VOLUME 42  •  NUMBER 5 March 31, 2022

TOPICS IN
OBSTETRICS & GYNECOLOGY Practical CE Newsletter for Clinicians

Vulvar Intraepithelial Neoplasia (VIN): Diagnosis and

Management
Allan Huang, MD, and Elizabeth Lokich, MD
Learning Objectives: After participating in this continuing professional development activity, the provider should be
better able to:
1. Identify patients with abnormal vulvar symptoms or lesions for biopsy.
2. Provide tailored advice and treatment options for patients with vulvar intraepithelial neoplasia.
3. Describe appropriate patient surveillance for vulvar intraepithelial neoplasia.
Key Words: Human papilloma virus (HPV), Lichen sclerosus, Lower genital tract dysplasia, Vulvar intraepithelial neoplasia
(VIN)

Epidemiology and Terminology The classification of VIN has undergone numerous

Vulvar intraepithelial neoplasia (VIN) is a widespread
condition that is increasing in incidence, estimated to affect
5 out of every 100,000 women between 1997 and 2004
according to data from the Surveillance, Epidemiology, and
End Results database.1,2 VIN is more commonly encoun-
tered in White women than in Black, Asian, or Hispanic
women, and the mean age at diagnosis is decreasing.2 If
untreated, up to 10% of patients may progress to invasive
carcinoma; the risk of progression is even higher in some
types of VIN. Prominent risk factors for developing VIN
include increasing age, smoking, immunosuppression,
human papilloma virus (HPV) infection, cervical dysplasia,
and vulvar dermatosis such as lichen sclerosus.3
Dr. Huang is a Resident, and Dr. Lokich is Assistant Professor, Division of
Gynecologic Oncology, Women and Infant’s Hospital of Rhode Island, 90 Plain
St, 2nd Floor, Providence, RI 02903; E-mail: elokich@wihri.org.
The authors, faculty, and staff in a position to control the content of this CME/
NCPD activity have disclosed that they have no financial relationships with, or
financial interests in, any commercial organizations relevant to this educational
activity.
The authors have disclosed that off-label use of imiquimod is discussed in this
article. Please consult the product labeling for approved indications.
changes in the past 2 decades. In 2004, the International
Society for the Vulvovaginal Disease (ISSVD) reclassified
VIN into usual type VIN (HPV-related) and differentiated
VIN (HPV-independent). The current terminology, and the
classification system that will be used in the remainder of
this review, arose from several reclassifications by the
Lower Anogenital Squamous Terminology (LAST) project
in 2012, the World Health Organization in 2014, and the
ISSVD in 2015 in an effort to standardize disparate termi-
nology for vulvar dysplasia.4,5 The current classification is
as follows:
• Vulvar low-grade squamous intraepithelial lesion
(vLSIL)—condyloma effect secondary to HPV infection
(previously VIN1);
• Vulvar high-grade squamous intraepithelial lesion
(vHSIL)—vulvar squamous dysplasia requiring treatment
(previously VIN2-3); and
• Differentiated vulvar intraepithelial neoplasia (dVIN)—
HPV-independent intraepithelial neoplasia, often found in
the context of other vulvar skin disorders such as lichen
sclerosus.

CME Accreditation
Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical
education for physicians.
Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should
claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and
evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This CME activity expires on March 30, 2024.
NCPD Accreditation
Lippincott Professional Development is accredited as a provider of nursing continuing professional development (NCPD) by the American Nurses Credentialing Center’s
Commission on Accreditation. Lippincott Professional Development will award 2.0 contact hours for this continuing professional development activity. Instructions for earning
ANCC contact hours are included on the test page of the newsletter. This NCPD activity expires on March 7, 2025.
1
Postgraduate Obstetrics & Gynecology March 31, 2022
Editors
William Schlaff, MD
Professor and Chair,
Department of Obstetrics
and Gynecology, Thomas
Jefferson Medical College,
Philadelphia, Pennsylvania
Lorraine Dugoff, MD
Professor and Chief, Division of
Reproductive Genetics,
Department of Obstetrics
and Gynecology, University
of Pennsylvania Perelman
School of Medicine,
Philadelphia, Pennsylvania
Founding Editors
Edward E. Wallach, MD
Roger D. Kempers, MD
Associate Editors
Meredith Alston, MD
Denver, Colorado
Amanda French, MD
Boston, MA
Nancy D. Gaba, MD
Washington, DC
Veronica Gomez-Lobo, MD
Washington, DC
Star Hampton, MD
Providence, Rhode Island
Enrique Hernandez, MD
Philadelphia, Pennsylvania
Bradley S. Hurst, MD
Charlotte, North Carolina
Jeffrey A. Kuller, MD
Durham, North Carolina
Peter G. McGovern, MD
New York, New York
Owen Montgomery, MD
Philadelphia, Pennsylvania
Christopher M. Morosky, MD
Farmington, Connecticut
William D. Petok, PhD
Baltimore, Maryland
Like cervical dysplasia, the majority of visual assessment of the pubis, lymph nodes,
VIN is associated with HPV infection, vulva, and perianal region.
which is thought to induce disordered cel- Assessment of vulvar lesions should
lular proliferation via the production of include anatomic site, size, focality (single or
viral oncoproteins.2 In one histologic case multifocal), shape, border regularity, color,
series of 587 VIN tissue samples, HPV was thickness, and abnormal vasculature. Vulvar
detected in 86.7% of samples, with HPV colposcopy after application of acetic acid
16, 33, and 18 being the most prevalent may be used to aid in diagnosis, especially in
genotypes.6 For this reason, the Centers for patients who are symptomatic but do not
Disease Control and Prevention recom- have visually apparent lesions.1,3 The presen-
mends routine vaccination with the 9-valent tation of vHSIL is variable, and can present
(Gardasil) HPV vaccine, which covers as opaline or pigmented macules, papules, or
against HPV 6, 11, 16, 18, 31, 33, 45, 52, plaques located near the introitus.3 On the
and 58. Two dosing schedules are recom- other hand, dVIN typically presents in the
mended: 2 doses at 0 and 6 to 12 months for background of lichen sclerosus (diagnosis
those initiating vaccination between ages 9 and treatment of lichen sclerosus is beyond
and 14 years or 3 doses at 0, 1 to 2, and 6 the scope of this review). Patients with dVIN
months for those initiating vaccination lesions may present with maculopapular
between ages 15 and 45 years or immuno- plaques with irregular warty or leukoplakic
compromised individuals initiating vaccina- appearance.3 Both vHSIL and dVIN lesions
tion between ages 9 and 26 years.7 may involve some degree of erythema.
Clinical judgment guides decision to biopsy.
Diagnosis The ACOG specifically recommends biopsy
The American College of Obstetricians of lesions unresponsive to topical therapy,
and Gynecologists (ACOG) does not rec- atypical vascular patterns, and dynamic
ommend a particular screening algorithm lesions changing in color or size and all
for vulvar dysplasia.1 Rather, screening warty lesions in postmenopausal patients.1
occurs via visual examination at the time of Ultimately, we recommend biopsy of any
routine gynecologic examination. new or unusual lesion and of any skin
Evaluation can be prompted by sympto- changes on the vulva before initiating
matic lesions, followed by biopsy of any treatment.
abnormal lesions. Thorough history taking
is a key component of diagnosis. A history Management
of HPV infection and related cervical or There is no known oncogenic potential for
anal dysplasia is a risk factor for vHSIL and vLSIL. Therefore, these lesions may only
a history of lichen sclerosus should prompt need treatment in patients with symptoms of
an increased suspicion for dVIN. Patients pain, bleeding, urinary or vaginal obstruc-
may describe symptoms of pruritus, irrita- tion, disfigurement, or psychosocial con-
tion, pain, dyspareunia, and bleeding; 70% cerns. Given the high risk of progression to
of patients with vHSIL will be sympto- carcinoma, the diagnosis of vHSIL or dVIN
matic.3 Physical examination should include necessitates treatment. Approximately 10%
The continuing professional development activity in Topics in Obstetrics & Gynecology is intended for obstetricians, gynecologists, advanced
practice nurses, and other health care professionals with an interest in the diagnosis and treatment of obstetric and gynecological conditions.
Topics in Obstetrics & Gynecology (ISSN 2380-0216) is published 18 times per year by Wolters Kluwer Health, Inc. at 14700 Citicorp
Drive, Bldg 3, Hagerstown, MD 21742. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, or E-mail
customerservice@lww.com. Visit our website at LWW.com. Publisher, Stella Bebos.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. Priority Postage paid at
Hagerstown, MD, and at additional mailing offices. POSTMASTER: Send address changes
to Topics in Obstetrics & Gynecology, Subscription Dept., Wolters Kluwer, P.O. Box 1610,
Hagerstown, MD 21742.
PAID SUBSCRIBERS: Current issue and archives from 2004 on are now available FREE online at www.topicsinobgyn.com.
Subscription rates: Personal: US $629, international $809. Institutional: US $1630, international $1882. In-training: US resident $156
with no CME, international $184. GST Registration Number: 895524239. Send bulk pricing requests to Publisher. Single copies: $106.
COPYING: Contents of Topics in Obstetrics & Gynecology are protected by copyright. Reproduction, photocopying, and storage or
transmission by magnetic or electronic means are strictly prohibited. Violation of copyright will result in legal action, including civil and/or
criminal penalties. Permission to reproduce copies must be secured in writing; at the newsletter website (www.topicsinobgyn.com),
select the article, and click “Request Permission” under “Article Tools” or e-mail customercare@copyright.com. Reprints: For com-
mercial reprints and all quantities of 500 or more, e-mail reprintsolutions@wolterskluwer.com. For quantities of 500 or under,
e-mail reprints@lww.com, call 1-866-903-6951, or fax 1-410-528-4434.
Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does
not constitute endorsement. All comments are for general guidance only; professional counsel should be sought for specific situations.
2
 March 31, 2022 Topics in Obstetrics & Gynecology
of untreated patients with vHSIL will progress to invasive
carcinoma and this risk can be reduced to 3% to 5% with
treatment.8 Differentiated VIN carries a significantly higher
risk of progression to invasive carcinoma of at least 33%.9
Management is guided by several factors, including ability
to completely remove the lesion(s), patient symptoms, pres-
ervation of vulvar anatomy and function, and avoiding
psychosexual impairment. Selection of an appropriate treat-
ment depends on several factors including the suspicion for
occult malignancy, size and location of lesion(s), comor-
bidities, reliability of follow-up, medical resources, and
provider experience.
Surgical Excision
Surgical excision is the preferred first-line treatment for
vulvar dysplasia, as it yields a pathologic specimen that can
be evaluated for invasive cancer.1 Wide local excision is the
most appropriate and commonly performed surgery for
vulvar dysplasia. Complete skinning vulvectomy is rarely
performed. Surgical management is always recommended
for dVIN, given the high risk of progression to invasive
carcinoma.
Visually abnormal tissue should be excised in its entirety.
There is no definitive consensus on what the minimum
margin of excision should be. However, a lateral margin of
at least 5 mm and up to 10 mm is recommended to decrease
the rate of recurrence.1-3 In terms of the depth of the exci-
sion, removal of the epidermis is sufficient for treatment of
vHSIL and removing a small amount of underlying dermis
serves to ensure the absence of early invasive carcinoma.
This may involve the removal of any involved hair folli-
cles.2,3 Margins and depth of excision should be adjusted to
avoid disrupting critical structures such as the urethra, clito-
ris, or anus. Negative margins are associated with a reduced
risk of recurrence, though the absolute risk remains high.
Grossly visible residual lesions require treatment, but
microscopically positive margins can be clinically observed.
In one case series of 405 patients with dysplasia treated
with surgical excision, Jones et al10 found a 50% risk of
retreatment within 5 years for patients with positive mar-
gins, but only a 15% risk for those with negative margins.
As vHSIL is often multifocal, a negative margin will only
reduce the recurrence risk at that site and not the lifelong
risk of the development of vHSIL at other sites on the vulva.
Risk of recurrence is also higher for multifocal lesions.11
Surgical Ablation
CO2 laser ablation represents an alternative to surgical
excision in patients who carry a low risk of malignancy, or
in whom biopsies have excluded malignancy. The advan-
tages of laser ablation include favorable cosmetic and func-
tional outcomes. However, ablative techniques will not
yield a specimen for pathologic evaluation and may be
associated with greater postoperative pain and wound care
requirements as compared with surgery.3 Laser ablation can
be particularly useful for patients with multifocal disease or
those who have lesions involving the clitoris, urethra, or
anus. Laser ablation is contraindicated in dVIN, given the
3
high risk of concurrent malignancy. The evidence compar-
ing recurrence rates between patients treated with laser
ablation versus surgical excision is poor, but the data we do
have do not seem to show any meaningful difference in
recurrence.12
Recommended ablative margins are the same as with sur-
gical excision. Lateral margins of 5 to 10 mm are ideal when
possible.1 Laser ablation must similarly target hair follicles,
which can contain vHSIL cells and extend to depths of 3
mm or greater. In regions without hair follicles, ablation to
the level of the dermis (2 mm in depth) is appropriate.1,3
Care must be taken to avoid deep coagulation injury, which
can result in poor cosmetic and functional outcomes.2 Use of
appropriate power density and intraoperative colposcopy
can help to reduce these risks. Given the treatment require-
ments, patients with large lesions involving many hair folli-
cles may be more appropriate excisional candidates.
Conversely, patients with small, multifocal lesions in areas
without hair may be excellent candidates for laser ablation.
Medical Treatment
Imiquimod is a toll-like receptor 7 agonist that stimulates
dendritic cells to increase expression of interferon-α and
tumor necrosis factor-α. These cytokines enhance the cyto-
toxic ability of innate immune cells to destroy HPV-infected
or dysplastic cells.13 Imiquimod has been approved by the
FDA for treatment of HPV-related genital warts (vulvar
LSIL or condyloma), but not for vHSIL. However, 2 rand-
omized controlled trials by van Seters et al14 and Mathiesen
et al15 have demonstrated the efficacy of topical imiquimod
5% in vulvar HSIL, leading to its off-label use. Reported
complete histologic response rates vary widely between
31% and 81%. Recurrence rates are poorly reported.14,15
Imiquimod is applied topically to individual lesions and
should not be applied to the entire vulva. Treatment involves
applying a thin layer of cream 3 to 5 times per week on
alternate days for 16 weeks.14,15
Topical imiquimod is associated with several adverse
effects, including application site pain, irritation, erythema,
erosion or edema, vaginal discharge, or fevers. These
adverse effects are usually mild to moderate, and the drug
is generally well-tolerated.13 Temporary dose reductions to
one application per week or a 1-week break from treatment
may be necessary if patients experience severe adverse
effects, but treatment pauses of greater than 1 week are not
recommended.15
Fluorouracil can be used when other therapies have
failed. Fluorouracil causes chemical desquamation of
vHSIL, and although response rates are high, it is rarely
used because it is poorly tolerated by patients due to burn-
ing, pain, inflammation, edema, and ulcerations.
Cidofovir is under investigation as a potential agent to
treat vHSIL. Cidofovir is a nucleoside analogue that com-
petitively inhibits viral DNA polymerases. Hurt et al16
examined the efficacy of cidofovir versus imiquimod in 180
patients in a phase II multicenter trial, the only randomized
controlled trial to compare these 2 therapies. The published
regimen consisted of topical cidofovir 1% applied 3 times a
Postgraduate Obstetrics & Gynecology March 31, 2022
week for 24 weeks.17 Rates of complete response were
similar in both arms; however, the cidofovir arm showed
significantly greater maintenance of complete response at
18-month follow-up (94% vs 71.6%).16 These results sug-
gest that cidofovir may be just as efficacious as imiquimod
in initial disease control with the added advantage of
increased time to recurrence. However, given the scarcity of
data, cidofovir is not yet routinely used.
Surveillance
The elevated lifetime risk of vulvar cancer and recurrent
dysplasia in this population highlights the need for close
surveillance after complete response to treatment for vulvar
dysplasia. The ACOG recommends follow-up examination
at 6 and 12 months after complete response followed by
visual inspection annually.1 Patients may be instructed to
perform visual self-inspection and to monitor for symp-
toms, but this does not replace clinical surveillance by a
provider. European surveillance guidelines published by the
European Academy of Dermatology and Venereology rec-
ommend lifetime surveillance every 6 to 12 months for
patients with vHSIL, in addition to annual cervical dyspla-
sia screening.18 Anal dysplasia screening may also be indi-
cated in certain populations (see the Risk of Associated
Anogenital Dysplasia subsection). Overall, gynecologic
examination with visual inspection of the vulva every 6
months for 5 years followed by annual examinations there-
after is a reasonable approach to surveillance for vHSIL.
For patients with dVIN, surveillance every 6 months at a
minimum is indicated. There are no associated recommen-
dations for other lower genital tract dysplasia, given its
HPV-independent pathophysiology.18
Risk Factors for Recurrence
Reported rates of recurrence for vulvar dysplasia are
high, regardless of treatment modality. Approximately one-
third of patients will develop recurrent vulvar squamous
intraepithelial lesion. Recurrences can occur late (>5 years)
and some of them will present as invasive cancer.1,19-21
Patient factors that increase recurrence risk include age
more than 50 years, immunosuppression, concurrent vagi-
nal intraepithelial neoplasia or cervical intraepithelial neo-
plasia, and smoking.19,21 Treatment and disease-related risk
factors for recurrence include positive margins after exci-
sion, multifocal lesions, larger initial lesions, and presence
of lichen sclerosus.19-21 The most significant of the afore-
mentioned risk factors include presence of lichen sclerosus,
positive surgical margins, and multifocal lesions, which
were associated with 9.9-fold, 8.1-fold, and 3.3-fold odds of
recurrence, respectively.19,21 Median times to recurrence
range from 16.9 to 25 months, but can be as long as 15+
years. Overall, there were no observed differences in recur-
rence across initial treatment modalities.
Risk of Associated Anogenital Dysplasia
The pathophysiology of anal cancer is strongly associated
with HPV coinfection (ranging from 30% to 80% in
perianal cancer).22 Given the shared pathophysiology of
4
HPV-induced cellular proliferation in both vulvar and anal
dysplasia, concerns have been raised about the need for anal
cancer screening in women with vulvar dysplasia. In a
small pilot study of 57 women with a history of vHSIL,
Proctor et al23 identified abnormal anal cotesting results in
56.1% and anal HSIL in 18.2% of patients. Anal cancer
incidence rates are higher in patients with a diagnosis of
vulvar cancer as well.24 In a study of 190 patients with cer-
vical, vulvar, and vaginal dysplasia or malignancy, the
prevalence of anal dysplasia was 41.2% and HPV was
detected in 20.8% of anal pap smears. Anal dysplasia was
found in 13.4% of these women who underwent anoscopy,
with 4.2% having anal intraepithelial neoplasia grade 2 or
more (AIN2+).25 Despite these associations, no major
oncologic societies have made recommendations for rou-
tine anal cancer screening in the general population, much
less patients with a history of vulvar dysplasia, as there is a
paucity of evidence demonstrating benefit for routine
screening.22
Practice Pearls
• All vulvar skin lesions that are new, changing, or do
not respond to topical treatments should be biopsied.
• vHSIL and dVIN always require treatment due to the
risk of progression to invasive cancer. Surgical excision
is required in patients with dVIN and is the preferred
treatment for vHSIL.
• Provided that invasive disease has been excluded, abla-
tion or topical treatment with imiquimod can be con-
sidered for patients with vHSIL, particularly in those
with multifocal disease or disease abutting the clitoris,
urethra, or anus.
• Surveillance every 6 months is ideal in the first 2 years
after treatment for vHSIL and dVIN, and then annual
surveillance thereafter.
• Up-to-date cervical cancer screening and, in some
cases, anal cancer screening is an important adjunct to
vulvar surveillance in patients with a history of vHSIL.
Special Considerations
Patients With HIV Infection
Patients with HIV are at increased risk of developing
lower genital dysplasia due to impaired ability to clear HPV
infections.26 Bradbury et al26 conducted a retrospective
cohort study of 107 women diagnosed with VIN and found
that 84.8% of HIV-positive patients had multicentric dys-
plasia (concurrent cervical or vaginal dysplasia) compared
with 43% of HIV-negative patients. In addition, HIV-
positive patients were more likely to present with multifocal
vulvar dysplasia (63.6% vs 22.2% in HIV-negative patients),
an independent risk factor for recurrence. Unsurprisingly,
HIV-positive status was associated with decreased recur-
rence-free survival and progression-free survival.26 There
are currently few data on the utility of using CD4 counts in
prognosticating the course of vulvar dysplasia, and similarly
 March 31, 2022 Topics in Obstetrics & Gynecology
sparse data describing the impact of highly active antiretro-
viral therapy on VIN outcomes.2,26 Given the higher risk of
dysplasia and progression to invasive cancer in this popula-
tion, increased frequency of surveillance and lower thresh-
old for repeat biopsies is appropriate.1 Ultimately, manage-
ment of vulvar dysplasia in HIV-positive patients will be
individualized to patient characteristics, clinical judgment
of the provider, and available clinical resources.
REFERENCES
1. Committee Opinion No. 675: management of vulvar intraepithelial neopla-
sia: correction. Obstet Gynecol. 2017;129(1):209-209. doi:10.1097/
AOG.0000000000001839.
2. Preti M, Scurry J, Marchitelli CE, et al. Vulvar intraepithelial neoplasia. Best
Pract Res Clin Obstet Gynaecol. 2014;28(7):1051-1062. doi:10.1016/j.
bpobgyn.2014.07.010.
3. Lebreton M, Carton I, Brousse S, et al. Vulvar intraepithelial neoplasia: clas-
sification, epidemiology, diagnosis, and management. J Gynecol Obstet
Hum Reprod. 2020;49(9). doi:10.1016/j.jogoh.2020.101801.
4. Darragh TM, Colgan TJ, Cox JT, et al. The Lower Anogenital Squamous
Terminology Standardization Project for HPV-Associated Lesions:
Background and Consensus Recommendations from the College of
American Pathologists and the American Society for Colposcopy and
Cervical Pathology. Arch Pathol Lab Med. 2012;136(10):1266-1297.
doi:10.5858/arpa.LGT200570.
5. Bornstein J, Bogliatto F, Haefner HK, et al. The 2015 International Society
for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar
Squamous Intraepithelial Lesions. J Low Genit Tract Dis. 2016;20(1):11-14.
doi:10.1097/LGT.0000000000000169.
6. de Sanjosé S, Alemany L, Ordi J, et al. Worldwide human papillomavirus
genotype attribution in over 2000 cases of intraepithelial and invasive
lesions of the vulva. Eur J Cancer. 2013;49(16):3450-3461. doi:10.1016/j.
ejca.2013.06.033.
7. Centers for Disease Control and Prevention. Administering HPV Vaccine.
https://www.cdc.gov/vaccines/vpd/hpv/hcp/administration.html. Published
2021. Accessed December 11, 2021.
8. Allbritton JI. Vulvar neoplasms, benign and malignant. Obstet Gynecol Clin
North Am. 2017;44(3):339-352. doi:10.1016/j.ogc.2017.04.002.
9. van de Nieuwenhof HP, Massuger LFAG, van der Avoort IAM, et al. Vulvar
squamous cell carcinoma development after diagnosis of VIN increases with
age. Eur J Cancer. 2009;45(5):851-856. doi:10.1016/j.ejca.2008.11.037.
10. Jones RW, Rowan DM, Stewart AW. Vulvar intraepithelial neoplasia.
Obstet Gynecol. 2005;106(6):1319-1326. doi:10.1097/01.AOG.0000187301.
76283.7f.
11. Modesitt S, Waters AB, Walton L, et al. Vulvar intraepithelial neoplasia III:
occult cancer and the impact of margin status on recurrence. Obstet Gynecol.
1998;92(6):962-966. doi:10.1016/S0029-7844(98)00350-0.
Visit www.topicsinobgyn.com
Your
{{ online subscription to Topics in Obstetrics & Gynecology offers:
•  Most popular articles feature
•  Access to the archive of pub-
lished issues
•  e-Pub downloads to access
articles on your e-reader device
•  e-Table of Contents deliv-
ered to your inbox
•  Personalization features,
such as saved search results
and article collections
•  NCPD access
{{ To activate your online access,
click “Register” at the top right
corner of the website.
5
12. Lawrie TA, Nordin A, Chakrabarti M, et al. Medical and surgical interven-
tions for the treatment of usual-type vulval intraepithelial neoplasia.
Cochrane Database Syst Rev. 2016;2006(1):CD011837. doi:10.1002/
14651858.CD011837.pub2.
13. de Witte CJ, van de Sande AJ, van Beekhuizen HJ, et al. Imiquimod in cervi-
cal, vaginal and vulvar intraepithelial neoplasia: a review. Gynecol Oncol.
2015;139(2):377-384. doi:10.1016/j.ygyno.2015.08.018.
14. van Seters M, van Beurden M, ten Kate FJW, et al. Treatment of vulvar
intraepithelial neoplasia with topical imiquimod. N Engl J Med.
2008;358(14):1465-1473. doi:10.1056/NEJMoa072685.
15. Mathiesen O, Buus SK, Cramers M. Topical imiquimod can reverse vulvar
intraepithelial neoplasia: a randomised, double-blinded study. Gynecol
Oncol. 2007;107(2):219-222. doi:10.1016/j.ygyno.2007.06.003.
16. Hurt CN, Jones S, Madden TA, et al. Recurrence of vulval intraepithelial
neoplasia following treatment with cidofovir or imiquimod: results from a
multicentre, randomised, phase II trial (RT3VIN). BJOG. 2018;125(9):1171-
1177. doi:10.1111/1471-0528.15124.
17. Tristram A, Hurt CN, Madden T, et al. Activity, safety, and feasibility of
cidofovir and imiquimod for treatment of vulval intraepithelial neoplasia
(RT3VIN): a multicentre, open-label, randomised, phase 2 trial. Lancet
Oncol. 2014;15(12):1361-1368. doi:10.1016/S1470-2045(14)70456-5.
18. van der Meijden WI, Boffa MJ, Ter Harmsel WA, et al. 2016 European
guideline for the management of vulval conditions. J Eur Acad Dermatol
Venereol. 2017;31(6):925-941. doi:10.1111/jdv.14096.
19. Satmary W, Holschneider CH, Brunette LL, et al. Vulvar intraepithelial
neoplasia: risk factors for recurrence. Gynecol Oncol. 2018;148(1):126-131.
doi:10.1016/j.ygyno.2017.10.029.
20. Wallbillich JJ, Rhodes HE, Milbourne AM, et al. Vulvar intraepithelial neo-
plasia (VIN 2/3): comparing clinical outcomes and evaluating risk factors
for recurrence. Gynecol Oncol. 2012;127(2):312-315. doi:10.1016/j.
ygyno.2012.07.118.
21. Fehr MK, Baumann M, Mueller M, et al. Disease progression and recur-
rence in women treated for vulvovaginal intraepithelial neoplasia. J Gynecol
Oncol. 2013;24(3):236. doi:10.3802/jgo.2013.24.3.236.
22. Leeds IL, Fang SH. Anal cancer and intraepithelial neoplasia screening: a
review. World J Gastrointest Surg. 2016;8(1):41. doi:10.4240/wjgs.v8.i1.41.
23. Proctor L, Grennan T, Albert A, et al. Screening for anal cancer in women
with a history of vulvar high-grade squamous intraepithelial lesions. J Low
Genit Tract Dis. 2019;23(4):265-271. doi:10.1097/LGT.0000000000000490.
24. Clifford GM, Georges D, Shiels MS, et al. A meta-analysis of anal cancer
incidence by risk group: toward a unified anal cancer risk scale. Int J
Cancer. 2021;148(1):38-47. doi:10.1002/ijc.33185.
25. Robison K, Cronin B, Bregar A, et al. Anal cytology and human papilloma-
virus genotyping in women with a history of lower genital tract neoplasia
compared with low-risk women. Obstet Gynecol. 2015;126(6):1294-1300.
doi:10.1097/AOG.0000000000001135.
26. Bradbury M, Cabrera S, García-Jiménez A, et al. Vulvar intraepithelial
neoplasia: clinical presentation, management and outcomes in women
infected with HIV. AIDS. 2016;30(6):859-867. doi:10.1097/QAD.0000000
000000984.
 Postgraduate Obstetrics & Gynecology March 31, 2022

Continuing Professional Development Quiz: Volume 42, Number 5

To earn CME credit, you must read the article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of
the 10 quiz questions correctly. Select the best answer and use a blue or black pen to completely fill in the corresponding box on the
enclosed answer form. Please indicate any name and address changes directly on the answer form. If your name and address do not appear
on the answer form, please print that information in the blank space at the top left of the page. Make a photocopy of the completed answer form
for your own files and mail the original answer form in the enclosed postage-paid business reply envelope. Your answer form must be received
by Lippincott CME Institute by March 30, 2024. Only two entries will be considered for credit. For more information, call (800) 638-3030.
Online CME quiz instructions: To take the quiz online, log on to your account at www.topicsinobgyn.com, and click on the “CME”
tab at the top of the page. Then click on “Access the CME activity for this newsletter,” which will take you to the log-in page for http://cme.
lww.com. Enter your username and password. Follow the instructions on the site. You may print your official certificate immediately.
Please note: Lippincott CME Institute, Inc., will not mail certificates to online participants. Online quizzes expire on the due date.
To earn NCPD credit, you must take the quiz online. Go to www.nursingcenter.com, click on Continuing Education on the toolbar at the
top, select Browse Journals, and select Topics in Obstetrics & Gynecology. Log-in (upper right hand corner) to enter your username and
password. First-time users must register. As a subscriber benefit, nurses can earn contact hours when taking CPD activities from Topics
in Obstetrics & Gynecology for free. You must enter your subscription number, preceeded by LWW, in your registration profile, where there
is a field for Link to my subscription. The 100% discount is applied when payment is requested. Non-subscribers pay a $49.00 fee to
earn ANCC contact hours for this activity. After log-in, locate and click on the CPD activity in which you are interested. There is only one
correct answer for each question. A passing score for this test is 7 correct answers. If you fail, you have the option of taking the test again.
When you pass, you can print your certificate of earned contact hours and access the answer key. For questions, contact Lippincott
Professional Development: 1-800-787-8985. The registration deadline for NCPD credit is March 7, 2025.

1. All of the following are risk factors for developing VIN, 6. The preferred first-line treatment for vulvar dysplasia is
except A. surgical excision.
A. lichen sclerosus. B. imiquimod ointment.
B. diabetes. C. clobetasol ointment.
C. smoking. D. CO2 laser.
D. cervical dysplasia.
7. Laser ablation can be useful for all of the following, except
2. Which one of the following has the highest risk of concur- A. multifocal lesions.
rent carcinoma? B. periclitoral lesions.
A. vHSIL (VIN 2-3) C. dVIN.
B. dVIN D. vHSIL (VIN2-3).
3. Vulvar dysplasia symptoms may include 8. Gross margins on an excisional specimen ideally should be
A. pruritis. A. <5 mm.
B. bleeding. B. 5--10 mm.
C. dyspareunia. C. 10--15 mm.
D. lack of symptoms D. 15--20 mm.
E. all of the above.
9. The recurrence rate of VIN after treatment is approximately
4. Which one of the following does not require biopsy? A. 15%.
A. 5-mm raised erythematous lesion that has been B. 35%.
unchanged for the past 10 years C. 50%.
B. 5-mm raised pruritic lesion in a new patient who D. 80%.
reports that the lesion has “been there for a while”
10. Risk factors for recurrence of VIN include all of the follow-
C. vulvar skin that has been diagnosed as lichen sclero-
ing, except
sus but has not responded to topical corticosteroids
A. positive margins after excision.
5. All of the following may be appropriate treatments for VIN, B. history of a kidney transplant.
except C. history of hysterectomy for cervical cancer.
A. surgical excision. D. diabetes.
B. imiquimod ointment.
C. clobetasol ointment.
D. CO2 laser.