysplasia is considered a non-invasive vulvar cancer, in which intensive cell proliferation and nuclear cell atypia do not extend to the basement membrane and stroma.
Causes
The main cause is a local, long-term persistent HPV infection (especially oncogenic types 16 and 18). The development of vulvar dysplasia is promoted by chronic inflammation of the external genitals (vulvitis, bartholinitis, colpitis), the state of immunodeficiency, as well as age-related metabolic and neuroendocrine disorders with changes in receptor reactions.
Vulvar dysplasia often develops against the background of dystrophic processes of the vulva, metaplasia of the multilayered squamous epithelium. In 35-60% of cases, there is a combination with cervical dysplasia (cervical intraepithelial neoplasia – CIN). Risk factors for the development are considered smoking, early onset of sexual activity, promiscuous sexual relations and STIs.
Symptoms
More than half of the patients have vulvar dysplasia without clinical manifestations, in other cases, the symptoms can be quite diverse. With vulvar dysplasia and HPV infection, condyloma of the external genitalia and anus are observed.
With concomitant microbial infections and background processes, disease may be accompanied by symptoms of vulvovaginitis, colpitis (swelling, itching, discharge), leukoplakia and vulvar kraurosis (dryness, itching, ulceration, whitish plaques). When patients complain of itching and pain in the vulva, vagina and anus, as a rule, moderate or severe vulvar dysplasia is detected. This disease may have one or more lesions.
Diagnostics
Diagnosis of vulvar dysplasia is difficult due to the low symptoms of the disease and the absence of specific manifestations. To confirm the diagnosis of vulvar dysplasia, a number of studies are performed: visual examination on a chair, simple and extended vulvoscopy using a colposcope (colposcopy); setting a Schiller test to determine the exact boundaries of white areas of the vulva that are not stained with iodine; cytological examination of prints taken from suspicious areas of the vulva. An examination for HPV of high carcinogenic risk is carried out by PCR.
Determining in the diagnosis of vulvar dysplasia is a biopsy of the external genitalia with histological examination of the material, which also allows differentiating vulvar dysplasia from benign lesions and vulvar cancer. Diagnosis and treatment of vulvar dysplasia is carried out by a gynecologist, together with a dermatologist, venereologist and oncologist.
Treatment
Vulvar dysplasia is a chronic disease that requires a comprehensive, strictly individual course of treatment, taking into account concomitant background diseases (somatic and genital), the patient’s age, the degree of pathology and contraindications. In the conservative treatment of this disease, it is important to observe a sparing diet, the use of desensitizing, sedative and restorative agents, hormonal drugs (corticosteroid ointments, estrogens, etc.), which allows to eliminate local manifestations, stabilize the patient’s psychoemotional state, and achieve remission of the disease.
When HPV is detected, antiviral drugs and immunocorrective therapy are treated. In young patients (up to 45 years old) with a local form and small foci of vulvar dysplasia, gentle surgical treatment is used: ablation of the vulva with a laser, liquid nitrogen, radio wave method; with large and multiple lesions, step-by-step surgical excision (excision) of pathological areas within healthy tissue. With a high risk of developing cancer (moderate and severe vulvar dysplasia, extensive lesions and relapses of the disease) at reproductive age and during peri- and postmenopause, a superficial vulvectomy is performed (removal of the surface layer of the vulva skin with subsequent defect plasty).
Photodynamic therapy (PDT) is one of the modern organ–sparing methods of treating vulvar dysplasia of the 1st – 3rd degree against the background of HPV infection. The method is based on the selective accumulation of photosensitized dye by dysplastic cells of the vulva and their subsequent selective destruction under the influence of light of a certain wavelength. During the rehabilitation period after surgical treatment of vulvar dysplasia, it is necessary to refrain from sexual intercourse, the use of hygienic tampons and douches, physical exertion, and follow doctor’s prescriptions.
Prognosis and prevention
The dynamics of the development depends on the degree and duration of the disease: a mild degree of dysplasia can regress, as the severity and duration of the process increases, the risk of developing oncological pathology increases. Severe vulvar dysplasia (obligate precancerous) progresses over time to invasive cancer, especially in the absence of treatment.
Only early diagnosis and timely treatment gives patients hope for a full recovery. After surgical treatment for vulvar dysplasia, there is a possibility of recurrence of the disease, therefore, it is important to follow up patients with a gynecologist with mandatory control of cure, and in severe vulvar dysplasia – registration with an oncologist.
Proper nutrition, smoking cessation, rehabilitation of foci of chronic infection, restriction of the number of sexual partners, the use of barrier contraception, regular visits to a gynecologist contribute to reducing the risk of developing and relapsing vulvar dysplasia.
