Vulvar Intraepithelial Neoplasia (VIN): Diagnosis and Treatment
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Apply the criteria for vulvar biopsy of a visible lesion 2. Identify risk factors for VIN
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
VIN is an increasingly common problem, particularly for women in their 40s, and should be considered a premalignant condition. A low threshold for consideration, biopsy and follow up should be maintained.
Detection is limited to visual assessment with biopsy confirmation when needed
Biopsy any visible lesion on the vulva that meets the following criteria
Diagnosis cannot be made on clinical grounds
Lesion not responding to usual therapy
Lesion with atypical vascular pattern
Lesion with rapid change in size/color/border
Presumed condyloma not responding to topical treatment
Perform colposcopy several minutes after the application of 3 to 5% acetic acid if lesions not clearly visualized or in women with persistent focal symptoms of pruritis/pain despite treatment for vulvo-vaginitis
Treatment is recommended for all with vulvar HSIL (see classification below)
Preferred treatment is wide local excision with gross margins of 0.5 to 1 cm
Laser ablation is acceptable if cancer is not suspected
Topical imiquimod 5% applied three times/week for 12 to 20 weeks with colposcopy every 4 to 6 weeks is effective though not FDA approved
Women with VIN are at risk of recurrent disease and vulvar cancer throughout their lives.
Surveillance is 6 and 12 months after treatment, then annual visual inspection of the vulva
In 2015 terminology for VIN was changed by the International Society for the Study of VulvoVaginal Disease (ISSVD) to unify nomenclature for HPV associated lesions of the cervix, vagina and vulva. In the new classification, low-grade squamous intraepithelial lesion of the vulva (vulvar LSIL) corresponds to ‘condyloma’, or ‘HPV effect’. High-grade squamous intraepithelial lesion of the vulva (vulvar HSIL) includes ‘usual type VIN’ (warty, basaloid type or mixed). Differentiated type VIN is unchanged from the 2004 classification. Of these three types, differentiated VIN is usually not HPV associated, being more often associated with a vulvar dermatologic condition such as lichen sclerosis, and with squamous cell carcinoma of the vulva.
Risk factors for VIN include HPV infection and cigarette smoking
Prevention should include vaccination in women under the age of 26, and smoking cessation
As differentiated VIN is associated with vulvar dermatoses, treatment of these disorders, especially lichen sclerosis, reduces the risk of cancer of the vulva
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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