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Clinical characteristics and risk factors to high-grade vaginal intraepithelial neoplasia: a single-institution study

BMC Women's Health volume 25, Article number: 44 (2025) Cite this article

Abstract

Background

To date, few studies have investigated the factors associated with high-grade vaginal intraepithelial neoplasia (VaIN). This study aimed to analyze the characteristics of high‐grade VaIN and identify its underlying risk factors.

Methods

This cross-sectional study included women with histologically confirmed high-grade VaIN and high‐grade cervical intraepithelial neoplasia (CIN), conducted between 2017 and 2021 at a single center. Baseline clinical characteristics, human papillomavirus (HPV) infection status, cytology results, and pathology findings were analyzed using standard statistical methods.

Results

Among 1819 patients, 8.47% (154/1819) were diagnosed with high-grade VaIN (mean age: 42.1 ± 12.4 years), while 91.53% (1665/1819) had high‐grade CIN (mean age: 36.7 ± 10.0 years). Older age, longer sexual life duration, higher gravidity and parity, menopause, and prior cervical treatment were identified as risk factors for high‐grade VaIN (p < 0.001). High‐grade VaIN was more likely to present with low-grade squamous intraepithelial lesion (LSIL) cytology among abnormal cytological results (p = 0.007). HPV was detected in 98.1% of VaIN2/3 cases (151/154), with HPV 16 being the most prevalent genotype, accounting for 39.89% (705/1767) of all infections, 36.4% of high‐grade VaIN, and 39% of high‐grade CIN cases. Single-genotype HPV infections were observed in 58.4% of high‐grade VaIN and 64.3% of high‐grade CIN, while multiple infections were found in 39.6% and 32.8%, respectively. The sensitivities of cytology for detecting high‐grade VaIN and high‐grade CIN were 62.3% and 69.5%, respectively (p = 0.067). HPV testing sensitivities were 98.4% and 97.1%, respectively (p = 0.578). Combined cytology and HPV testing improved sensitivities to 100% and 99.8%, respectively.

Conclusions

High-grade VaIN is significantly associated with older age. The sensitivity of cytology and HPV testing for detecting high‐grade VaIN is comparable to that for high‐grade CIN. Thus, these tests may facilitate early detection of high‐grade VaIN.

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Introduction

Vaginal intraepithelial neoplasia (VaIN) is a precancerous condition of the vagina [1], with an incidence estimated at 0.2–2 per 100,000 woman-years [2,3,4]. It accounts for only 0.4% of premalignant lesions in the female lower genital tract [5, 6], but it can progress to vaginal carcinoma, a rare malignancy that represents approximately 2% of all gynecological cancers [7, 8]. VaIN has often been overlooked clinically due to its asymptomatic nature and reliance on singular diagnostic methods such as colposcopy-guided biopsy of suspicious areas [9]. However, with advancements in cytology, HPV screening, and colposcopy techniques, the incidence of VaIN has increased steadily in recent years [10].

According to the American Society for Colposcopy and Cervical Pathology and the College of American Pathologists, cervical intraepithelial neoplasia (CIN) is classified into low-grade CIN and high-grade CIN. Similarly, VaIN is categorized into low-grade VaIN and high-grade VaIN [11, 12]. Low-grade lesions consist of mature and differentiable squamous cells and have a low risk of progression to invasive cancer. In contrast, high-grade lesions feature the proliferation of immature squamous epithelial cells after HPV infection, which, if untreated, are more likely to recur or progress to invasive cancer. High-grade VaIN has a variable clinical course, and its natural progression to carcinoma remains incompletely characterized. Reports indicate that high-grade VaIN (VaIN II–III) progresses to invasive vaginal cancer in 2–12% of cases [13, 7].

Few studies have focused on factors related to high-grade VaIN. While more studies have examined related factors such as cytology and HPV genotypes in VaIN or CIN complicated by VaIN, data comparing cytology and HPV genotype results between high-grade VaIN and high-grade CIN are limited due to the rarity of VaIN. Thus, this study aimed to analyze the baseline clinical characteristics, HPV infection status, cytology results, and pathology findings in patients with high-grade VaIN. The objective was to identify the features and risk factors of high-grade VaIN.

Methods

This study included patients with biopsy-confirmed high-grade VaIN and high-grade CIN at Guangdong Women and Children Hospital, PR, between 2017 and 2021. All participants consented to the study, which was approved by the Ethics Committee of Guangdong Women and Children Hospital (202201291). Each patient underwent cervical or vaginal wall biopsy via colposcopy.

Exclusion criteria: histologically negative cases (absence of lesions or benign cellular changes such as inflammation, reactive changes, and squamous metaplasia); histologically confirmed vaginal or cervical cancer; cases with only CIN1 or VaIN1; concurrent CIN1 and VaIN1; concurrent high-grade CIN and high-grade VaIN without ThinPrep cytologic test (TCT) or HPV reports. A flow chart of the inclusion and exclusion criteria is shown in Fig. 1. Data, including demographics, medical history, HPV genotype, and cytology results, were retrieved from medical records. If a patient exhibited varying grades of VaIN or CIN in the same biopsy, the highest grade of VaIN was recorded as the final pathologic diagnosis.

Fig. 1
figure 1

Flow diagram of the screening and enrollment of study participants

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Clinical characteristics

Clinical data were collected on age, age at first sexual intercourse, duration of sexual activity, number of sexual partners, menopausal status, contraceptive use, gravidity, parity, clinical symptoms, family history of cancer, prior cervical treatment, previous CIN treatment, HPV genotype, and cytology results. The cytology and HPV genotype referred to the most recent results before the initial pathological diagnosis of CIN or VaIN. Cytology and HPV specimens were collected using cervical swabs for patients with an intact uterus and vaginal swabs for those who had undergone a hysterectomy.

Cytological, colposcopy and biopsy

Cytology results were reported based on the Bethesda System 2014. Cervical cytology diagnoses followed the Bethesda System (TBS) [14]. Cytology tests were performed using the ThinPrep Pap test (Hologic, Bedford, MA). For sensitivity analysis, the cut-off for cytology was atypical squamous cells of undetermined significance (ASC-US). Cytology results were categorized as negative for intraepithelial lesion or malignancy (NILM), low-grade squamous intraepithelial lesion (LSIL), ASC-US, atypical squamous cells-cannot exclude HSIL (ASC-H), high-grade squamous intraepithelial lesion (HSIL), atypical glandular cells (AGC), adenocarcinoma in situ (AIS), or squamous cell carcinoma (SCC). Colposcopy was conducted using a Leisegang electronic colposcope (3ML LED, Germany) after cervical preparation with 5% acetic acid and Lugol's solution. Findings were documented following the criteria of the International Federation for Cervical Pathology and Colposcopy [15]. For suspicious lesions, colposcopy-guided biopsy or cervical curettage was performed. Histological slides were independently reviewed by two experienced pathologists, and a final diagnosis was determined through consensus. Histological analysis was considered the gold standard for diagnosing VaIN and CIN. In this study, the most recent pathological examination results were used when multiple records were available.

HPV testing

HPV testing was conducted using polymerase chain reaction (PCR) and flow-through hybridization. The HPV DNA test was performed with the Kaipu HPV genotyping kit (Kaipu Biotechnology Co., Ltd., Guangzhou, China), which uses DNA amplification with HPV L1 consensus PCR primers and the flow-through hybridization technique. HPV genotypes were categorized as 15 high-risk types (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, and 68), five low-risk types (HPV 6, 11, 42, 43, and 44), and other types (HPV 53, 73, 82, and CP8304).

Statistical analysis

Participant characteristics were summarized as mean ± standard deviation (SD) or median (interquartile range [IQR]) for continuous variables and percentage frequencies (95% confidence intervals [CIs]) for categorical variables. Continuous data were analyzed using t-tests, while categorical data were compared using the χ² test. Due to the low percentage of missing data, no imputation methods were applied. Logistic regression analysis was used to estimate odds ratios (ORs) and corresponding 95% CIs for the association between HPV and high-grade CIN or high‐grade VaIN. All statistical analyses were conducted using R (http://www.R-project.org, The R Foundation) and Free Statistics software, version 1.7. A two-sided p-value < 0.05 was considered statistically significant.

Results

Characteristics of the participants

A total of 1819 patients met the study criteria. Table 1 summarizes the patient demographics. The mean age at diagnosis was 37.2 years, with a range of 15 to 76 years. Among the participants, 1665 (91.5%) were histologically diagnosed with high-grade CIN, and 154 (8.4%) with high‐grade VaIN. The mean age of the high‐grade CIN group was 36.7 years (SD 10), while that of the high‐grade VaIN group was 42.1 years (SD 12.4) (p < 0.001). Patients with high‐grade VaIN were older, more likely to be menopausal, and had higher gravidity, parity, longer sexual life, and a history of cervical or CIN treatment (p < 0.001). The cytology distribution for high‐grade CIN and high‐grade VaIN is shown in Fig. 2. Among participants with LSIL cytology, 370 (22.2%) were histologically diagnosed with high‐grade CIN, and 49 (31.8%) with high‐grade VaIN (p = 0.007). As shown in Table 1, the HPV-positive rate was 97.1% (1761/1819). The HPV-positive rates for high‐grade CIN and high‐grade VaIN were 97.1% (1616/1665) and 98.1% (151/154), respectively (p = 0.619). Single HPV genotype infections were detected in 58.4% of high‐grade VaIN and 64.3% of high‐grade CIN, while multiple infections were observed in 39.6% of high‐grade VaIN and 32.8% of high‐grade CIN. No significant differences were found between groups for single (p = 0.046) or multiple infections (p = 0.086).

Table 1 Baseline characteristics of the study participants
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Fig. 2
figure 2

Data are expressed as number of events (percentage).Distribution of cytology in histological high‐grade CIN and high‐grade VaIN patients.ASCUS,atypical squamous cells undetermined significance; AGC,atypical glandular cell; LSIL, low‐grade squamous intraepithelial lesion;ASC-H, atypical squamous cells cannot exclude high‐grade squamous intraepithelial lesion;HSIL, High-grade squamous intraepithelial lesion;SCC, squamous cell carcinoma;CIN, cervical intraepithelial neoplasia; VAIN, vaginal intraepithelial neoplasia

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Table 2 shows the distribution of HPV genotypes for single and multiple infections. The most common genotypes were HPV 16, 52, 58, 18, 33, and 51. HPV 16 was the most prevalent genotype, accounting for 39.8% (705/1767) of all infections, including 36.4% of high-grade VaIN and 39% of high‐grade CIN cases. Among single infections, HPV 16 was detected in 24.1% of high‐grade VaIN and 22.1% of high‐grade CIN cases, while among multiple infections, it was detected in 14.8% and 14.3% of cases, respectively. Significant differences in the prevalence of HPV 52, HPV 59, and multiple infections with HPV CP8304 were observed between the high‐grade CIN and high‐grade VaIN groups (p < 0.05).

Table 2 HPV genotypes in high-grade CIN and high‐grade VaIN (n = 1819)
Full size table

The sensitivities of cytology, HPV testing, and combined testing are summarized in Table 3. The sensitivity of cytology for high-grade CIN was 69.5% and for high‐grade VaIN was 62.3% (p = 0.067). No significant difference was observed between the sensitivity of HPV testing for high‐grade CIN (97.1%) and high‐grade VaIN (98.4%) (p = 0.578). The sensitivity of combined cytology and HPV testing was 99.8% for high‐grade CIN and 100% for high‐grade VaIN (p = 1).

Table 3 sensitivity of cytology/HPV test in high-grade CIN and high‐grade VaIN patients (n = 1819)
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Univariate regression analyses

The risk of specific HPV genotypes for high-grade CIN and high‐grade VaIN outcomes is shown in Fig. 3. HPV 51 (OR 1.87, 95% CI 1.05–3.31), HPV 56 (OR 2.18, 95% CI 1.15–4.15), HPV 59 (OR 2.69, 95% CI 1.16–6.24), HPV 44 (OR 2.46, 95% CI 1.00–6.05), and HPV CP8304 (OR 3.72, 95% CI 1.90–7.29) were significantly associated with high‐grade VaIN.

Fig. 3
figure 3

Data are expressed as number of events (percentage). The ORs of hpv genotype in high-grade CIN and high-grade VaIN patients. OR, odds ratio. HPV, human papillomavirus;CIN, cervical intraepithelial neoplasia; VAIN, vaginal intraepithelial neoplasia

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Discussion

With the widespread adoption of cervical cancer screening and HPV vaccination, the incidence of CIN and cervical cancer has steadily declined, whereas that of VaIN has increased annually [6]. VaIN is often asymptomatic and underdiagnosed, leaving its prevalence and progression poorly understood. Despite its low prevalence, VaIN II to III carries a risk of progression to invasive vaginal wall cancer. Few studies have investigated factors associated with high-grade VaIN. This study aimed to analyze the features of high-grade VaIN and identify its risk factors. In this cross-sectional study, we examined factors such as age, duration of sexual activity, age at first intercourse, number of sexual partners, gravidity, parity, menopausal status, contraceptive use, clinical symptoms, prior cervical treatment, HPV infection status, and cytology results using data from medical records to identify risk factors and support early detection and intervention.

Age is a critical risk factor for high-grade VaIN. The age distribution of participants is shown in Table 1. The mean age in the high-grade VaIN group was 42.1 ± 12.4 years, significantly older than that in the high-grade CIN group (p < 0.001), consistent with previous studies. Yanqing Ye et al. found that the median age of patients with VaIN + CIN and solitary VaIN (s-VaIN) was higher than that of those with solitary CIN (s-CIN) (p < 0.001) [16]. Similarly, Shitai Zhang et al. reported that VAIN2/3 cases had a mean age of 49.7 years, compared to 36.6 years for CIN2/3 cases (Mann-Whitney U test, p < 0.001) [17]. VaIN is known to progress more slowly than CIN, making detection more challenging. Menopausal and perimenopausal women are at a higher risk of high-grade VaIN, aligning with the findings of Li et al. [18]. Reduced estrogen levels in postmenopausal women allow HPV to penetrate the thin vaginal epithelium more easily. In our study, the high-grade VaIN group had higher gravidity and parity than the high-grade CIN group. Previous studies also showed that women with s-VaIN had higher gravidity and parity compared to those with s-CIN [16]. This may be due to mucosal and epithelial barrier damage caused by multiple pregnancies, increasing the risk of persistent HPV infection and subsequent lesion development [19, 20].

A history of cervical treatment is another significant risk factor for high-grade VaIN. Studies have indicated that uterine cancer, cervical cancer, and CIN are independent risk factors for VaIN. Since the vaginal and cervical epithelia share the same embryological origin and environment, CIN is likely the most significant risk factor for VaIN [14, 21]. These findings highlight the importance of thoroughly examining vaginal lesions during colposcopy for cervical lesions, particularly in women with higher gravidity, parity, or a history of cervical treatment, as well as those in the perimenopausal or menopausal phase.

The association between cervical cytology and cervical lesions is well-established. Jiahui Wei et al. recommended vaginal cytology screening for patients who have undergone hysterectomy for cervical cancer or CIN [20]. Hongmin Zeng et al. reported that ASC-US and LSIL cytology were more prevalent than other abnormal cytological types [21, 22]. Camille C. et al. observed a high incidence of dysplasia in women with abnormal vaginal cytology, with LSIL cytology frequently linked to VaIN [23]. In our study, 370 participants (22.2%) with LSIL cytology were histologically diagnosed with high-grade CIN, while 49 (31.8%) were diagnosed with high‐grade VaIN (p = 0.007). Special attention should be given to patients with HPV 51, 56, or 59 infections and LSIL cytological abnormalities.

The overall prevalence of HPV genotypes in the study was 97.1%. The HPV-positive rates for high-grade CIN and high‐grade VaIN were 97.1% and 98.1%, respectively (p = 0.619). This finding aligns with other studies. Yanqing Ye et al. reported an HPV positivity rate of 92.5% in VaIN2 and 96.8% in VaIN3 [24], while Alemany L et al. documented 96% HPV DNA positivity in VaIN2/3 [25]. In our study, HPV 16 was the most common genotype, accounting for 36.4% of high‐grade VaIN and 39% of high‐grade CIN cases, followed by HPV 52, 58, 18, 33, and 51. However, HPV 18 was less frequent in the high‐grade VaIN group. The most common genotypes in high‐grade VaIN were HPV 16, 58, 52, and 51, whereas in high‐grade CIN, the top genotypes were HPV 16, 52, 58, and 18. These findings are consistent with other reports from China [16, 24, 26]. In contrast, studies from Japan identified HPV 16, 52, 53, and 31 as the most prevalent genotypes, while those from the United States and Europe reported HPV 16, 18, 31, and 33 as the leading types [17, 25, 27]. These results suggest geographic variability in HPV genotype distribution for VaIN, similar to CIN. This variability may be due to factors such as the small number of cases in each study, differences in HPV DNA detection methods, sample types, PCR primer selection, and behavioral and social characteristics of the populations studied. Our analysis showed that patients with HPV 51, 56, 59, 44, or CP8304 had a higher risk of high‐grade VaIN compared to those with high‐grade CIN. Notably, single HPV 52, single HPV 59, and multiple HPV CP8304 infections were significantly more frequent in the high‐grade VaIN group than in the high‐grade CIN group (p < 0.05). For patients infected with these specific HPV types, thorough examination of the vaginal wall during colposcopy is crucial. Given the limited sample size in our study, these findings should be interpreted cautiously, and further well-designed prospective studies are needed to validate these results.

The sensitivities of cytology for high-grade CIN and high‐grade VaIN were 69.5% and 62.3%, respectively (p = 0.067). HPV testing sensitivities for high‐grade CIN and high‐grade VaIN were 97.1% and 98.4%, respectively (p = 0.578). The sensitivities of combined cytology and HPV testing for high‐grade CIN and high‐grade VaIN were 99.8% and 100%, respectively (p = 1). Previous studies have shown that cytology has a sensitivity of 67.5–76.2% and is more reliable than colposcopy for detecting vaginal lesions [26]. When combined with high-risk HPV (hr-HPV) testing, detection accuracy improves to 95% [26]. In our study, the sensitivity of cytology and HPV testing for high‐grade VaIN was comparable to that for high‐grade CIN.

Limitations

This study has several limitations. First, its retrospective design may have introduced selection bias. Second, as a cross-sectional study, it lacks information on disease outcomes. Third, it was conducted at a single institution, so the findings may not be generalizable to the broader population. Lastly, some clinical details, such as lesion locations, use of immunosuppressive medications, and smoking status, were unavailable. Despite these limitations, multicenter, controlled trials are needed to confirm our findings.

Conclusions

Our findings indicate that high-grade VaIN is associated with older age, higher gravidity and parity, the perimenopausal or menopausal phase, and a history of cervical treatment. Most high‐grade VaIN cases were HPV-positive, with HPV 16 being the most common genotype. The sensitivity of cytology and HPV testing for high‐grade VaIN was comparable to that for high‐grade CIN. Vaginal examination and screening are crucial, particularly for older, perimenopausal, and postmenopausal women, as well as those with higher gravidity, parity, a history of cervical treatment, cytological abnormalities such as LSIL, or infections with specific HPV types. Early detection of high‐grade VaIN can be facilitated through vaginal biopsy when necessary, preventing misdiagnosis or underdiagnosis and enabling timely intervention.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Authors and Affiliations

  1. Department of Gynecology, Guangdong Women and Children Hospital, 521 Xingnan Avenue, Panyu District, Guangzhou, 511442, China

    Min Lu, Xiaoshan Hong, Tingyan Liu, Bi Mai, Guiying Hu & Xiaoli Sun

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Contributions

LM wrote the main manuscript text. SXL designed this study. HXS,LTY,MB and HGY prepared tables and figures.SXL edited and review the manuscript.All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Min Lu, Bi Mai, Guiying Hu or Xiaoli Sun.

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This study was approved by the Ethics Committee of Guangdong Women and Children Hospital and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.

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The authors declare no competing interests.

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Lu, M., Hong, X., Liu, T. et al. Clinical characteristics and risk factors to high-grade vaginal intraepithelial neoplasia: a single-institution study. BMC Women's Health 25, 44 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03585-7

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