Vaginal Adenosis - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Vaginal adenosis is an extremely rare condition that is defined as “the development of columnar epithelium in the vagina. It is the most common anomaly in young girls and female adults exposed to diethylstilbestrol (DES) in utero.” DES is a synthetic hormone (estrogen). Although DES has been banned throughout the world, it was widely used to prevent abortion during pregnancy. This drug was more common in European countries and the United States. Vaginal adenosis is associated with the occurrence of vaginal cancer. Vaginal adenosis is a benign disease and is mostly asymptomatic.

What Is the Incidence of Vaginal Adenosis?

Although the exact prevalence rate of this disease is not known, vaginal adenosis is estimated to affect between 34 percent and 91 percent of women exposed to DES and less than 4 percent of unexposed women. Adenosis has increased with earlier administration and higher doses of DES treatment.

Specifically, exposure prior to the 18th week of gestation was strongly associated with a higher incidence of adenosis. The incidence of adenosis is also associated with clear-cell adenocarcinoma incidence. The chance of getting vaginal adenosis is 30 percent higher in DES-exposed fetus than in non-DES-exposed women.

What Are the Causes of Vaginal Adenosis?

1. Diethylstilbestrol-induced Vaginal Adenosis:

DES was first synthesized at the University of Oxford by a team of scientists in 1938. It became the first artificial estrogenic substance to be administered. The United States Food and Drug Administration (FDA) has approved the use of DES to treat only gonorrhoeal vaginitis, atrophic vaginitis, menopausal symptoms, and postpartum lactation suppression. But from the 1940s to the 1960s, DES was widely given to pregnant ladies to prevent complications during pregnancy. After a decade, vaginal clear cell adenocarcinoma was confirmed in the fetus whose mothers took DES during pregnancy. An estimated number of five million pregnant women were prescribed DES from 1940 to 1960.

Further studies proved that exposure to DES during pregnancy causes abnormalities in the female reproductive tract. In that, cervical and vaginal adenosis were the most common. And these two are considered to be the precursors of vaginal cancer (clear cell adenocarcinoma- CCA). A statistically significant association between DES exposure and vaginal clear cell carcinoma was discovered. A lot of studies came in the following years confirming the association.

2. Non-Diethylstilbestrol- Induced Vaginal Adenosis:

Only 10 percent of women are reported with non-diethylstilbestrol-induced vaginal adenosis. But the reasons are unknown. However, some of the causes that are believed to be the cause of non-DES-induced vaginal adenosis are:

• Sulfonamide-Induced Stevens-Johnson Syndrome - It is an allergic reaction to Sulfonamide drugs causing severe skin and mucous membrane irritation.

• Carbon Dioxide Laser Treatment - It is a technique used for both aesthetic and medical purposes.

• 5- Fluorouracil Therapy - It is a drug used to treat certain types of cancers like digestive tract and cervical cancer.

• Tamoxifen Uterine Exposure - Tamoxifen is a drug used to treat a certain type of breast cancer, so exposure to this drug while pregnant, the child may get vaginal adenosis.

What Are the Symptoms of Vaginal Adenosis?

Vaginal adenosis is mainly asymptomatic. Normally, it is discovered during a routine examination for some other problem. The presence of a lesion may be seen in some patients. The lesion can be single or multiple. The locations where the lesions may be found include the lower vagina, the upper part of the vagina, both the upper and lower parts of the vagina, the middle wall of the vagina, and the posterior wall of the vagina. Other symptoms may be:

• Vaginal pain.

• Profuse mucoid vaginal discharge.

• Pruritus (itching)

• Palpable cysts.

• Ulcers.

• Patchy or diffuse stippling.

• Bleeding.

• Uterine prolapse.

• Imperforate hymen.

• Post-coital bleeding.

How Is Vaginal Adenosis Diagnosed?

• Vaginal adenosis is usually diagnosed in a pelvic examination. A round red-colored mass can commonly be seen on the upper wall of the vagina.

• A vaginal biopsy is sometimes done to confirm vaginal adenosis. A small tissue is removed from the lesion and examined under a microscope.

• Papanicolaou smear and colposcopy to rule out cancer. A colposcopic examination is the most accurate method where other diagnostic methods are not apparent.

• Magnetic resonance imaging (MRI) for assessing the extent of the lesion.

What Are the Treatments?

Medications like Metronidazole and Tetracycline are the conventional treatments in early cases.

Surgical treatment is the main mode of treatment in advanced cases. Different types of surgical treatment are the following:

• Local Vaginal Resection - The lesion and a rim of normal tissue are removed in local vaginal resection.

• Hysterectomy - It is the removal of the uterus and cervix along with fallopian tubes and ovaries.

• Salpingo-oophorectomy - Removal of one or both of the ovaries and fallopian tubes.

• Vaginoplasty - It is the reconstruction or repair of the vagina.

• Unipolar Cauterization - It is the method of burning (cauterizing) the affected area.

What Are the Complications?

Vaginal adenosis has a potential for malignant transformation. There is a chance for local recurrence in some patients who have undergone local vaginal resection. There is a proven association between in-utero DES exposure and increased risk of vaginal and cervical cancer. And these carcinomas develop from vaginal or cervical adenosis. Although there is an association between vaginal adenosis and vaginal carcinoma, it is highly rare for malignant changes to take place. Some patients have reported cancer changes years after treatment for vaginal adenosis. Some of the different types of cancers reported are:

1. Mucinous Carcinoma - A rare type of cancer that develops in the mucous cells of the vagina.

2. Squamous Cell Carcinoma - It is a common cancer that develops in the squamous epithelium of the vagina.

3. Clear Cell Carcinoma - A rare type of cancer affecting the clear cells of the vagina.

4. Adenocarcinoma - It is a type of cancer affecting the glands inside organs.

Conclusion

Vaginal adenosis is a rare pre-cancerous lesion mainly induced by Diethylstilbestrol. As DES is now withdrawn from the market, the incidence of vaginal adenosis has decreased. Even after the treatment is completed, regular follow-up is necessary to rule out any cancerous development. With early diagnosis, timely treatment, and regular follow-ups, the patient can lead a worry-free and healthy life.