If a woman experiences unexplained vaginal bleeding—particularly after having sex—she should see her doctor for an evaluation. That’s because, although it can be attributed to a host of other causes, painless bleeding after sex is a common sign of vaginal cancer.  

Vaginal cancer is very rare, even among cancers of the female genital tract, which are themselves uncommon. About 1,200 cases are diagnosed each year. Vaginal cancer most commonly affects postmenopausal women aged 50 and older. It’s more common among Black and Latinx women than white women.  

The majority of cases of cancer of the vagina are metastic disease, meaning that the cancer started elsewhere in the body and spread to the vagina. Most metastatic vaginal cancers have spread from either the cervix or vulva because they are all HPV-related.  

Sometimes with vaginal cancer there are no symptoms at all. A gynecologist may discover cancer during a pelvic exam, or abnormal Pap test results may identify the cancer.  

About 77% of people with stage I vaginal cancer survive 5 years or longer when the condition is found and treated early.  

“Like other cancers of the lower genital tract [cervix, vagina, vulva, anus], they are related to exposure to the human papillomavirus (HPV),” says Yale Medicine gynecologist Mitchell Clark, MD. “There is a safe and effective vaccine that is recommended for boys and girls as early as 9 years old but up to 45 years of age in order to help prevent the negative side effects of HPV infection, which can prevent a cancer from occurring.”

Vaginal cancer describes cancers that originate in the vagina. Only 1 or 2% of cancers of the female genital tract are considered vaginal cancer, because of the way cancers are classified: If a vaginal tumor extends to the cervix, it’s considered cervical cancer. If it extends to the vulva, it’s considered vulvar cancer, even if the tumor’s center lies in the vaginal region.  

Several types of cancer may occur in the vagina:

• About 80 to 90% of vaginal cancers are squamous cell carcinomas, which begin in the cells that line the inside of the vagina
• Fewer than 15% are adenocarcinomas, which begin in the glands that make the fluid that lubricates the vagina
• 3% are sarcomas, which typically form in the muscle deep within the vaginal wall
• Fewer than 3% are melanoma, a fast-growing, aggressive form of skin cancer

Doctors aren’t sure what causes all types of vaginal cancer, but human papillomavirus (HPV) has been linked to the most prevalent type, vaginal squamous cell carcinoma.  

HPV is the most commonly diagnosed sexually transmitted infection. Most people who are sexually active have been exposed to HPV at some point in their lives, but it doesn’t always lead to cancer. In many cases, it is harmless, causes no symptoms, and disappears on its own. 

Only certain HPV subtypes may increase a person’s risk of health problems, including genital warts or certain cancers. HPV subtypes HPV-16 and HPV-18 have been associated with vaginal cancer.  

The presence of a harmful HPV subtype in the body may lead to inflammation, which may encourage the growth of abnormal cells. Cells may develop into vaginal intraepithelial neoplasia, which sometimes precedes vaginal cancer—or cells may become cancerous.

Some women don’t experience vaginal cancer symptoms. Those who do may notice the following symptoms:

• Painless bleeding or vaginal discharge after sex
• Postmenopausal bleeding or vaginal discharge
• Pelvic pain
• Urinary frequency
• Pain or burning with urination
• Constipation
• Feeling the urge to make a bowel movement, even after going
• A noticeable vaginal mass

Some people are at increased risk of vaginal cancer, including women who have, or have had:

• HPV
• Abnormal Pap test results
• Genital warts
• Hysterectomy
• Past vaginal trauma
• Herpes simplex virus
• Trichomoniasis
• In-utero exposure to diethylstilbestrol (DES), a drug that was used to reduce the risk of miscarriage decades ago
• Vaginal intraepithelial neoplasia
• Cervical, vulvar, and/or endometrial cancers
• Radiation or chemotherapy treatments

Whether doctors suspect vaginal cancer because of symptoms or abnormal Pap test results, they try to find out as much information by taking a medical history and doing a physical exam.  

A doctor should ask questions about pelvic health history, to see if the patient has had abnormal Pap test results or sexually transmitted infections. The doctor may ask about a person’s sexual history, including the age when they became sexually active and their total number of sexual partners. They will also want to know whether the person has had cancer of the female genital tract.  

During the physical exam, a doctor will visually inspect the vagina while using a speculum. The doctor will also examine the pelvic region by hand, placing two fingers within the vagina and the other hand on the abdomen to feel whether there are any abnormalities. 

Sometimes, if a vaginal tumor is detected toward the anus, the doctor may place one finger in the vagina and one in the anus to assess the tumor’s size and location. Occasionally, a doctor may use vaginoscopy to examine the inside of the vagina—a thin tube with a camera on the end is inserted into the vagina, and images are transmitted to a screen for the doctor to view.  

If a doctor sees a suspicious area, or if an abnormal Pap test warrants it, the doctor will perform a biopsy to determine whether cancer is present. If doctors can’t determine the location of a potential tumor or lesion, they can swab the vagina with an iodine or vinegar wash, which makes abnormal cells appear white. They then use a colposcope—a magnifying tool with a built-in light source—to spot atypical areas.  

Once vaginal cancer is diagnosed, a doctor may order an imaging exam—a CT scan, MRI, or PET scan—to see how large the tumor is, what stage the cancer is, and whether it has spread to other body parts.

If vaginal cancer is diagnosed early, when the tumor is small and hasn’t spread, doctors may be able to perform surgery to remove the cancer. This is only recommended when doctors can remove the tumor and a margin of healthy surrounding tissue plus lymph nodes without damaging the function of the bladder or rectum. Sometimes, a hysterectomy is also performed.  

Vaginal cancer often isn’t caught early, so surgery isn’t an option for many people; they instead receive radiation therapy.  

Certain people with vaginal cancer receive chemotherapy along with radiation therapy, but this treatment recommendation isn’t universal.  

In rare cases, if a person is ineligible for radiation therapy (due to prior radiation therapy) or if vaginal cancer recurs, they may need a radical surgical procedure called pelvic exenteration. During surgery, doctors remove the vagina and may also remove the cervix, uterus, bladder, anus, rectum and/or parts of the colon. 

What is removed depends on how far the cancer has spread. If the bladder is removed, an individual receives a permanent urostomy. When the rectum and anus are removed, they need a permanent colostomy.  

If the vagina is surgically removed, doctors may perform vaginal reconstruction, sometimes using tissue from elsewhere in the body. This allows a woman to remain sexually active.

When vaginal cancer is caught and treated before it spreads beyond the vagina, 75% of people survive for 5 years or longer. When the cancer spreads to the lymph nodes, the 5-year survival rate is 40%. And when the cancer spreads to distant body parts, only 21% of people live 5 years or longer.

“Like many gynecologic cancers, outcomes are best when care is managed by experts in high-volume centers with experience in advanced surgical techniques and targeted, individualized treatments,” says Dr. Clark. “Not only are Yale surgeons highly specialized and experienced in the surgical treatment of vaginal cancer, patients also have access to cutting-edge clinical trials and personalized tumor analysis in order to select the best treatment for each individual. Researchers at Yale are actively investigating the role of HPV in cancers of the lower genital tract with the goal of early detection and prevention before a cancer even develops.”