Vaginal stenosis is the medical name for narrowing of the vagina, often with a loss of elasticity, most often occurring as a negative outcome of external beam radiotherapy, brachytherapy, and/or vaginal/pelvic surgery. Typically vaginal stenosis comes with vaginal dryness and poorly-functioning scar tissue. Read more about pelvic radiation and its effect on your vagina here.
The extent of vaginal stenosis depends on where the cancer is, the treatment type and dose, scheduling of doses, any concurrent chemotherapy, the patient’s age and radiosensitivity. There isn’t a lot of research into post-radiation vaginal stenosis, but a growing pool of post-treatment cases exists. A review1 stated that variations in literature cited rates of vaginal stenosis at between 1.25 per cent to 88 per cent. Radiation-induced vaginal stenosis is understood to be a common, underreported toxicity after pelvic radiation that typically occurs within the first year after radiation and gets worse over time.
Incidence of radiotherapy-induced vaginal stenosis
One study of 54 patients reported that vaginal stenosis increases over time, with the first year after follow-up usually about a grade one, with moderate-to-severe stenosis increasing up to three years post-treatment. Another study of women with stage 1B to stage IV cervical cancer treated with radiotherapy or a combination of radiotherapy and brachytherapy recorded the incidence of vaginal stenosis at 38 per cent.
What vaginal stenosis feels like
The most common cause of vaginal narrowing and tissue damage is radiation therapy for cancer of the vagina, bladder, lymph glands, uterus, cervix or rectum. The radiation may be applied externally or internally, but has a negative impact on vaginal tissue, causing thinning, drying, scar tissue formation, and a shortening and narrowing of the vaginal canal. Blood vessels are reduced in number, making the tissue fragile. This makes the performance of vaginal tissue poor, and can make sex very uncomfortable or painful. Sex may cause bleeding.
The cancer may have caused premature menopause, with a lack of oestrogen perpetuating the problem, since vulvar and vaginal tissue is very sensitive to oestrogen. Oestrogen has a protective and stimulating effect on vulvar cells.
Vaginal tissue – what happens in vaginal stenosis
The vaginal lining covers the lamina propria and longitudinal muscle fibres. Vaginal stenosis is caused when the mucosa becomes inflamed, blood vessels proliferate (hyperaemia), and epithelial cells degrade and disappear (denudation), resulting in ulcers and tissue injury. This results in small-vessel thrombosis, swelling and muscle degradation.
The vaginal mucosa is damaged by increased collagen production in the submucosal connective tissue layer, leading to atrophic changes in the vaginal mucosa. This leads to the muscles and blood vessels being obliterated, resulting in a lack of oxygen to tissue, and tissue atrophy and fibrosis (scarring and thickening).
Risk factors for vaginal stenosis
- Those over 50 years of age
- Cigarette smoking
- Assessment of grade II vaginal pallor reaction at six months
Treating vaginal stenosis – the sooner you start, the better
There are several methods used to keep the vagina functional, including the use of vaginal dilators to stretch the tissue out over time. These dilators require regular use, from the very beginning, to be effective. The sooner you start using them, the better the outcomes over time. Talk to your specialist about recommendations for your case. Oestrogen creams containing just E3 (oestriol) may also be useful, along with pelvic exercises.
Additionally, a study looked into a combination of olive oil, pelvic floor exercises, and a vaginal moisturiser and found this to be an effective and cheap way to improve vaginal function. Read more about the OVERcome study here.
Depending on your treatment, sex and contraception use may be out of the question at least temporarily, but your specialist will talk this over with you.
- Morris L, Do V, Chard J, Brand AH. Radiation-induced vaginal stenosis: current perspectives. International Journal of Women’s Health. 2017;9:273-279. doi:10.2147/IJWH.S106796. ↩