Treatment for vaginal cancer

In EBRT, a machine precisely directs radiation beams from outside the body to the affected areas of the pelvis. You will lie on a treatment table under the radiation machine. Each treatment session takes around 10–15 minutes and is painless.

EBRT for vaginal cancer is usually given daily, Monday to Friday, over 4–6 weeks. The exact number of treatment sessions you have will depend on the type and size of the cancer, and whether it has spread to the lymph nodes.

Brachytherapy delivers radiation directly to the tumour from inside your body. It is usually given after you have finished having EBRT. Brachytherapy uses a small amount of radioactive material, called a source, to deliver the radiation. There are different ways to have brachytherapy, depending on the size of the cancer after EBRT.

After brachytherapy, you may feel uncomfortable in the vaginal region. Pain medicines can help if needed. You may have some vaginal discharge or bleeding for a few days. To reduce the risk of infection, use sanitary pads, not tampons.

• Wide local excision (partial vaginectomy): The surgeon cuts out the cancer and a margin. Only the affected part of the vagina is removed.
• Total vaginectomy: The whole vagina is removed.
• Radical vaginectomy: The whole vagina and surrounding tissue are removed.
• Hysterectomy: The uterus and cervix are removed. Your gynaecological oncologist will let you know if it is also necessary to remove your ovaries and fallopian tubes. If you are premenopausal, removing your ovaries will bring on menopause.
• Lymph node surgery: Lymph nodes in the pelvis or groin may be removed to check for the spread of cancer. This is called a lymphadenectomy (lymph node dissection).
• Reconstructive surgery: If the entire vagina is removed, in some cases a reconstructive (plastic) surgeon can make a new vagina using skin and muscle from other parts of your body. This is called vaginal reconstruction or formation of a neovagina.

Your recovery time will depend on the type of surgery you had and your general health. It is common to be in hospital for a few days to a week.

You will be given pain medicine to control any pain. Do not put anything into your vagina after surgery until your doctor says the area is healed (usually 6–8 weeks). This includes tampons and menstrual cups. You can expect some light vaginal bleeding, which should stop within 2 weeks.

You will be given advice about a range of issues before you go home. The following information is a general overview of what to expect.

• Wound care: Your doctors and nurse will give you instructions about how to look after the wound. If there is any redness, swelling, wound discharge or unusual smell, contact your doctor.
• Rest: You will need to take things easy and get plenty of rest in the first week. Avoid sitting for long periods of time if it is uncomfortable, or try sitting on a pillow or two rolled towels placed under the buttocks.
• Exercise: Check with your treatment team about when you can start doing your regular activities. You may not be able to lift anything heavy, but gentle exercise, such as walking, can help speed up recovery. Because of the risk of infection, avoid swimming until your doctor says you can.
• Emotions: If part of your genital area is removed, you may feel a sense of loss and grief. It may help to talk about how you are coping with someone you trust or seek professional support.
• Sex: Sexual activity needs to be avoided for about 6–8 weeks after surgery, or longer if reconstructive surgery was performed. Ask your doctor when you can restart sexual activity, and explore other ways you and your partner can be intimate. 
• Driving: You will need to avoid driving after the surgery until your wound has healed and you are no longer in pain. Discuss this issue with your doctor. Check with your car insurer for any restrictions about driving after surgery

Treatment can change the look and feel of the vulva and vagina. Radiation therapy may make skin in the treatment area dry, itchy and tender. Ask your treatment team about ways to manage these changes. Skin reactions will gradually improve after treatment finishes.

Pelvic radiation therapy can narrow the vagina, causing thinning of the walls and dryness. Surgery for vaginal cancer may also make the vagina shorter or narrower.

You may be offered vaginal dilators to help keep the vagina open and prevent it from closing over. Dilators may help make sex and follow-up pelvic examinations more comfortable. Your treatment team may also suggest using hormone creams or vaginal moisturisers to help with vaginal discomfort and dryness.

Incontinence is when urine leaks from your bladder without your control. Bladder control may change after surgery or radiation therapy to the vagina. You may find that you need to pass urine more often or feel that you need to go in a hurry, or you may leak a few drops of urine when you cough, sneeze, strain or lift. For ways to manage incontinence, talk to the hospital continence nurse or physiotherapist.

If the lymph nodes have been removed during surgery or scarred during radiation therapy, lymph fluid can build up in the tissues under the skin. This is called lymphoedema, and it can cause swelling in the legs, vulva or the area above the vulva covered with pubic hair (mons pubis). Lymphoedema may appear during treatment or months or years late. Not everyone who is at risk will develop it. It is important to seek help as soon as possible, because early diagnosis and treatment can lead to better outcomes. A lymphoedema practitioner can develop a treatment plan for you.

 If you have not yet been through menopause, radiation therapy for vaginal cancer or having your ovaries removed can cause early menopause. Your periods will stop, and you may have symptoms such as hot flushes, insomnia, dry or itchy skin, mood swings, or loss of interest in sex (low libido). Loss of the hormone oestrogen at menopause may also cause bones to weaken and break more easily (osteoporosis).

Menopausal hormone therapy (MHT), previously known as hormone replacement therapy (HRT), is medicine that replaces the hormones usually produced by the ovaries. It has been shown to treat menopausal symptoms and help prevent osteoporosis. There are also non-hormonal drugs that can help. Talk to your doctor about the risks and benefits of MHT, and other ways to deal with the symptoms of menopause.

After menopause, you will not be able to become pregnant. If this is a concern for you, talk to your doctor before starting radiation therapy.

See Understanding Fertility and Cancer for more information.

Whether sexual intercourse is still possible depends on how much tissue was removed from the vagina. Sometimes radiation therapy or surgery to the pelvic area can also affect nerves and tissue in this area, causing scarring, narrowing of the vagina, swelling and soreness. If scar tissue forms around the outside of the vagina, it can narrow the entrance to the vagina, making penetration during sex painful. Using extra lubrication may make sexual activity more comfortable. Choose a water-based or silicone-based gel without perfumes or colouring.

See Sexuality, Intimacy and Cancer for more information.

Changes to the look and feel of your vagina can cause embarrassment, loss of sexual pleasure, and less interest in sex. The experience of having cancer can also reduce your desire for sex. You may wish to have counselling to help understand the impact treatment has had on your sexuality. A sex therapist or psychologist can help you (and your partner if you have one) adjust to changes and find new ways to express intimacy and enjoy sex. Ask your doctor for a referral.