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DESCRIPTION
Information about description, diagnosis and treatment for vaginal and vulvar cancer are very similar. Both have been included in here for discussion. For more detailed information or answers to your concerns, consult with your health care provider.
The vulva is the outside part of the female reproductive system that opens into the vagina. There are two prominent skin folds, known as the labia majora, and two more barely visible, hairless skin folds called the labia minora. These inner and outer labia (Latin for lips) meet, protecting the vaginal opening and, just above it, the opening of the urethra (the short tube that carries urine from the bladder).
At the front of the vagina, the labia minora meet to form a fold or small hood of skin called the prepuce. Beneath it lies the clitoris, an approximately 3/4-inch structure of highly sensitive tissue that becomes swollen with blood during sexual stimulation. At the lower end, just beneath the vaginal opening, is the fourchette, where the labia minora meet. Beyond the fourchette is the anus, the opening to the rectum. The space between the vagina and the anus is called the perineum.
Vaginal or vulvar cancer is uncontrolled growth of malignant cells in the vagina or on the vulva (vaginal lips). The peak growth occurs in older women in the postmenopausal years. One type (rhabdomyosarcoma) occurs in children. Cancer of the vulva most often affects the inner edges of the labia majora or the labia minora. Less often, cancer occurs on the clitoris or in Bartholin glands (small mucus-producing glands on either side of the vaginal opening).
Definition of vaginal cancer is Cancer that forms in the tissues of the vagina (birth canal). The vagina leads from the cervix (the opening of the uterus) to the outside of the body. The most common type of vaginal cancer is squamous cell carcinoma, which starts in the thin, flat cells lining the vagina. Another type of vaginal cancer is adenocarcinoma, cancer that begins in glandular cells in the lining of the vagina. Estimated new cases and deaths from vaginal (and other female genital) cancer in the United States in 2007: New cases: 2,140, Deaths: 790
Over 90% of cancers of the vulva are squamous cell carcinomas, which means they begin in squamous cells, the main cell type of the skin. This type of cancer usually forms slowly over many years and is usually preceded by pre-cancerous changes that may last for several years. The medical term most often used for this pre-cancerous condition is vulvar intraepithelial neoplasia (VIN). "Intraepithelial" means that the pre-cancerous cells are confined to the epithelium (surface layer of the vulvar skin). VIN is often divided into three categories - VIN 1, VIN 2, and VIN 3, with the last indicating furthest progression toward a true cancer.
Dysplasia is often used as another term for VIN. Using this terminology, there is also a range of increasing progress toward cancer - first, mild dysplasia; next, moderate dysplasia; then severe dysplasia; and, finally, carcinoma in situ. Most women with VIN or dysplasia will not develop vulvar cancer. However, it is not predictable which women will develop vulvar cancer, so treatment of women with VIN is very important. In the past, cases of VIN were included under the broad category of disorders known as vulvar dystrophy. Since this category included a wide variety of other diseases, most of which are not pre-cancerous, most health care providers no longer use this term.
The second most common type of vulvar cancer (about 2% to 4%) is melanoma. Melanomas develop from the pigment-producing cells that determine the skin's color. About 5% to 8% of melanomas in women occur on the vulva, usually on the labia minora and clitoris.
A small percentage of vulvar cancers develop from glands and are called adenocarcinomas. Some develop from Bartholin glands, which are found at the opening of the vagina and produce a mucus-like lubricating fluid. Although most Bartholin gland cancers are adenocarcinomas, some (particularly those developing from the ducts of the gland) may be different types, either transitional cell carcinomas or squamous cell carcinomas. Adenocarcinomas can also form in the sweat glands of the vulvar skin, although this is quite rare.
Paget disease of the vulva is a condition in which adenocarcinoma cells are found in the vulvar skin. Between 20% and 25% of patients with vulvar Paget disease also have an invasive adenocarcinoma of a Bartholin gland or sweat gland. In the remaining 75% to 80%, the malignant cells are found only in the skin's top layer and do not involve the tissues under that layer. Since a tumor in the Bartholin gland is easily mistaken for a cyst (accumulation of fluid in the gland), delay in accurate diagnosis is common.
Less than 2% of vulvar cancers are sarcomas, tumors of the connective tissues under the skin that tend to grow rapidly. Unlike other cancers of the vulva, vulvar sarcomas can occur at any age, including in childhood.
Verrucous carcinoma resembles a large wart and requires a biopsy to distinguish it from a benign (non-cancerous) growth. This form of vulvar cancer is a slow-growing subtype of squamous cell carcinoma and tends to have a good prognosis (outlook for chances of survival).
Basal cell carcinoma, the most common cancer of sun-exposed areas of the skin, occurs very rarely on the vulva.
Models of Vulvar Cancer
Characteristic Type 1 Type 2 Age Younger (35 to 65 years old) Older (55 to 85 years old) Cervical neoplasia High association Low association Cofactors Age, immune status, viral integration Vulvar atypia, possibly mutated host genes Histopathology of tumor Intraepithelial-like (basaloid), poorly differentiated Keratinizing; squamous cell carcinoma, well differentiated HPV DNA Frequent (>60 percent) Seldom (<15 percent) Pre-existing lesion VIN Vulvar inflammation, lichen sclerosus, squamous cell hyperplasia History of condyloma Strong association Rare association History of STD Strong association Rare association Cigarette smoking High incidence Low incidence HPV = human papillomavirus; VIN = vulvar intraepithelial neoplasia; STD = sexually transmitted disease.
Adapted from Crum CP. Carcinoma of the vulva: epidemiology and pathogenesis. Obstet Gynecol 1992; 79:448-54.
In 1998, approximately 3,200 women in the United States developed cancer of the vulva, and 800 women died of the disease.1 Over the past decade, an increase in vulvar intraepithelial neoplasia (VIN) and VIN-related invasive vulvar cancer has been noted in women younger than 50 years. Overall, vulvar cancer is relatively uncommon, accounting for 3 to 5 percent of female genital-tract malignancies.
Vulvar intraepithelial neoplasia. Extensive involvement, mainly of nonhairy vulvar skin, in a 26-year-old heavy smoker. The lesion is multifocal, papular, and partically pigmented, with a somewhat verrucous surface. Biopsy showed basalo / verrucous carcinoma in situ. 
Invasive squamous cell carcinoma of nonhairy vulvar skin in a 79 year old woman. The lesion arises in an area of lichen sclerosus related to longstanding, untreated prutitus.
Photos courtesy of AAFP.org
FREQUENT SIGNS & SYMPTOMS
Vulvar Intraepithelial Neoplasia (VIN); The must common symptoms of VIN is persistent itching that does not improve. However, most patients do not have symptoms. Areas of VIN are usually thicker and lighter in color than the surrounding skin. However, some cases of VIN can appear red, pink, or darker than the surrounding skin. Because these symptoms can be caused by other conditions that are not pre-cancerous, some women fail to recognize the seriousness of their condition and attempt to treat the problem themselves with over-the-counter remedies. Sometimes even health care providers may not recognize the condition at first.
Invasive Squamous Cell Vulvar Cancer: Small or large, firm, ulcerated, painless lesion of the vulva. These growths on the vulva have thick, raised edges and bleed easily. The signs and symptoms of early invasive vulvar cancer are similar to those of symptomatic VIN. As invasion and growth progress, a distinct tumor is more likely to be recognized. The most common symptoms are a red, pink, or white bump or bumps with a wart-like or raw surface. An area of the vulva may appear white and feel rough.
About half of the women with vulvar cancer complain of persistent itching and a growth. Some also complain of:
- Pain and/or burning in the pelvic area or genital, vaginal region.
- An ulcer that persists for more than a month is another sign.
- Abnormal vaginal bleeding and/or discharge not associated with normal menstrual bleeding.
- Discomfort, pain or bleeding with intercourse.
- Uncomfortable or painful urination, if cancer spreads to the bladder.
- Rectal bleeding, if it spreads to the rectum.
Other Types of Vulvar Cancer & Symptoms
Vulvar melanoma: The appearance of a darkly pigmented growth or a change in a mole that has been present for years may indicate melanoma. The ABCD rule can help tell a normal mole from one that could be melanoma.
- Asymmetry: One-half of the mole does not match the other.
- Border irregularity: the edges of the mole are ragged or notched.
- Color: The color over the mole is not the same. There may be differing shades of tan, brown, or black and sometimes patches of red, blue, or white.
- Diameter: The mole is wider than 6 mm (about 1/4 inch).
The most important sign of melanoma is a change in size, shape, or color of a mole. Some melanomas, however, do not fit the ABCD rule.
Bartholin gland cancer: A distinct mass on either side of the opening to the vagina may indicate a Bartholin gland carcinoma. However, similar symptoms may be due to a Bartholin gland cyst, which is much more common.
Paget disease: Soreness and a red, scaly area are symptoms of Paget disease of the vulva.
Verrucous carcinoma: This is one subtype of invasive squamous cell vulvar cancer with a particularly good prognosis. Verrucous carcinoma appears as cauliflower-like growths similar to genital warts.
Knowing what to look for can sometimes help with early detection, but it is even better not to wait until you notice symptoms. Have a regular Pap test and pelvic examination.
CAUSES
Unknown, except for intrauterine exposure to DES (diethylstilbestrol, a drug prescribed to control spotting or bleeding in pregnant women up to 1971).
A possible connection may be exposure to human papillomavirus (HPV), the cause of genital warts.
Several risk factors for cancer of the vulva are known, and we are beginning to understand how these factors can cause cells in the vulva to become cancerous. Researchers have made great progress in understanding how certain changes in DNA can cause normal cells to become cancerous. DNA is the chemical that carries the instructions for nearly everything our cells do. We usually resemble our parents because they are the source of our DNA. However, DNA affects more than our outward appearance. Some genes (parts of our DNA) contain instructions for controlling when our cells grow and divide. Certain genes that promote cell division are called oncogenes. Others that slow down cell division or cause cells to die at the right time are called tumor suppressor genes. Cancers can be caused by DNA mutations (defects) that turn on oncogenes or turn off tumor suppressor genes. Usually DNA mutations related to cancers of the vulva occur during life rather than having been inherited before birth. Acquired mutations may result from cancer-causing chemicals in tobacco smoke. Sometimes they occur for no apparent reason.
Recent studies suggest that squamous cell vulvar cancer (the most common type) can develop in at least 2 ways. In about 1/3 to 1/2 of cases, human papillomavirus (HPV) infection appears to have an important role. Vulvar cancers associated with HPV infection seem to have certain distinctive features. In addition to being younger, women with these cancers often have multiple areas of vulvar intraepithelial neoplasia (VIN) elsewhere on their vulvas and are usually smokers.
The second process by which vulvar cancers develop does not involve HPV infection. Vulvar cancers not linked to HPV infection usually are diagnosed in older women (age 55 to 85) who rarely have VIN but often have lichen sclerosis. DNA tests from vulvar cancers in older women not infected by HPV often show mutations of the p53 tumor suppressor gene. The p53 gene is important in preventing cells from becoming cancerous. When the gene has undergone mutation, cancer readily develops. Younger patients with HPV infection and vulvar cancer rarely have p53 mutations.
These recent discoveries have not yet affected treatment. But, in the future, they will probably be important in developing prevention strategies and in selecting the most appropriate treatment for distinct older and younger women with squamous cell vulvar cancer. Because of their rarity, much less is known about how vulvar melanomas and adenocarcinomas develop.
RISK INCREASES WITH
Age: Almost 85% of women with vulvar cancer are over age 50, and half are over age 70 at the time their cancer is first diagnosed. However, 15% of new patients are under age 40. The average age of women diagnosed with invasive cancer is 70, whereas women diagnosed with non-invasive vulvar cancer average about 20 years younger.
Human Papillomavirus (HPV) Infection: HPV infection is thought to be responsible for most of the vulvar cancers in younger women. HPVs are a group of more than 100 types of viruses that are called papillomaviruses because they can cause papillomas or warts. Different HPVs cause different types of warts in different parts of the body. Some types cause common warts on the hands and feet; other types tend to cause warts on the lips or tongue. Certain HPV types can infect the female and male genital organs and the anal area. These HPV types are passed from one person to another during sexual contact. Sexual contact at a young age increases the likelihood of HPV infection. Having a large number of sexual partners or having sex with persons who have had many sexual partners increases the risk of exposure to HPV. When HPVs infect the skin of the external (outer) genital organs and anal area (around the opening of the intestinal tract), they often cause raised, bumpy warts. These may be barely visible, or they may be several inches across. The medical term for genital warts is condyloma acuminatum. Most genital warts are caused by 2 HPV types, HPV 6 and HPV 11. These rarely develop into cancer and are called "low-risk" viruses. However, other sexually transmitted HPVs have been linked with genital or anal cancers in both men and women. These are considered "high-risk" types of HPV and include HPV 16, HPV 18, HPV 31, as well as some others. Infection with high-risk HPVs often produces no visible signs until pre-cancerous changes or cancer develops. In general, vulvar cancer in younger women tends to be associated with infection with the high-risk HPV types. In elderly women HPV is less likely a risk factor. In elderly women HPV is less likely a risk factor. Some health care providers think there are two kinds of vulvar cancer. One kind is associated with HPV infection and tends to occur in younger women. The other kind is not associated with HPV infection, and more often is found in older women.
Human Immunodeficiency Virus (HIV) Infection: HIV is the virus that causes the acquired immunodeficiency syndrome (AIDS). Because this virus damages the body's immune system, it makes women more susceptible to persistent HPV infections, which may, in turn, increase the risk of pre-cancerous vulvar changes and vulvar cancer. Scientists also believe that the immune system plays a role in destroying cancer cells and slowing their growth and spread.
Vulvar Intraepithelial Neoplasia (VIN): Women with VIN have an increased risk of developing invasive vulvar cancer. Although most cases of VIN never progress to cancer, it is not possible to tell which will, so treatment or close medical follow-up is needed.
Lichen Sclerosus: This disorder, also called lichen sclerosus et atrophicus (LSA), causes the vulvar skin to become very thin and itchy. The risk of vulvar cancer appears to be slightly increased by LSA, with about 4% of women with LSA later developing vulvar cancer.
Melanoma or Atypical Moles On Nonvulvar Skin: Women with a family history of melanoma or dysplastic nevi (atypical moles) elsewhere on the body are at risk for developing a melanoma on the vulva.
Smoking. Smoking exposes the body to many cancer-causing chemicals that affect more than the lungs. These harmful substances can be absorbed into the lining of the lungs and spread throughout the body. Among women who have a history of genital warts, smoking further increases the risk of developing vulvar cancer. Women are infected with a high risk HPV have a much higher risk of developing vulvar cancer if they smoke.
Multiple Sex Partners: Women having multiple sex partners are at higher risk of sexually transmitted diseases and infections.
Family or Personal History of Other Cancers: Women with vulvar cancer also have a higher risk of cervical cancer. The likely reason for this association is the role of HPV infection in causing both of these cancers. Smoking is associated with an increased risk of cervical cancer. Because of the smoking, women also have a higher risk of other smoking-related cancers.
Helpful Links To Related Disorders
Breast Cancer Cervical Dysplasia Cervical Cancer Ovarian Cancer Pruritus Vulvae Sexually Transmitted Diseases Uterine Cancer
PREVENTIVE MEASURES
There are no specific preventive measures. The risk of vulvar cancer can be reduced by avoiding controllable risk factors and by treating pre-cancerous conditions before an invasive cancer develops. These steps cannot guarantee prevention but can greatly reduce your chances of developing vulvar cancer.
Have a yearly pelvic exam and Pap smear to detect the disease during early stages when treatment is most effective. Pre-cancerous vulvar conditions can be identified by having regular reproductive system (gynecologic) checkups and by having a doctor evaluate any persistent vulvar rashes, moles, lumps, or other abnormalities. Treatment of vulvar intraepithelial neoplasia (VIN) can prevent many cases of invasive squamous cell vulvar cancer.
Some vulvar melanomas can be prevented by removal of atypical moles. Examination of the vulva is routinely done at the same time a woman has a Pap test and pelvic examination. The American Cancer Society recommends:
- All women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse, but no later than when they are 21 years old. Screening should be done every year with the regular Pap test or every 2 years using the newer liquid-based Pap test.
- Beginning at age 30, women who have had 3 normal Pap test results in a row may get screened every 2 to 3 years with either the conventional (regular) or liquid-based Pap test. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, or a weakened immune system due to organ transplant, chemotherapy, or chronic steroid use should continue to be screened annually. Another reasonable option for women over 30 is to get screened every 3 years (but not more frequently) with either the conventional or liquid-based Pap test, plus the HPV DNA test.
- Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having cervical cancer screening. Women with a history of cervical cancer, DES exposure before birth, HIV infection or a weakened immune system should continue to have screening as long as they are in good health.
- Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having cervical cancer screening, unless the surgery was done as a treatment for cervical cancer or pre-cancer. Women who have had a hysterectomy without removal of the cervix should continue to follow the guidelines above.
Use condoms and avoid sexually transmitted diseases and infections. Human papillomavirus (HPV) infection is a vulvar cancer risk factor that can be reduced by avoiding certain sexual practices outlined in the section on risk factors and by delaying onset of sexual activity. Until recently, it was thought that the use of condoms ("rubbers") could prevent infection with HPV. But recent research shows that condoms cannot fully protect against infection with HPV. This is because HPV can be passed from one person to another by skin-to-skin contact with any HPV-infected area of the body such as skin of the genital or anal area not covered by the condom.
It is still important to use condoms to protect against HIV/AIDS and other sexually transmitted diseases that are passed on through some body fluids. Because HPV can be present for years with no symptoms and passed on to another person even when there are no visible symptoms, the absence of visible warts cannot be used to decide whether caution is warranted. The earlier sexual contact with others is begun, the more likely it is that a person will become infected with HPV, and the more time any HPV infection will have to progress to cancer. For these reasons, postponing the beginning of sexual activity in life and limiting the number of sexual partners are 2 ways to reduce the risk of developing HPV infection and vulvar cancer.
A new vaccine has been approved by the FDA that will protect against infection with HPV types 16 and 18. It is currently recommended for use in young females before they become sexually active (to prevent cervical cancers and pre-cancers), and it is being looked at for possible use in males. While studies have not yet been done, the hope is that this may eventually help prevent other cancers linked to HPV, including vulvar cancers. If you are interested in the vaccine - be sure to research the pros, cons, side effects, risks, and contraindications of the vaccine before getting it. It may not be right for you. The vaccine does not protect you from all forms of HPV infections.
Not smoking is another way to lower vulvar cancer risk, in addition to obvious benefits of greatly reducing your risk of developing far more common cancers of the lungs, mouth, throat, bladder, kidneys, and several other organs.
Become familiar with the appearance of your genitals. Use a mirror and examine once a month. Be aware of any changes in appearance, irritation, white or darkly pigmented area, abnormal growths, nodules, bumps, or ulcers and report these to your health care provider since these may indicate vulvar cancers or pre-cancerous conditions. Darker spots around the vagina on the labia are generally not associated with vaginal or vulvar cancer, but may represent melanoma, a skin cancer. Any dark skin discoloration should be brought to the attention of your health care provider for further evaluation.
EXPECTED OUTCOME
Early detection and treatment offer a good chance for normal life expectancy. Symptoms can be relieved or controlled during treatment.
POSSIBLE COMPLICATIONS
Fatal spread to other body parts. Common sites of spread are the lymph nodes in the groin, wall of the pelvis, bladder, rectum, bone, lungs or liver.
TREATMENT
GENERAL MEASURES
Having pelvic examinations and being alert to any signs and symptoms of vulvar cancer greatly improve the chances of early detection and successful treatment. If you have any of the signs or symptoms discussed below you should see a health care provider. If the health care provider sees or feels anything unusual during a pelvic examination, more medical procedures will be needed. If your health care provider is not a gynecologist (specialist in problems of the female genital system), a referral to one may be made. There is no standard screening for this disease other than routine physical examinations.
DIAGNOSIS
MEDICAL HISTORY & PHYSICAL EXAM: The first step is to take a complete medical history to check for risk factors and symptoms. Then your health care provider will perform a complete physical examination to evaluate your general state of health, including a pelvic examination. He or she will feel your uterus, ovaries, cervix, and vagina for anything irregular. Your health care provider will also look into the vagina and cervix using a speculum and will perform a Pap smear. In addition, he or she will pay special attention to the lymph nodes, particularly those in the groin region, to check for evidence of metastasis. Depending on the biopsy results, several more tests may be done to determine if the vulvar/vaginal cancer has spread to other areas.
BIOPSY: Although certain signs and symptoms may strongly suggest vulvar cancer, many of them can be caused by benign (non-cancerous) conditions. The only way to be certain that a vulvar cancer is present is to remove a small piece of tissue from the suspicious area to examine under the microscope. This procedure is called a biopsy. A pathologist (a health care provider specializing in diagnosing diseases by laboratory tests) will look at the tissue sample under a microscope to see if cancer or a pre-cancerous condition is present and, if so, what type it is.
In order to find all areas of abnormal vulvar skin and to select the best areas to take a biopsy from, the health care provider may rarely use toluidine blue to paint the vulva. This dye causes skin with certain diseases to turn blue, including vulvar intraepithelial neoplasia (VIN) and vulvar cancer.
The health care provider may use a colposcope, an instrument with binocular magnifying lenses, or a hand held magnifying lens, to select areas to biopsy. The skin is treated with a dilute solution of acetic acid (which is also the main ingredient in vinegar) that causes areas of VIN and cancer to turn white, making them easier to see through the colposcope.
Once the abnormal areas are found, local anesthetic is injected into the skin to make it numb. If the abnormal area is small, it may be completely removed by an excisional biopsy. For this procedure, the health care provider uses a scalpel to remove a small ellipse of skin and sews the skin edges together with surgical thread.
If the abnormal area is larger, a punch biopsy is used to take a small sample. The instrument used looks like a tiny apple corer and removes a small, cylindrical piece of skin 4 mm (about 1/6 inch) across. No stitches are needed after the punch biopsy. Depending on the results of the punch biopsy, additional surgery may be necessary.
OTHER DIAGNOSTIC TESTS
Diagnostic tests may be numerous, first to diagnose the cancer, and the to determine any spread to other body organs (staging). Testing may include laboratory blood studies, Pap smear, chest x-ray, CT scan, mammogram, barium enema, cystoscopy, colposcopy with biopsy, or sigmoidoscopy (the last 3 use a telescopic instrument with fiberoptic light for diagnosis.
It is important to find out how far the cancer has spread. This is called staging (see below). The stage of your cancer is the most important factor in selecting the right treatment plan. The results of your physical examination and certain diagnostic tests will be used to determine the size of the tumor, how deeply it has invaded tissues at the site of origin, the extent of any invasion into surrounding organs, and the extent of metastasis (spread to lymph nodes or distant organs).
If your biopsy indicates that you have vulvar/vaginal cancer, your health care professional will refer you to a gynecologic oncologist, a specialist in female reproductive system cancers. The first step will be a complete personal and family medical history to obtain information related to risk factors and symptoms of vulvar cancer.
CYSTOSCOPY: This is an examination using a lighted tube to check the inside surface of the bladder. Some advanced cases of vulvar cancer can spread to the bladder, so any suspicious areas noted by this exam are removed for biopsy. This procedure can be done using a local anesthetic, but some patients may require general anesthesia. Your health care provider will let you know what to expect before and after the procedure.
PROCTOSCOPY: This is a visual inspection of the rectum using a lighted tube. Some advanced cases of vulvar cancer can spread to the rectum. A biopsy is performed on any suspicious areas.
Examination of the pelvis under anesthesia: This permits a more thorough examination that can better evaluate the extent of cancer spread to internal organs of the pelvis.
IMAGING TESTS
CHEST E-RAY: A plain x-ray of your chest will be done to see if your cancer has spread to your lungs. This is very unlikely unless your cancer is far advanced. This x-ray can be done in any outpatient setting. If the results are normal, you probably don't have cancer in your lungs.
COMPUTED TOMOGRAPHY(CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread). The machine will take pictures of multiple slices of the part of your body that is being studied. Often after the first set of pictures is taken you will likely receive an intravenous injection of a "dye" or radiocontrast agent that helps better outline structures in your body. A second set of pictures is then taken.
CT scans take longer than regular x-rays and you will need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. The newest CT scanners take only seconds to complete the study. Also, you might feel a bit confined by the ring-like equipment you're in when the pictures are being taken.
The contrast "dye" is injected through an IV line. Some people are allergic to the dye and get hives, a flushed feeling, or rarely more serious reactions like trouble breathing and low blood pressure. Be sure to tell your health care provider if you have ever had a reaction to any contrast material used for x-rays. If you have, you may need medicine before you can have such an injection during your test.
You may also be asked to drink a contrast solution. This helps outline your intestine if your health care provider is looking at organs in your abdomen. The CT scan will provide precise information about the size, shape, and position of a tumor, and can help find enlarged lymph nodes that might contain cancer.
MAGNETIC RESONANCE IMAGING (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body.
A contrast material might be injected just as with CT scans, but is used less often. MRI scans take longer -- often up to an hour. Also, you have to be placed inside a tube-like piece of equipment, which is confining and can upset people with claustrophobia. The machine makes a thumping noise that you may find annoying. Some places will provide headphones with music to block this out. MRI images are particularly useful in examining pelvic tumors. They may often detect enlarged lymph nodes in the groin. They are also helpful in detecting cancer that has spread to the brain or spinal cord.
POSITRON EMISSION TOMOGRAPHY (PET): Positron emission tomography uses glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. This test is useful to see whether the cancer has spread to lymph nodes. PET scans are also useful when your health care provider thinks the cancer has spread, but doesn't know where. PET scans can be used instead of several different x-rays because they scan your whole body. Newer devices combine a CT scan and a PET scan to even better pinpoint the tumor.
STAGING: The FIGO/AJCC System for Staging Vulvar Cancer
The stage of vulvar cancer is most often described using the FIGO (International Federation of Gynecology and Obstetrics) System of Staging combined with the American Joint Committee on Cancer TNM system. This system classifies the diseases in Stages 0 through IV depending on the extent of the tumor (T), whether the cancer has spread to lymph nodes (N) and whether it has spread to distant sites. The definition of T, N and M is as follows:
Tumor Extent (T)Tis: The cancer is not invading into the underlying tissues.
T1: The cancer is growing only in the vulva or perineum and is smaller than 2 cm. (about 0.8 inches).
T1a: The cancer invades no more than 1 mm into underlying tissue.
T1b: The cancer invades more than 1 mm into underlying tissue.
T2: The cancer is growing only in the vulva or perineum and is larger than 2 cm. (about 0.8 inches).
T3: The cancer is growing into the lower urethra, anus or vagina.
T4: The cancer is growing into the upper urethra, bladder or rectum or into the pubic bone.
Lymph Node Spread of Cancer (N)N0: No lymph node spread.
N1: Spread to lymph nodes on the same side as the cancerous vulva.
N2: Spread to lymph nodes on the same and opposite side as the cancerous vulva.
Distant Spread of Cancer (M)M0: No distant spread.
M1: The cancer has spread to distant sites.
Stage Grouping
The grouping of T, N, and M determines the stage:Stage 0: Tis, N0, M0: This is a very early cancer found in the surface of the skin of the vulva only. Stage 0 squamous cell cancer of the vulva is also known as carcinoma in situ and as Bowen disease.
SURVIVAL BY STAGE
Stage I: T1, N0, M0: The cancer is in the vulva or the perineum (the space between the rectum and the vagina) or both. The tumor is 2 cm or less (about 3/4 inch) in diameter and has not spread to lymph nodes or distant sites.
Stage IA: T1a: These are stage I cancers with invasion no deeper than 1 mm (about 1/25 inch).
Stage IB: T1b: These are stage I cancers that have invaded deeper than 1 mm.
Stage II: T2, N0, M0: The cancer is in the vulva or perineum or both, and the tumor is larger than 2 cm. It has not spread to lymph nodes or distant sites.
Stage III: T1-T2, N1, M0, or T3, N0-N1, M0: Cancer is found in the vulva or perineum or both and has spread to nearby tissues, such as the urethra, vagina, or anus, and/or has spread to nearby lymph nodes on one side of the groin. It has not spread to distant sites.
Stage IVA: T1-3, N2, M0, or T4, N0-N3, M0: Cancer has spread to lymph nodes on both sides of the groin or it has spread beyond nearby tissues to the upper part of the urethra, bladder, rectum, or pelvic bone.
Stage IVB: Cancer has spread to distant organs of the body. This is the most advanced stage of cancer.
Recurrent: The cancer has come back after treatment.
The numbers below are based on patients diagnosed from 1985 to 1989. Because of newer treatments, the survival rates for women diagnosed now should be better. These numbers come from the American College of Surgeons, National Cancer Data Base. (Cancer 1997;80:505).
Stage Relative 5-Years Survival Rate
I 93% II 87% III / IVA 43%
A recent report from the Mayo clinic divided patients into 2 groups - those with or without lymph node spread of the cancer. Women who had no lymph node spread had a 5-year survival of 96%. Those with spread to the lymph nodes had a 5-years survival of 64%. These survival numbers are disease-specific. This means that women who died of other causes than cancer were not included.
The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Five-year rates are used to produce a standard way of discussing prognosis. Of course, many people live much longer than 5 years. Five-year relative survival rates assumes that people will die of other causes and compares the observed survival with that expected for people without vulvar cancer. That means that relative survival only talks about deaths from vulvar cancer.
Keep in mind that 5-year survival rates are based on patients diagnosed and initially treated more than 5 years ago. Improvements in treatment often result in a more favorable outlook for women more recently diagnosed with vulvar cancer.
TREATMENT
Your health care provider may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.
After the stage of your vulvar/vaginal cancer has been established, your cancer care team will recommend a treatment strategy. Consider the options without feeling rushed. If there is anything you do not understand, ask to have it explained again.
The choice of treatment depends largely on the stage of the disease at the time of diagnosis, but other factors can play a part in choosing the best treatment plan, such as your age, your general health and physical condition, your individual circumstances, extent of the disease, the location of the cancer and your preferences. Be sure you understand all the risks and side effects of the various therapies before making a decision.
You may want to get a second opinion. This can provide more information and help you feel confident about the treatment plan you choose. Some insurance companies require a second opinion before they will pay for treatments. The 3 main types of treatment used for patients with vulvar cancer are surgery, radiation therapy, and chemotherapy.
SURGERY
Surgery (usually) may include vulvectomy, vaginectomy, hysterectomy and lymph node removal. Laser vaporization is often used for treatment of some vulvar cancer.
Choosing the best surgical treatment for each woman involves balancing the importance of maintaining sexual functioning with the need to remove all the cancer. In the past, surgeons removing a vulvar cancer also took out a large amount of surrounding normal tissue and possibly local lymph nodes, regardless of the stage of the cancer, because they wanted to be sure that no undetected cancer cells remained. Such extensive surgery resulted in a good chance of cure, but it caused disfigurement and impaired the woman's ability to function sexually if the clitoris were removed. The removal of all the lymph nodes in the groin often led to disabling swelling of the leg on that side.
Today, the importance of sexuality to a woman's quality of life is well recognized. It has also been established that, when cancer is detected early, it is not necessary to remove so much surrounding healthy tissue to achieve a cure. In addition, the sentinel node biopsy procedure avoids removing lymph nodes if the cancer has not spread. However, the use of sentinel lymph node biopsy has not been conclusively shown to be as effective as standard groin dissections. Studies are on-going to evaluate their role (see below) When cancer is more advanced, an extensive procedure may be necessary. Radiation can be combined with chemotherapy and surgery to kill more cancer cells in advanced cases.
The following types of surgery are listed in order of how much tissue is removed (from least to most):
Laser surgery: A focused laser beam vaporizes (burns off) the layer of vulvar skin containing abnormal cells. Laser surgery is used as a treatment for VIN (pre-invasive vulvar cancer). It is not used to treat invasive cancer.
Excision: The cancer and a margin of normal-appearing skin (usually about 1/2 inch) around it are excised (cut out). This is sometimes called wide local excision. If extensive, it may be called a simple partial vulvectomy.
Vulvectomy: There are several operations in which part of the vulva or all of the vulva is removed:
- A skinning vulvectomy means only the top layer of skin affected by the cancer is removed. Although this is an option for treating extensive VIN3, this operation is rarely done.
- In a simple vulvectomy, the entire vulva is removed.
- A radical vulvectomy can be complete or partial. When part of the vulva, including the deep tissue, is removed, the operation is called a partial vulvectomy. In a complete radical vulvectomy, the entire vulva and deep tissues, including the clitoris, are removed.
- An operation to remove the lymph nodes near the vulva is called a groin dissection. It is important to remove these lymph nodes if they contain cancer.
If these procedures are used to remove a large area of skin from the vulva, skin grafts from other parts of the body may be needed to cover the wound. However, the surgical wounds resulting from these procedures can usually be closed without grafts and provide a very satisfactory appearance. If a graft is required, the gynecologic oncologist may perform the surgery and consult with a plastic/reconstructive surgeon.
Reconstructive surgery is available for women who have had more extensive surgery. A reconstructive surgeon will take a piece of skin and underlying fatty tissue and sew it into the area where the cancer was removed. Several sites in the body can be used, but it is complicated by the fact that the blood supply to the transplanted tissue needs to be kept intact. This is where a skillful surgeon is needed because the tissue must be moved without damaging the blood supply. If you are having this procedure, ask the surgeon to explain how this will be done in your case, because there is no set way of doing it.
Inguinal (groin) node dissection: Because vulvar cancer often spreads to lymph nodes in the groin, these must be removed. Usually only lymph nodes on the same side as the cancer are removed. If the cancer is in the middle, then both sides may have to be done. In the past, this was done with one large incision extending from the incision used to remove the vulva and the cancer. Now, health care providers favor making a separate incision about 1 cm below and parallel to the groin crease. The incision is made fairly deep, down through membranes that cover the major inguinal vein and artery. This will expose most of the lymph nodes, which are then removed. A major vein, the saphenous, may or may not be closed off by the surgeon. Some surgeons will try and save the saphenous vein in an effort to prevent leg swelling, which is often a problem with this surgery. After the surgery, a suction drain is placed into the incision for a few days, and the wound is closed.
Sentinel lymph node biopsy: This is a new and very promising procedure that can help some women avoid the side effects of inguinal node dissection. It can find the lymph nodes that drain lymph fluid from the area of the vulva where the cancer developed. These lymph nodes will then be checked for any spread of cancer, because if the cancer does spread, these lymph nodes will be the first place it will go. So far, this approach is still experimental and not regarded as standard treatment.
On the day before surgery, a small amount of radioactive material and/or blue dye is injected into the tumor site. The groin is scanned to identify the side (left or right) that picks up the radioactive material. This will be the side that will be operated on. During the surgery to remove the cancer, blue dye will be injected into the tumor site. This allows the surgeon to find the sentinel node by its blue color. Often both the radioactive detector is used with the blue dye. The suspicious lymph node is removed for microscopic examination (this examination takes a day or two). If cancer cells are found, the remaining lymph nodes in this area are surgically removed. If the sentinel node does not contain cancer cells, further lymph node surgery is not needed.
If a lymph node near a vulvar cancer is abnormally large, a sentinel lymph node biopsy is usually not done. Instead, a fine needle aspiration (FNA) biopsy or surgical biopsy of that lymph node is done.
Sexual impact of vulvectomy: After vulva surgery, women often feel discomfort if they wear tight slacks or jeans because the "padding" around the urethral opening and vaginal entrance is gone. The area around the vagina also looks very different.
Women often fear their partners will feel "turned off" by the scarring and loss of the outer genitals, especially if they enjoy oral stimulation of the woman as part of lovemaking. Some women may be able to have surgery to rebuild the outer and inner lips of the genitals.
Women who have had a vulvectomy may have problems reaching orgasm. The outer genitals, especially the clitoris, are important in a woman's sexual pleasure. For many women, the vagina is just not as sensitive an area. Women may also notice numbness in their genital area after radical vulvectomy. Feeling may return over the next few months.
In touching the area around the vagina, and especially the urethra, a light caress and the use of a lubricant can help prevent painful irritation. If scar tissue narrows the entrance to the vagina, penetration may be painful. Vaginal dilators can sometimes help stretch the opening. When scarring is severe, the surgeon can use skin grafts to widen the entrance.
When the lymph nodes in the groin have been removed, women often have swelling of their genital area or legs. This can result in pain and fatigue. It also can be a problem during sex. A couple needs to use good communication to cope with such problems.
Pelvic exenteration: Pelvic exenteration is an extensive operation that includes vulvectomy and removal of the pelvic lymph nodes, as well as removal of one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix, and vagina.
Complications and side effects of vulvar surgery: Removal of wide areas of vulvar skin may result in failure of the wound to heal, failure of the skin graft to take, or wound infections. The more tissue removed, the greater the risk of significant complications.
Removal of lymph nodes during a radical vulvectomy with radical lymphadectomy can result in poor fluid drainage from the legs, causing fluid retention, prominent swelling of the legs, and increased risk of infections. Support stockings or special compression devices often help this rare complication called lymphedema. Women with lymphedema should also take these precautions:
- Avoid infections of the affected leg or legs.
- Carefully protect the leg and foot from sharp objects and care for any cuts, scratches, or burns without delay.
- Avoid sunburn of the affected leg(s) and avoid cutting or tearing cuticles of the toenails.
- Report any redness, swelling, or other signs of infection to your health care provider without delay.
Other complications of vulvar and groin node surgery include formation of fluid-filled cysts near the surgical wounds, blood clots that may travel to the lungs, urinary infections, and reduction of sexual desire or pleasure.
RADIATION TREATMENT
Radiation therapy uses high-energy rays (such as gamma rays or x-rays) and particles (such as electrons, protons, or neutrons) to kill cancer cells. In treating vulvar cancers, radiation is delivered from outside the body in a procedure that is much like having a diagnostic x-ray. This is called external beam radiation therapy. It is sometimes used along with chemotherapy to treat more advanced cancers in the hope of shrinking them so they can be removed with surgery. Radiation alone may be used to treat the groin nodes and pelvic nodes.
The skin in the treated area may look and feel sunburned, but this gradually fades into a tanned look, returning to a normal appearance in 6 to 12 months. When radiation is given to the pelvis, premature menopause and problems with urination may also occur. If you have side effects from radiation, discuss them with your cancer care team. There are often methods to relieve these symptoms.
External radiation shrinks the primary tumor. Internal radiation (implants) affects cancer that has spread to adjoining tissues.
CHEMOTHERAPY
Chemotherapy uses anticancer drugs that are usually given intravenously (into a vein), by mouth, or applied to the skin in an ointment. Drugs taken by mouth or injected into a vein, called systemic chemotherapy, enter the bloodstream to reach throughout the body, making this treatment potentially useful for cancer that has spread beyond the vulva.
If this treatment is chosen, a combination of drugs may be given because combination chemotherapy is sometimes more effective than just one drug alone. Drugs most often used in treating vulvar cancer include cisplatin, mitomycin, and fluorouracil (5-FU). Vulvar cancers that have spread to other organs tend to be resistant to chemotherapy.
The role of chemotherapy in treating vulvar cancer remains to be determined. In more advanced disease, chemotherapy may be combined with radiation therapy. This combined treatment may make future surgery less extensive because it shrinks the tumor.
Drugs used in cancer chemotherapy specifically attack cells that are rapidly dividing. However, some normal tissues, such as the lining of the mouth and intestines, the hair follicles, and the bone marrow, also grow rapidly to replace cells that wear out. Therefore, side effects can include:
- Nausea and vomiting.
- Loss or increase of appetite.
- Temporary loss of hair.
- Mouth or vaginal sores.
- Increased chance of infections (due to low white blood cell count).
- Increased chance of bleeding and bruising (due to low blood platelet count).
- Tiredness (due to anemia, that is, low red blood cell count).
- Changes in the menstrual cycle, premature menopause, and infertility (inability to become pregnant). Note: Most women with vulvar cancer are post-menopausal.
Side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of time you are treated. Most of these side effects are temporary and stop when the treatment is over. Be sure to talk with your cancer care team about any side effects you are experiencing because there are remedies for many of them. For example, medications can be given to reduce or prevent nausea and vomiting.
Sometimes fluorouracil (5-FU) is applied as a cream directly to the skin. This is called topical chemotherapy and is rarely used for VIN but not recommended for invasive cancer of the vulva. Chemotherapy applied directly to the skin in ointment form will cause local irritation and peeling. This is normal and is part of the local destruction of cancer cells. Medicated ointments suggested by the health care team can help relieve the discomfort of this treatment. Topical chemotherapy for VIN is less effective than laser treatment or surgery.
Information obtained in part from the American Cancer Society (www.cancer.org).
Additional information available from:
The American Cancer Society
(800) ACS-2345
Web site: http://cancer.org
or
National Cancer Institute
(800) 4-CANCER
Web site: www.nci.nih.gov.
MEDICATION
Anticancer drugs are usually not prescribed for this disease.
Pain relievers as needed.
Antibiotics, if urinary tract infection results from use of a urinary catheter during radiation treatments.
Stool-softening laxative, if needed to prevent constipation.
ACTIVITY
After surgery, resume your normal activities gradually, allowing 6 weeks for full recovery. Most patients can maintain a fully active lifestyle while receiving radiation therapy. Discuss recovery details with your health care provider.
Sexual relations may be resumed where healing is complete in 8 to 10 weeks.
DIET
No special diet after treatment. However, it is important to eat a nutritious diet full of antioxidants, fresh fruit, vegetables, whole grains and low in red meats. You will need to not only heal from your cancer treatment or surgery, but also you will want to build your immune system. See link below for more dietary suggestions.
MoonDragon's Health Information: Cancer Nutrition & Holistic Recommendations
HERBS & SUPPLEMENTS FOR FEMALE CANCER IN THE REPRODUCTIVE SYSTEM
Coenzyme Q10: improves cellular oxygenation. CoQ10, NOW Foods, 400 mg, 60 Softgels
Colostrum promotes accelerated healing and boosts the immune system. Super Strength FarmFresh Colostrum Chewables, Natural Vanilla Flavor, 480 mg, 60 Chews
DMG (Dimethyl Glycine) enhances oxygen utilization. DMG Supplement, NOW Foods, 125 mg, 100 Caps
Inositol Hexaphosphate has powerful anticancer properties. Inositol (Vitamin B-8), 100% Natural Pure Crystalline, Nature's Way, 500 mg, 100 Caps
Melatonin is a powerful antioxidant. Melatonin, Pharmaceutical Grade, NOW Foods, 3 mg, 60 Caps, Sublingual Melatonin, Nature's Way, 2.5 mg, 100 Lozenges
MSM (Methylsulfonylmethane) is a powerful cancer prevention agent. MSM Supplement, 1000 mg, 120 Caps Pure Lignisul
Proteolytic Enzymes are powerful free radical scavengers. MetabolicZyme (Hypoallergenic), Allergy Research Group / Nutricology, 900 Tabs
Selenium protects against cancer. Selenium Supplement, Yeast Free, NOW Foods, 200 mcg, 100 Caps, Selenium Ionic Mineral Supplement, Fully Absorbable, 50 +/- ppm, 16 fl. oz., Ionic Selenium, 300 mcg, 2 fl. oz., Trace Minerals
Shark Cartilage can reverse the growth of some types of tumors. Shark Cartilage, NOW Foods, 750 mg, 100 Caps
Cayenne, Ginger, Rosemary, Sage and Thyme have anti-cancer properties. Tincture Supplement Form: Cayenne Pepper Tincture, 100% Organic, 2 fl. oz., Ginger Root Tincture, 100% Organic, 2 fl. oz., Rosemary Leaf (Rosmarinus officinalis) Tincture, 100% Organic, 2 fl. oz., Sage Tincture, 100% Organic, 2 fl. oz., Thyme Tincture, 100% Organic, 2 fl. oz.
Note: Bulk Herbs are available through Mountain Rose Herbs. See links below.
Alfalfa: Take in tablet, extract, or tincture form or drink as an herbal green tea. If using tablets or liquid extract, follow directions on label. Alfalfa is a good food source of vitamin K and needed minerals, including iron. Alfalfa supplements come in various forms and is an ingredient in many products. Powdered Alfalfa contains vitamins A, B-1, B-6, B-12, C, E, & K-1, niacin, pantothenic acid, biotin, folic acid and many essential and nonessential amino acids. The powdered form also contains high amounts of calcium, phosphorus, manganese, iron, zinc, and copper. The recommended dose is 500 to 1,000 mg of the dried leaf per day or 1-2ml of tincture. For tablets or capsules it is best to read and follow product label directions. Here are a couple of examples of some dosages:
- The recommended dose is 500 to 1,000 mg of the dried leaf per day or 1-2ml of tincture.
- Alfalfa for tea - 1 to 2 teaspoons per cup, steeped in boiling water for 10 to 20 minutes
- Fluid extract, 30 - 60ml / week
Alfa Max, Alfalfa Extract, Nature's Way, 525 mg, 100 Caps
Alfalfa, NOW Foods, 650 mg (10 grain), 500 Tabs
Alfalfa Tincture, 100% Organic, 2 fl. oz.
Alfalfa Leaf Root (Medicago sativa) Powder, Kosher, 4 oz. Bulk
Astragalus: Astragalus Root slows the spread of cancer; activates T and NK cells. It can be taken in capsule, tincture, or herbal form. Tincture Dosage: 1 to 1-1/2 teaspoons (4-6 ml) in 1/4 water 3 times daily. Do not use astragalus if you have a fever or a skin infection.
Astragalus Root, Nature's Way, 470 mg, 180 Vcaps
Astragalus Root Tincture, 100% Organic, 2 fl. oz.
Astragalus Root (Astragalus Membranaceus) Powder, 4 oz. Bulk
Cat's Claw: Raises T cell counts and enhances immune system. Cat's claw can be taken in tincture form. Take dose as recommended on the label in 1/2 cup water with 1 teaspoon lemon juice. Do not take Cat's claw if you have to take insulin for diabetes. Do not use if you are pregnant or nursing.
Cat's Claw Bark, Nature's Way, 485 mg, 100 Caps
Cat's Claw Tea Spice System Builder, Regular, 100% Organic, Loose Leaf, 8 oz. - Reduces inflammation in arthritis, protects the body from harmful substances, supports the body while undergoing cancer treatments, helps to boost the immune system.
Cat's Claw Tincture, 100% Organic, 2 fl. oz.
Cat's Claw Bark (Uncaria tomentosa) Powder, 4 oz. Bulk
Chamomile: German Chamomile (Matricaria recutita) contains chemicals that prevent cancer cells from anchoring to new sites. German chamomile tea can be prepared with 1 bag per 1 cup hot water. Take 1 cup, 2-3 times daily.
Chamomile Flowers; German Chamomile, Nature's Way, 350 mg, 100 Caps
Chamomile Tincture, 100 % Organic, 2 fl. oz
Chamomile Tea, Caffeine Free, NOW Foods, 30 Tea Bags
Chamomile Standardized Extract, Nature's Way, 345 mg, 60 Caps
Garlic: Garlic retards angiogenesis and metastasis and enhances the immune system. Use fresh garlic, garlic oil tincture, or enteric-coated tablets. Take at least 900 mg a day. Garlic counteracts the effects of Bifidus and lactobacillus cultures taken as digestive aids. Do not take these supplements at the same time. Precaution: Consult a health care provider before using garlic on a regular basis if you are on an anticoagulant drug, such as warfarin (Coumadin). Discuss the use of garlic with your health care provider before having any type of surgery.
Garlic Bulb Cloves, Garlic Supplement, Nature's Way, 580 mg, 100 Caps
Garlic Oil Tincture, Alcohol Free, Nature's Way, 1 fl. oz
Every Day Garlic Supplement, Kwai, 30 Tabs - Kwai Every Day contains all the constituents of naturally grown Chinese garlic cloves the most potent form of garlic in an enteric coated tablet to ensure odor control and tolerability. Each concentrated Kwai tablet is equivalent to 1350 mg of fresh high grade garlic yielding 2700 mcg of allicin, a primary active constituent of garlic.
Green Tea: Green Tea has anti-cancer properties. Green tea contains polyphenols, which block estrogen from tumors. Use as tea bag form, prepared with 1 cup of hot water. Take 1 cup 3 times daily, To avoid dilution, do not use within one hour of taking other medications.
Green Tea Extract, Standardized Green Tea Supplement, Nature's Way, 170 mg, 60 Vcaps
Green Tea, 100% Darjeeling Green Tea, NOW Foods, 30 Tea Bags
Green Tea, Premium Chinese, 100 Tea Bags
Coriolus Mushroom PSP Extract, 400 mg, 90 Vcaps - Rich in polysaccharides and other immune boosting compounds, the high potency extract contains both PSK and PSP, the most active components in Coriolus, and some of the first all natural extracts used in Traditional Chinese Medicine to be fully backed by modern clinical research. Clinical Research: The research suggests that the polysaccharide portion of the extract may enhance the cell-mediated immune response. Although the mechanism of action is not clearly understood, the 1-4, 1-3 proteoglycans act as a biological response modifier and have been found to support and enhance Natural Killer cell function, to stimulate depressed lymphocyte proliferation, and to support the healthy growth of white blood cells. Also, the research shows these constituents to be effective in supporting normal cell growth, improving cell-mediated cytotoxicity, and increasing interleukin-2 production and T-cell proliferation. Polysaccharide kureha (PSK) is shown to increase 3 and 5 year survival rates. Take 6,000 mg daily or follow direction on the label.
Soy Isoflavones with Digestive Enzymes, NON-GMO SoyLife, 500 mg, 100 Caps - Soy isoflavones provide gentle estrogen-like activity. This product contains special digestive enzymes to prevent discomforts often associated with consuming soy. Contains genistein, which inhibits growth of estrogen-dependent cancers. Tablets: Take about 3,000 mg once daily or follow label instructions.
Anti-Cancer Formula, 100% Organic, 16 fl. oz. - The Anti Cancer Formula builds the immune system and adds many anti-tumor constituents to help fight cancer. Suggested Dosage or Use: Start with 1 and 1/2 teaspoons in juice or water, 3 times daily. Dosage may be increased to 1 tablespoon plus 1 teaspoon 3 times a day. Shake well. Store in cool, dark place. Keep out of reach of children.
Mountain Rose Bulk Herbs
Mountain Rose Aromatherapy Oils
Mountain Rose Herbs, Aromatherapy Oils A-B
Mountain Rose Herbs, Aromatherapy Oils C-E
Mountain Rose Herbs, Aromatherapy Oils F-L
Mountain Rose Herbs, Aromatherapy Oils M-P
Mountain Rose Herbs, Aromatherapy Oils Q-Z
Mountain Rose Herbs, Aromatherapy Oils: Oil Blends & Resins
Mountain Rose Herbs, Aromatherapy Oils: Diffusers, Nebulizers, & Burners
Mountain Rose Herbs, Aromatherapy Oils: Oil Kits
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NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or a family member has symptoms of cancer of the vagina or vulva.
The following occur at the treatment site after surgery or other treatment:
- Signs of infection, such as increasing pain, fever and swelling.
- Excessive vaginal bleeding.
- Any unusual or unexpected symptoms. Medication taken may product side effects in some individuals.
