Pigmented Lesions of the Vulva – Yes you can get melanoma down there!

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The vulva refers to the external female genitalia, which includes the labia, the opening of the vagina, the clitoris, and the space between the vagina and anus. Because these areas are not sun exposed, it is not generally recognized by women that melanoma can develop in this location. Lesions such as moles and freckles, referred to as pigmented lesions, occur on the vulva of 10% to 12% of women.  It is not uncommon for women to have typical moles in the vulvar region, and as with other typical moles, most of these are benign and can cause no further problems. However, it is idmportant that women are aware that moles can exist on the vulva and some of these may have premalignant or malignant changes in them, just like other parts of the body. Women should be aware that the change in any mole such as a change in color or size should always be brought to the attention of their gynecologist and evaluated.

Other benign pigmented lesions include lentigines , also known as freckles; melanosis, the accumulation of pigment deposits;  post-inflammatory hyper pigmentation, a collection of pigment in reaction to trauma and other skin conditions; seborrheic keratoses; hemangiomas, and warts.

Benign nevus. (University of Utah)

Moles, or melanocytic nevi, are composed of nests of melanocytes, the cells that produce the pigment of the skin. Melanocytic nevi commonly form during early childhood and occur as a response to sun (ultraviolet) exposure. However, genetic factors are also in the development of some types of melanocytic nevi. Moles may transform into the potentially lethal form of skin cancer, melanoma. The true frequency of transformation of a melanocytic nevus into melanoma is not known, and the estimated prevalence varies widely. The main clinical concern is distinguishing between a benign nevus, a dysplastic nevus,and a melanoma.

Dysplastic nevus. (Webster's)

Dysplastic nevi contain atypical looking cells which do not meet the criteria for melanoma and may be a precursor of or marker of melanoma. These should usually always be completely excised.

Melanoma. (Wikimedia Commons)

Approximately 3% of all melanomas are located in the genital tract. Melanoma of the vulva accounts for 5-7% of invasive vulvar cancers and has an estimated annual incident rate of 1 per 1,000,000 women. The disease can affect women of all ages, but is more common in the older population, with almost half of the patients aged 70 years or older. More than 90% of melanomas occur in white women. Vulvar melanoma usually occurs on the labia minora or the clitoris and signs of vulvar melanoma can include a black or brown raised area or a change in the size, shape or color of a pre-existing mole Melanoma of the vulva has a poorer prognosis overall than melanoma on the torso, most likely due to the extent of the disease at the time of diagnosis.  If the disease has not invaded the deeper layers of the skin, the cure rate is close to 100% and is reported to be as high as 99% with invasion of 1.5 mm or less. The survival rate drops to 65-70% if the lesion invades 1.5-4 mm. Melanoma is usually treated with surgical excision and evaluation of the regional lymph nodes.

Improving mortality and survival —with this potentially lethal disease—depends on early recognition and experience counts.  Management of women includes careful inspection of the vulva with each full-skin or gynecologic examination, and biopsy of any suspicious lesion.

A skin biopsy is required when clinical diagnosis is inadequate or when malignancy is suspected. Physicians and medical professionals should have a low threshold for referring patients to individuals with special expertise in pigmented lesions of the vulva, such as gynecologist oncologists, melanoma surgeons and dermatologists, for evaluation and management of pigmented lesions of the vulva when the diagnosis or management is uncertain. The stakes are high and experience counts. Once a biopsy has been performed on a lesion and a histopathological diagnosis has been made, strong consideration should be given to the possibility of consultation with a board-certified dermatopathologist, a pathologist with  a special expertise with pathology of the skin.

A woman should note any change in appearance in her vulvar skin, pain or itching, to her physician. Women may also need to be persistent about getting a diagnosis as many women with vulvar cancer may see multiple physicians prior to getting a diagnosis. Regular gynecological examinations are necessary to detect precancerous conditions that can be treated before the cancer becomes invasive. Since some vulvar cancer is a type of skin cancer, the American Cancer Society also recommends self-examination of the vulva using a mirror. If moles are present in the genital area, use the ABCD rule:

• Asymmetry. A cancerous mole may have two halves of unequal size.
• Border irregularity. A cancerous mole may have ragged or notched edges.
• Color. A cancerous mole may have variations in color.
• Diameter. A cancerous mole may have a diameter wider than 6 millimeters (1/4 inch).

If you have any questions, ask your physician for an exam and biopsy if necessary and be aware of your vulvar skin. When you perform your general skin checks, do not forget the vulva, it could save your life.

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