Treatment of these preinvasive lesions is individualized and depends on the extent, location and general medical condition of the patient. Recommended treatment may be local surgical excision, laser therapy under colposcopic control, topical 5-FU, particularly in cases where discrete multifocal lesions are noted, and on occasion partial or total vaginectomy with split thickness skin grafting. On occasion, high vaginal vault lesions and selected other vaginal disease may be suitable for radiotherapy.
Carcinoma at the introitus and lower half of the vagina may be amenable to radical vulvectomy and vaginectomy. Patients with lesions inoperable either because of extent or general medical condition may be treated by radiotherapy.
The treatment principles for tumours in the upper half of the vagina are similar to those for cervical cancer: a combination of intracavitary and external beam pelvic irradiation.
Vaginal sarcomas are treated by surgery when possible. Radiation and chemotherapy may be utilized on an individual basis.
No data exist to show a contraindication for hormone replacement in cervical or vaginal cancer. Many of these patients are young and at high risk for estrogen deprivation related morbidity. It is the feeling of the group that these patients should be encouraged to take estrogen replacement. In the presence of a uterus we recommend continuous estrogen and progestogen with the estrogen at a moderate dose (0.625-1.25 mg Premarin) and the progestogen at a low dose (2.5 mg Provera). Histologic studies have shown that continuous therapy with combined estrogen and progestogen induces an atrophic bland endometrium. This regime may result in some initial bleeding for the first one to two months but in general the women are amenorrheic.
An alternative regime would be to use cyclical estrogen and progestogen. This has the disadvantage of inducing a withdrawal bleed in some patients who have not had total ablation of the endometrium. Hematometra may develop if there is cervical stenosis present leading to abdominal pain or a mass.
Recommendation: Continuous estrogen and progestogen, e.g.:
Provera 2.5 mg
(note: these small doses of Provera do not seem to have the same deleterious effects on serum lipids as the higher doses.)
In the absence of a uterus there is no theoretical need for progestogen, therefore estrogen alone in usual doses is recommended