Remember back in the 1960s, at the height of the feminist movement, when women were encouraged to look at their vulvas (external genitalia) in a hand mirror in order to learn about their bodies? Turns out there's a medical rationale for this, too-because such self-exams help detect genital skin cancer.

It can be surprising to learn that women can get skin cancer down there." Though men also get genital skin cancer, a recent study found that women are almost three times more likely to die of the most common type of this disease. It's not clear why women's mortality rates are higher-it might be that women are more susceptible or that this cancer is more aggressive in women...or just that growths are easier to find on male genitalia, so men get treated earlier in the progression of the disease.

The vulva includes the clitoris, labia (vaginal lips) and opening to the vagina. There are several types of vulvar cancer. Andrew Bronin, MD, is associate clinical professor of dermatology at Yale School of Medicine in New Haven, Connecticut, and a dermatologist in private practice in Rye Brook, New York. Here are bis prevention and early detection strategies for protecting yourself from…

  • Squamous cell vulvar cancer. This skin cancer arises in the squamous cells (the layer of cells on the surface of the skin) and accounts for nearly 90% of vulvar cancers. Risk factors include age (85% of women who contract the disease are over age 50)...chronic vulvar or vaginal inflammation... infection with HIV (the AIDS virus)...or a history of cervical cancer or lichen sclerosus (a disorder characterized by thin, itchy vulvar tissues).
  • Squamous cell cancer can be linked to certain strains of human papillomavirus (HPV). The HPVs are a group of more than 100 related viruses, some of which are also associated with genital warts and cervical cancer. The sexually transmitted strains of HPV usually spread during vaginal, anal or oral sex via skin-to-skin contact (rather than via bodily fluids). Though the virus sometimes clears up on its own, there is no surefire way to eradicate HPV—so prevention is important. To reduce your risk...
  • Get tested for HPV. Like a Pap smear, the HPV test analyzes cervical cells. If you are not infected, ask your doctor whether you should get the Gardasil vaccine, which protects against four of the most troublesome strains of HPV. "Although the vaccine is currently FDAapproved for women age 26 and under, it also may benefit older women," Dr. Bronin said. "Even if you are infected with one strain of HPV, consider vaccination because it may protect you against three other strains."
  • Even if a man has no visible genital warts, he could have a "preclinical" HPV infection—meaning that the virus is present and contagious but hasn't yet produced visible symptoms. So if you enter a new relationship, have your partner use condoms. But understand that this is not foolproof since it protects you from infections only in areas covered by the condom.

Also: Be aware that the more sexual partners you've had—and the more partners your partner has had—the higher your likelihood of having been exposed to HPV.

  • Don't smoke! Smoking increases vulvar cancer risk, especially if you have HPV.
  • Vulvar malignant melanoma. This type accounts for only about 4% of vulvar skin cancers, but it is the most deadly because it spreads rapidly. Melanoma develops in the melanocytes, the skin's pigment-producing cells. You probably know that sun exposure increases the risk for malignant melanoma—but sun is not a requirement for the development of this disease. In fact, melanoma has the potential to occur anywhere that you have pigment cells...and that's every square inch of your skin, including your vulva. You can get malignant melanoma even where the sun never shines.

"Having moles that are atypical—in other words, funny-looking to the eye and under the microscope anywhere on your body increases your risk for vulvar malignant melanoma, So does a personal or family history of any malignant melanoma," Dr. Bronin said. Unfortunately, vulvar melanomas have some of the worst prognoses of all malignant melanomas, with a five-year survival rate of only 50%...precisely because they often are not caught until it is too late.

  • Vulvar adenocarcinoma. This type begins in the gland cells just inside the vaginal opening or in the top layer of vulvar skin. It accounts for about 8% of vulvar cancers. Though less deadly than melanoma, it has a relatively high recurrence rate.

Concern: Diagnosis often is delayed because a cancerous growth may be easily mistaken for a cyst.

Key: Early Detection

Catching vulvar cancer early offers the best chance for a good outcome. Potentially lifesaving strategies…

  • Give yourself periodic vulvar self-exams. The frequency depends on your personal risk factors, so ask your gynecologist to recommend a schedule. What to do: "Use a mirror to check the inner and outer labia, vaginal opening, clitoris and perineal area between the vagina and anus. Look for abnormal lumps or growths... red, white or grayish lesions...changes in pigmentation...swelling...or sores that don't heal," Dr. Bronin suggested. If you spot any such signs, see your gynecologist or dermatologist as soon as possible.
  • Also be on the lookout for unexplained itching, tenderness, pain or nonmenstrual bleeding—and again, alert your doctor without delay.
  • Get an annual gynecologic checkup. Your doctor will be watching for the disease (among other things)—but it doesn't hurt to ask, "Do you see any signs of vulvar cancer?"

Diagnosis and treatment: When suspicious growths are found, the tissue is biopsied. If the precancerous condition vulvar intraepithelial neoplasia is diagnosed, laser therapy or surgery can keep it from turning into a squamous cell cancer. If the biopsy does reveal squamous cell cancer, treatment options include laser therapy, surgery, radiation and/or chemotherapy.

If a pigmented skin lesion is suspected of being malignant melanoma, it should be surgically removed by a dermatologist or gynecologist and examined at a pathology lab. Early recognition and removal of a malignant melanoma can be lifesaving.

For vulvar adenocarcinoma, treatment also is surgical, with the extent of the surgery depending on the extent of the disease. Again, Dr. Bronin emphasized, early detection offers the best chance for limiting the necessary surgery and enhancing the prognosis.

Safer Estrogen Therapy

Estrogen replacement relieves menopausal hot flashes but can raise the risk for potentially deadly blood clots.

Recent study: Women who were at elevated risk for clots used estrogen either orally or transdermally (as a gel, spray or skin patch). After eight weeks, blood tests showed increased clotting in oral estrogen users-but not in transdermal users.

Oral Estrogen Problem "Leaks" Out

Women who took oral conjugated equine-estrogen (such as Premarin) to relieve menopausal symptoms were more likely than those taking a placebo to develop or experience a worsening of urinary incontinence.

But: In women using topical estrogen (such as a vaginal cream or ring), incontinence symptoms improved. Estrogen increases breast cancer and stroke risk-so discuss pros and cons of various types with your doctor.

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