# Clinical Cases: Cervical and Vulvar Disease

## Case 1: Cervical Intraepithelial Neoplasia Progressing to Early Invasive Cervical Cancer

### Patient Demographics
- **Age:** 38 years
- **Sex:** Female
- **Occupation:** Office manager

### Chief Complaint
"My Pap smear was abnormal and my doctor said I need more tests."

### History of Present Illness
The patient presents for colposcopy after her routine cervical cancer screening showed abnormal results. She has had normal Pap smears in the past and is surprised by the abnormal result. She denies any vaginal bleeding, discharge, or pelvic pain. She has been sexually active since age 17 and reports multiple lifetime partners (estimated 8-10). She was not vaccinated against HPV as it was not available during her adolescence.

### Gynecologic History
- Menarche: Age 12
- Menstrual cycles: Regular, 28 days
- LMP: 2 weeks ago
- Prior Pap smears: Normal at ages 25, 28, 31, 34 (q3 years with HPV co-testing)
- HPV co-test at age 34: Negative
- Contraception: Tubal ligation after third child
- Prior pregnancies: G3P3
- STI history: Chlamydia at age 21 (treated)

### Past Medical History
- Hypothyroidism (on levothyroxine)
- Former smoker: 1 pack per day x 10 years, quit 3 years ago

### Current Screening Results
- **Pap smear cytology:** High-grade squamous intraepithelial lesion (HSIL)
- **HPV testing:** Positive for high-risk HPV type 16

### Risk Factors for Cervical Dysplasia/Cancer
- HPV 16 positive: **Present** (highest risk type)
- Multiple sexual partners: **Present**
- Early sexual debut (age 17): **Present**
- Smoking history: **Present** (quit 3 years ago)
- Prior STI (chlamydia): **Present**
- No HPV vaccination: **Present**
- Immunocompromise: Absent

### Colposcopy Procedure

**Visualization:**
- Transformation zone fully visible (adequate colposcopy)
- Squamocolumnar junction visible

**After Acetic Acid Application:**
- Large area of dense acetowhite epithelium from 10 o'clock to 3 o'clock
- Sharp, raised borders
- Coarse punctation pattern
- Coarse mosaicism at 12 o'clock
- **Atypical vessels noted at 1 o'clock** - concerning for possible invasion

**Schiller's Iodine Test:**
- Non-staining area corresponding to acetowhite lesion (iodine-negative)

**Impression:** High-grade lesion with features concerning for possible early invasion

### Biopsies Obtained
- Directed cervical biopsies x 4 (from most abnormal areas, including atypical vessels)
- Endocervical curettage (ECC)

### Pathology Results

**Cervical Biopsies:**
- 10 o'clock: CIN 3
- 12 o'clock: CIN 3
- 1 o'clock: **Microinvasive squamous cell carcinoma** (invasion 2 mm depth, 4 mm width)
- 2 o'clock: CIN 3

**ECC:** CIN 2

### Diagnosis
**Microinvasive Cervical Cancer (FIGO Stage IA1)**
- Squamous cell carcinoma
- Depth of invasion: 2 mm (Stage IA1 = less than 3 mm depth)
- Width: 4 mm (less than 7 mm)
- HPV 16 associated

### Staging Workup

**FIGO Staging (Clinical):**
- Stage IA1: Stromal invasion ≤3 mm depth and ≤7 mm width
- No lymphovascular space invasion reported on biopsy

**Additional Evaluation:**
- Pelvic examination: No gross lesion, cervix appears normal grossly
- No parametrial involvement
- Chest X-ray: Normal

### Multidisciplinary Discussion

**Key Questions:**
1. Is there lymphovascular space invasion (LVSI)?
2. Does the patient desire fertility preservation?

**Patient Discussion:**
- Patient has completed childbearing (3 children, tubal ligation)
- Does not desire fertility preservation
- Prefers definitive treatment

### Treatment Options for Stage IA1

**If No LVSI:**
- Simple hysterectomy (standard treatment for non-fertility desiring patients)
- Or conization with negative margins if fertility desired

**If LVSI Present:**
- Modified radical hysterectomy with pelvic lymph node assessment
- Or radical trachelectomy with lymphadenectomy if fertility desired

### Treatment Plan

**Procedure: Cold Knife Conization (Diagnostic Excision)**

**Rationale:**
- Need to assess margins and LVSI status
- Biopsy cannot evaluate complete lesion
- Will guide definitive treatment

**Conization Pathology:**
- CIN 3 and microinvasive squamous cell carcinoma
- Depth of invasion: 2.5 mm
- Width: 5 mm
- **No lymphovascular space invasion**
- Endocervical margin: Positive for CIN 3 (not invasive cancer)
- Ectocervical margin: Negative

### Definitive Treatment

Given:
- Stage IA1 without LVSI
- Positive endocervical margin for CIN 3
- No fertility desires

**Recommendation: Simple Total Hysterectomy**

**Surgical Procedure:**
- Total laparoscopic hysterectomy
- Ovaries preserved (age 38)
- No lymphadenectomy required (Stage IA1 without LVSI has <1% nodal metastasis risk)

**Final Pathology:**
- Residual CIN 3 in cervix
- No residual invasive carcinoma
- All margins negative

### Prognosis
- Stage IA1 without LVSI: >99% cure rate
- Excellent prognosis
- No adjuvant therapy required

### Surveillance
- Vaginal cytology (Pap) annually x 5 years
- History and physical examination every 6 months x 2 years, then annually
- Patient education on symptoms of recurrence

### Patient Counseling
- Discussed HPV transmission and vaccination for her children
- HPV vaccination recommended for her 12-year-old daughter and 14-year-old son
- Partner does not require treatment (HPV likely already shared)

### Teaching Points
- HPV 16 is responsible for approximately 50% of cervical cancers
- Atypical vessels on colposcopy are the most concerning finding for invasion
- Microinvasive cervical cancer (Stage IA1 without LVSI) can be treated with simple hysterectomy
- LVSI status determines need for lymph node assessment
- Conization provides definitive diagnosis and may be adequate treatment if fertility desired
- Post-treatment surveillance with vaginal cytology is essential

### Clinical Image
![Cervical Cancer Colposcopy](case_01_image.jpg)

**Image Description:** Colposcopic image of the cervix after acetic acid application demonstrating a large high-grade lesion with dense acetowhite epithelium, sharp borders, coarse punctation, and atypical vessels. The presence of atypical vessels (irregular, branching vessels that do not conform to normal patterns) raises concern for invasive disease.

**Attribution:** Educational illustration. Adapted from colposcopy teaching resources.

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## Case 2: Vulvar Lichen Sclerosus with Vulvar Intraepithelial Neoplasia

### Patient Demographics
- **Age:** 67 years
- **Sex:** Female
- **Occupation:** Retired librarian

### Chief Complaint
"I've had terrible vulvar itching for years that won't go away, and now I noticed a new raised area."

### History of Present Illness
The patient has a 10-year history of vulvar itching and discomfort. She was diagnosed with lichen sclerosus 8 years ago and was prescribed topical clobetasol, which she used intermittently with partial relief. Over the past 6 months, she noticed a new raised, firm area on her right labia majora that is occasionally tender. The lesion has slowly increased in size. She also reports dyspareunia and has avoided intercourse for the past year.

### Gynecologic History
- Menarche: Age 13
- Menopause: Age 52
- No hormone replacement therapy
- Prior pregnancies: G2P2
- Last Pap smear: 5 years ago (discontinued per guidelines after age 65)
- No history of abnormal Pap smears
- Prior vulvar biopsy 8 years ago: Lichen sclerosus

### Past Medical History
- Lichen sclerosus (diagnosed 8 years ago)
- Hypertension
- Osteoporosis
- Autoimmune thyroiditis

### Social History
- Non-smoker
- Married, lives with husband
- No history of sexually transmitted infections

### Physical Examination

**Vulvar Inspection:**
- Diffuse white, thin, atrophic skin affecting bilateral labia majora, minora, clitoral hood, and perineum
- "Cigarette paper" wrinkling of skin
- Loss of normal vulvar architecture:
  - Resorption of labia minora
  - Clitoral phimosis (clitoral hood adherent)
  - Introital narrowing
- **New finding:** 1.5 cm raised, hyperkeratotic, slightly erythematous plaque on right labia majora
- No ulceration or obvious necrosis

**Vaginal Examination:**
- Vaginal mucosa atrophic
- Cervix appears normal
- Uterus small, atrophic
- No adnexal masses

### Clinical Assessment
**Lichen sclerosus with new suspicious lesion**

**Concern:** New raised lesion in the setting of chronic lichen sclerosus requires biopsy to rule out:
- Differentiated vulvar intraepithelial neoplasia (dVIN)
- Vulvar squamous cell carcinoma

### Vulvar Biopsy

**Procedure:**
- Local anesthesia with 1% lidocaine
- 4 mm punch biopsy of raised lesion (right labia majora)
- Additional biopsy from adjacent lichen sclerosus area
- Hemostasis with silver nitrate

**Pathology Results:**

**Biopsy 1 (raised lesion):**
- **Differentiated vulvar intraepithelial neoplasia (dVIN)**
- Background lichen sclerosus
- No invasion identified

**Biopsy 2 (adjacent area):**
- Lichen sclerosus
- No dysplasia

### Diagnosis
**Differentiated VIN (dVIN) arising in lichen sclerosus**

### Understanding the Pathology

**Differentiated VIN (dVIN):**
- Non-HPV-related vulvar precancer
- Arises in background of chronic vulvar dermatoses (especially lichen sclerosus)
- Associated with keratinizing squamous cell carcinoma
- Higher risk of progression than usual-type VIN
- Often unifocal and subtle

**Compared to Usual-type VIN (uVIN):**
- HPV-related
- Occurs in younger women
- Often multifocal
- Classic warty or basaloid appearance

### Risk Discussion
- dVIN has 33-86% risk of progression to invasive SCC
- Higher malignant potential than uVIN
- Requires complete excision

### Treatment Plan

**Surgical Excision:**
- Wide local excision of dVIN lesion
- Goal: 5-10 mm margins
- Primary closure anticipated

**Procedure Performed:**
- Local anesthesia
- Elliptical excision of lesion with 1 cm margins
- Primary closure with absorbable sutures
- Specimen sent for permanent pathology

**Final Pathology:**
- Differentiated VIN
- **Margins clear** (closest margin 6 mm)
- No invasive carcinoma
- Adjacent lichen sclerosus

### Postoperative Care
- Wound care instructions
- Sitz baths
- Activity restrictions for 2 weeks
- Pain management with acetaminophen/NSAIDs

### Long-term Management of Lichen Sclerosus

**Importance of Continued Treatment:**
- Lichen sclerosus is a chronic condition with 4-6% lifetime risk of vulvar SCC
- Consistent treatment may reduce cancer risk

**Optimized Treatment Regimen:**
- Clobetasol 0.05% ointment:
  - Daily x 4 weeks
  - Then every other day x 4 weeks
  - Then twice weekly for maintenance
- Vaginal estrogen for atrophy and dyspareunia
- Emollient (petroleum jelly) for barrier protection
- Avoid irritants (scented products, tight clothing)

### Surveillance Plan
- Vulvar examination every 6 months given history of dVIN
- Self-examination monthly with mirror
- Biopsy any new lesions immediately
- Continue topical corticosteroid maintenance
- Patient education: Report any new bumps, color changes, or non-healing areas

### Follow-up (3 months)
- Surgical site well-healed
- Using clobetasol as directed
- Pruritus improved
- No new lesions

### Follow-up (1 year)
- No recurrence of dVIN
- Lichen sclerosus stable on maintenance therapy
- Vulvar architecture unchanged
- Will continue every 6-month surveillance

### Teaching Points
- Lichen sclerosus has 4-6% lifetime risk of vulvar SCC
- Differentiated VIN arises in chronic vulvar dermatoses (lichen sclerosus, lichen planus)
- dVIN has higher malignant potential than HPV-related usual-type VIN
- Any new lesion in lichen sclerosus requires biopsy
- Wide local excision with clear margins is treatment of choice for VIN
- Long-term surveillance is essential - these patients remain at elevated risk
- Consistent treatment of underlying dermatosis may reduce cancer risk

### Clinical Image
![Lichen Sclerosus with VIN](case_02_image.jpg)

**Image Description:** Clinical photograph of the vulva demonstrating lichen sclerosus with characteristic white, atrophic skin changes and loss of normal architecture including labial resorption and clitoral phimosis. A raised, hyperkeratotic lesion is visible on the labia, representing differentiated vulvar intraepithelial neoplasia requiring biopsy.

**Attribution:** Educational illustration. Used for medical education purposes.

---

## Case 3: HPV Vaccination Counseling and Cervical Cancer Screening

### Patient Demographics
- **Age:** 24 years
- **Sex:** Female
- **Occupation:** Graduate student

### Chief Complaint
"I'm here for my first Pap smear, and I want to know if I should get the HPV vaccine."

### History of Present Illness
The patient presents for her first gynecologic examination and cervical cancer screening. She has never had a Pap smear before. She recently became sexually active with her first partner 6 months ago and is using combined oral contraceptive pills for contraception. She has heard about the HPV vaccine but was not vaccinated as a child and wants to know if it's too late.

### Gynecologic History
- Menarche: Age 12
- Cycles: Regular, 28 days (on OCPs)
- LMP: 3 weeks ago
- Sexual history: One lifetime partner (current boyfriend x 6 months)
- Contraception: Combined oral contraceptive pills
- Prior pregnancies: None
- STI history: None known
- HPV vaccination: None

### Past Medical History
- No chronic conditions
- No medications other than OCPs
- No allergies

### Family History
- No family history of cervical cancer
- Mother had abnormal Pap smear treated with cryotherapy in her 30s

### Social History
- Non-smoker
- Social alcohol (weekends)
- Graduate student in biology
- In monogamous relationship

### Physical Examination
- **General:** Healthy-appearing young woman
- **External genitalia:** Normal
- **Speculum:** Cervix appears normal, nulliparous os, small physiologic ectropion
- **Bimanual:** Uterus normal size, anteverted, no adnexal masses

### Cervical Cancer Screening Discussion

**Current Guidelines (ASCCP/ACOG):**

| Age | Screening Recommendation |
|-----|-------------------------|
| 21-24 years | Cytology (Pap) alone every 3 years |
| 25-29 years | HPV primary testing every 5 years (preferred) OR cytology every 3 years |
| 30-65 years | HPV primary testing every 5 years (preferred) OR co-testing every 5 years OR cytology every 3 years |
| >65 years | Discontinue if adequate prior screening |

**For This Patient (Age 24):**
- Pap smear (cytology) alone
- No HPV testing recommended at this age (high rates of transient HPV infection)
- Repeat in 3 years if normal

### Cervical Cancer Screening Performed
- Pap smear collected
- No HPV co-test (per guidelines for age 21-24)

### HPV Vaccination Counseling

**Patient Questions:**

**Q: "Is it too late for me to get the HPV vaccine since I'm already sexually active?"**

**A:** No, it's not too late. The vaccine is FDA-approved for individuals ages 9-45. For those who begin vaccination before age 15, only 2 doses are needed. For those starting at age 15 or older, 3 doses are required. The vaccine is most effective before any HPV exposure, but it still provides protection against HPV types you haven't been exposed to.

**Q: "What does the vaccine protect against?"**

**A:** The current vaccine (Gardasil 9) protects against 9 HPV types:
- Types 16 and 18: Cause ~70% of cervical cancers
- Types 31, 33, 45, 52, 58: Cause additional ~20% of cervical cancers
- Types 6 and 11: Cause 90% of genital warts

The vaccine prevents:
- ~90% of cervical cancers
- ~90% of anal cancers
- Vulvar and vaginal cancers
- Oropharyngeal cancers
- Genital warts

**Q: "Since I already have a partner, have I already been exposed?"**

**A:** You may have been exposed to some HPV types, but likely not all 9 types covered by the vaccine. The vaccine will still protect against types you haven't encountered. Studies show catch-up vaccination still reduces cancer risk.

### HPV Vaccination Plan

**Recommendation: HPV Vaccination (Gardasil 9)**

**Schedule for patients age 15+ (3-dose series):**
- Dose 1: Today
- Dose 2: 1-2 months after Dose 1
- Dose 3: 6 months after Dose 1

**Administered:**
- Gardasil 9 0.5 mL IM (deltoid)
- Dose 1 given today
- Return appointments scheduled for doses 2 and 3

### Counseling on HPV and Cervical Cancer Prevention

**Key Points Discussed:**

1. **HPV is extremely common:**
   - 80% of sexually active individuals will acquire HPV at some point
   - Most infections clear spontaneously within 1-2 years
   - Only persistent high-risk HPV causes cancer

2. **Cervical cancer is preventable:**
   - Regular screening detects precancerous changes
   - HPV vaccination prevents most cervical cancers
   - Smoking cessation reduces risk

3. **What to do with abnormal results:**
   - ASCUS or LSIL at her age: Usually observation
   - Most low-grade abnormalities resolve spontaneously
   - Will not overtreat young patients

4. **Partner considerations:**
   - Male partners can also be vaccinated (reduces their cancer risk and transmission)
   - No need for partner to be tested or treated for HPV

### Pap Smear Result (1 week later)
- **Result:** Negative for intraepithelial lesion or malignancy (NILM)
- **Interpretation:** Normal
- **Next screening:** 3 years (age 27)

### Follow-up Visit (1 month - Dose 2)
- HPV vaccine dose 2 administered
- Tolerated well, mild injection site soreness

### Follow-up Visit (6 months - Dose 3)
- HPV vaccine dose 3 administered
- Series complete
- Counseled that protection develops over several months
- Still needs regular cervical cancer screening despite vaccination

### Vaccine Side Effects Discussed
- **Common:** Injection site pain, redness, swelling (most common)
- **Less common:** Headache, fever, nausea, fatigue
- **Rare:** Syncope (observe 15 minutes post-injection)
- **No increased risk of autoimmune disease, infertility, or serious adverse events**

### Teaching Points
- Cervical cancer screening begins at age 21 regardless of sexual history
- HPV testing is not recommended in ages 21-24 due to high transient infection rates
- HPV vaccination is recommended for all individuals ages 9-26 (catch-up to age 45)
- Vaccination is beneficial even after sexual debut
- The 9-valent vaccine prevents ~90% of cervical cancers
- Vaccination does not replace the need for cervical cancer screening
- Both males and females benefit from vaccination

### Clinical Image
![HPV Vaccine](case_03_image.jpg)

**Image Description:** Illustration depicting the HPV vaccination schedule and the types of cancers prevented by the nonavalent HPV vaccine (Gardasil 9). The image shows the dosing schedule (2 doses if started before age 15, 3 doses if started at age 15 or older) and highlights protection against cervical, vulvar, vaginal, anal, and oropharyngeal cancers.

**Attribution:** Educational illustration adapted from CDC immunization resources. Public domain.