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How is vulvar cancer diagnosed?
The main tests used to diagnose vulvar cancer are a physical examination, a procedure called a colposcopy, and the removal of a tissue sample (biopsy). Because vulvar cancer is sometimes associated with cervical cancer, the doctor may check for abnormal cells in the vagina and cervix as part of these initial tests.
Your doctor will ask to do a physical examination of your groin and pelvic area, including the genitals. You will remove your clothing from the waist down, then lie on a table with your knees bent and legs apart. If you feel embarrassed or scared about this examination, let your doctor know. A nurse may be present during the examination, but you can also ask for a family member or friend to be in the room.
Although the vulva is the outer part of your genitals, the doctor may also do an internal examination at the same time to check your vagina and cervix. This involves the doctor gently inserting an instrument with smooth, curved sides (speculum) into your vagina. A lubricant is used to make the speculum easier to insert. The sides of the speculum spread the vaginal walls apart so the doctor can see the vagina and cervix. This examination may be done under a general anaesthetic if you have a skin condition such as lichen planus or lichen sclerosus that has narrowed the vagina.
To examine the vulva, vagina and cervix in detail, the doctor looks through a magnifying instrument called a colposcope. The colposcope is placed near your vulva but does not enter your body. A colposcopy that examines the vulva is sometimes called a vulvoscopy, and one that examines the vagina may be called a vaginoscopy.
You will lie on your back on an examination table with your knees up and apart. The doctor will use a speculum to spread the walls of the vagina apart, and then apply a vinegar-like liquid or iodine to your vulva and vagina. This makes it easier to see abnormal cells through the colposcope. The liquid may sting or burn, and you may have a brown discharge afterwards. During a colposcopy, the doctor will usually take a biopsy (see below) from the vulva and/or the vagina.
You will be advised not to have sex or put anything in your vagina (e.g. tampons, medicine) for 24 hours before a colposcopy. Talk to your doctor about whether you should take over-the-counter pain relief about an hour before the procedure to ease discomfort.
During the colposcopy, your doctor will usually take a small tissue sample (biopsy) from the vulvar and possibly also the vaginal area. A biopsy is the best way to diagnose vulvar cancer.
The doctor may put a local anaesthetic into the affected area of your vulva to numb it before the biopsy. There should not be any pain when the sample is taken, but you may feel a little discomfort.
If large areas of the vulva look suspicious, you may have several biopsies taken under general anaesthetic. This is known as vulvar mapping and it helps the doctor plan the best treatment for you.
After the biopsy your vulva may bleed a little, and sometimes stitches are needed to close up the wound. Ask your doctor how much bleeding to expect afterwards, and how to care for the wound to keep it from becoming infected. You may have some soreness, which can be relieved by taking painkillers, and you will be advised not to have sex or put anything in your vagina for 24 hours after the biopsy.
The tissue sample will be sent to a laboratory, and a specialist doctor called a pathologist will examine the cells under a microscope. The pathologist will be able to confirm whether or not the cells are cancerous, and which type of vulvar cancer it is.
If you haven’t had one recently, your doctor may do a cervical screening test. This test has replaced the Pap test.
The cervical screening test detects cancer-causing types of HPV in a sample of cells taken from the cervix or vagina. While the speculum is in place for the internal examination, the doctor will use a small brush or swab to remove some cells from the surface of the cervix. This can feel slightly uncomfortable, but it usually takes only a minute or two.
The sample is sent to a laboratory to check for the presence of HPV. If HPV is found, the pathologist will do an additional test on the sample to check for cell abnormalities.
Sometimes further tests are needed to assess your general health, determine the size and position of the cancer, and find out whether the cancer has spread. You will probably not need to have all of these tests:
Blood test – This checks the number of cells in your blood, and how well your kidneys and liver are working.
Chest x-ray – A painless scan that produces an image of your lungs.
Cystoscopy – The doctor uses a slender, flexible tube with a camera and light (cystoscope) to look inside the urethra and bladder. This can be done under local or general anaesthetic.
Proctoscopy – The doctor uses a slender tube with a camera and light (proctoscope) to look inside the rectum and anus. This can be done under local or general anaesthetic.
CT scan – A CT (computerised tomography) scan uses x-ray beams to create detailed, cross-sectional pictures of the inside of your body. Before the scan, you may be given a drink or injection of a dye called contrast that makes the pictures clearer. If you have the injection, you may feel hot all over for a few minutes. The CT scanner is large and round like a doughnut. You will lie on a flat table that moves in and out of the scanner. The scan is painless and takes 5–10 minutes.
MRI scan – An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed, cross-sectional pictures of the inside of your body. During the MRI scan, you will lie on a treatment table that slides into a metal cylinder that is open at both ends. Sometimes, dye will be injected before the scan to make the pictures clearer. The machine can be quite noisy, but you will usually be given earplugs or headphones. Some people feel anxious lying in the narrow cylinder. Tell your medical team beforehand if you feel concerned, as they may offer you some medicine to help you relax.