Vaginal Cancer After Hysterectomy: Who Is at Risk, Symptoms and Checks

Vaginal cancer is one of the rarest gynecologic cancers. Cancers that start in the vagina make up only about 1% to 2% of cancers of the female reproductive tract, and most are diagnosed around the age of 70.^[1] After a hysterectomy the vagina is still there, so it can still, very rarely, develop cancer. For most women who had a hysterectomy for a benign condition such as fibroids or heavy bleeding, the risk stays very low. The picture is different if you had the operation because of cervical precancer or cervical cancer. This guide explains who is at higher risk, which symptoms to report, how vaginal cancer is found and treated, and who still needs checks after a hysterectomy.

The short answer

• Hysterectomy for a benign reason, no history of cervical precancer: vaginal cancer is extremely rare. Routine Pap tests of the vagina are not recommended.^[4][6][7]
• Hysterectomy for cervical precancer (CIN 2 or 3) or with abnormal cells found at surgery: the risk of vaginal precancer and cancer is clearly higher, and follow-up testing continues for years.^[4][5][8]
• Hysterectomy for cervical cancer: your cancer team sets the follow-up schedule.
• Everyone: bleeding from the vagina after you have healed, a new lump, or unusual discharge should be checked, whatever the reason for your surgery.^[9]

What vaginal cancer is

The vagina is the muscular tube that runs from the vulva, the outer genitals, up to where the cervix used to be. After a total hysterectomy the top of the vagina is stitched closed, forming what doctors call the vaginal cuff or vault. Most cancers in this area start in the thin, flat cells that line the vagina (squamous cell carcinoma). About 1 in 10 are adenocarcinomas, which start in gland cells, and a small number are melanomas or sarcomas.^[2]

Squamous cell vaginal cancer usually develops slowly. It often starts as precancerous changes called vaginal intraepithelial neoplasia, or VAIN, which is graded 1 to 3. VAIN 1 often clears up by itself. VAIN 2 and 3 are usually treated because they are more likely to turn into cancer over time, a process that can take many years.^[2] Finding and treating VAIN is the main way doctors prevent vaginal cancer in women at higher risk.

Cancer that spreads to the vagina from nearby organs, such as the cervix, the uterus, the bladder or the rectum, is more common than cancer that starts in the vagina itself. It is named and treated after the organ where it began.^[2]

Does a hysterectomy raise the risk of vaginal cancer?

This is the question most women ask, and the honest answer depends on why you had the operation. The best evidence comes from a Swedish study that followed every woman in the country aged 20 and over from 1987 to 2011, about 5 million women, and found 898 cases of vaginal cancer.^[4]

After a hysterectomy for a benign condition

In the Swedish study, women whose hysterectomy was for a benign reason and who had no history of serious cervical precancer had a rate of vaginal cancer a little over twice that of women who had not had a hysterectomy. That sounds alarming, but both numbers are tiny: about 2 cases per 100,000 women per year after a benign hysterectomy, compared with fewer than 1 per 100,000 in women who still had their uterus. The researchers concluded that this rate is too low to justify screening.^[4]

Other studies agree. In a US hospital that reviewed more than 9,600 vaginal Pap tests from about 5,700 women who had a hysterectomy for benign disease, only five women had low or moderate precancer (VAIN 1 or 2), and not one had vaginal cancer.^[6] In a large Chinese hospital study of 7,747 women with no cervical lesions before their hysterectomy, 0.3% were later found to have VAIN.^[5]

Why might the rate be slightly higher at all? Researchers are not sure. Some abnormal cells may already have been present, unnoticed, at the time of surgery, and women who have a hysterectomy may differ in other ways from women who do not. A 2024 review of the medical literature found only 56 published cases of primary vaginal cancer after a hysterectomy for a benign condition, and many of them appeared more than 10 years after surgery. A number of those cancers were of a type (endometrioid adenocarcinoma) that the authors thought might have developed from endometriosis rather than from HPV.^[15] If you had a hysterectomy for endometriosis, this is not a reason to worry, but it is one more reason not to ignore new bleeding.

After a hysterectomy for cervical precancer or with abnormal cells at surgery

This is the group that needs attention. The human papillomavirus (HPV), which causes almost all cervical precancer, also causes about 75% of vaginal cancers, and it can persist in the vaginal lining after the cervix has been removed.^[1][3] In the Swedish study:^[4]

• women who had a history of severe cervical precancer (CIN 3 or adenocarcinoma in situ) before their hysterectomy had about 6 times the vaginal cancer rate of women with a benign history;
• women in whom cervical precancer (CIN) was still present in the removed cervix had about 21 times the rate, and their risk stayed high even 15 years after surgery.

Even in this group the absolute numbers are small, about 17 and 51 cases per 100,000 women per year, but they are high enough that experts recommend continued testing.^[4] The Chinese study found a similar pattern for precancer: VAIN developed in 7.3% of women with a history of CIN, compared with 0.3% of those without. Women whose HPV test stayed positive after surgery were at the highest risk, and women whose HPV test was negative rarely developed VAIN.^[5]

If you are not sure why your hysterectomy was done or what the pathology report on your uterus and cervix showed, ask your gynecologist or request a copy of the report. It is the single most useful piece of information for deciding whether you need follow-up. Our guide to LEEP and cervical dysplasia explains what CIN grades mean.

After a hysterectomy for cervical cancer

Women treated for cervical cancer have regular follow-up with their cancer team, which includes checking the vagina. Some studies have linked pelvic radiation for cervical cancer to a later vaginal cancer, but the evidence is not settled.^[3] Our article on hysterectomy for cervical cancer covers treatment and recovery.

Other risk factors

Many women who develop vaginal cancer have no obvious risk factor. Those that are known include:^[3]

• Age. Almost half of cases are in women aged 70 or older, and very few are in women under 40.
• HPV infection, especially high-risk types such as HPV 16 and 18.
• Smoking, which more than doubles the risk.
• HIV or another cause of a weakened immune system, which makes it harder for the body to clear HPV.
• Exposure to DES before birth. Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy have a higher risk of a rare type called clear cell adenocarcinoma, although about 999 in 1,000 never develop it.

Symptoms to watch for

VAIN and very early vaginal cancer usually cause no symptoms, which is why testing matters for women at higher risk. Most women with invasive vaginal cancer do notice at least one of the following:^[9]

• bleeding from the vagina, often after sex
• unusual vaginal discharge, sometimes watery, bloody or smelly
• a lump or mass in the vagina that you or your partner can feel
• pain during sex

More advanced cancer can cause pain when peeing, constipation, pain in the pelvis or lower belly, back pain, or swelling in the legs.^[9]

After a hysterectomy you no longer have periods, so any vaginal bleeding once the first weeks of healing are over is worth reporting. It is far more often caused by something harmless, such as thin, dry vaginal tissue after menopause, granulation tissue at the vaginal cuff, or an infection, but only an examination can tell. Itching and discharge are usually caused by common problems too; our article on yeast infection after hysterectomy covers the usual look-alikes. Low estrogen after surgical menopause is one of the most common reasons for spotting and pain during sex.

Who still needs checks after a hysterectomy

US guidelines are based on two things: whether your cervix was removed, and whether you have ever had high-grade cervical precancer or cervical cancer.^[7][8]

• Cervix removed, benign reason, no history of CIN 2 or worse: you can stop cervical screening. Testing the vagina in these women finds almost nothing and leads to unnecessary procedures.^[6][7]
• Treated for CIN 2, CIN 3 or adenocarcinoma in situ, with or without a hysterectomy: HPV-based testing continues for 25 years after treatment, even if that takes you past 65. After a hysterectomy the sample is taken from the top of the vagina.^[8]
• Cervix kept (supracervical or subtotal hysterectomy): keep having cervical screening on the normal schedule.^[7]

Our guide to Pap smears after hysterectomy explains these rules step by step, and our article on partial vs total hysterectomy explains how to tell whether your cervix was removed. Stopping screening does not mean stopping gynecology visits: a pelvic exam is still the time to raise new symptoms, dryness or pain.

How vaginal cancer is diagnosed

If you have symptoms or an abnormal test, the usual steps are:^[10]

1. Pelvic and speculum exam to look at the whole vagina, including the cuff, and to feel for lumps. The doctor may also check the lymph nodes in the groin.
2. Pap and HPV tests of cells from the vagina.
3. Colposcopy, a close look at the vaginal lining through a magnifying instrument, usually in the office.
4. Biopsy of any abnormal area. This is the only way to confirm VAIN or cancer.
5. Imaging, such as MRI, CT or PET scans, if cancer is found, to see whether it has spread.

If cancer is confirmed, you will usually be referred to a gynecologic oncologist, a surgeon who specializes in cancers of the female reproductive organs.^[10]

Treatment

Treating VAIN (precancer)

Options include laser treatment, cutting out the affected area (wide local excision), a medicated cream applied inside the vagina, or, less often, internal radiation or removal of part of the vagina. The choice depends on how large the area is, where it is, and the grade.^[11] After a hysterectomy, an abnormal area near the scar at the top of the vagina can be harder to see and treat, so it is worth being looked after by a gynecologist experienced with these lesions.

Treating vaginal cancer

Treatment depends on the type of cancer, its stage and its position in the vagina:^[11]

• Radiation therapy is the main treatment for many vaginal cancers. It is often a combination of external beam radiation and internal radiation (brachytherapy), in which a radiation source is placed inside the vagina for a short time.
• Chemotherapy given with radiation is used for more advanced cancers, borrowing from the way cervical cancer is treated.
• Surgery can be used for some small, early cancers, for example removing the tumor with a margin of healthy tissue or removing part or all of the vagina, sometimes with reconstruction.

Treatment for vaginal cancer can affect sexual function, the bladder and the bowel. Ask your team about vaginal dilators, pelvic floor therapy and sexual health support before treatment starts, not only afterwards.

Outlook

The earlier vaginal cancer is found, the better the outlook. Based on US women diagnosed between 2015 and 2021, the 5-year relative survival was about 76% when the cancer was confined to the vagina, 59% when it had spread to nearby tissue or lymph nodes, and 24% when it had spread to distant organs.^[12] These figures are averages from years ago and cannot predict what will happen to one person, but they show why new symptoms should be checked promptly.

Lowering your risk

• Follow your testing plan if you had cervical precancer or cancer. This is the most effective step for the women at highest risk.^[8]
• Don’t smoke. Stopping lowers the risk of vaginal cancer and many others.^[13]
• HPV vaccination helps prevent vaginal cancers and precancers. It works best before any exposure to HPV, so it is routinely recommended up to age 26. Adults aged 27 to 45 who were not vaccinated can discuss it with their doctor, although the benefit is smaller at that age, and it does not treat an existing infection.^[13][14]
• Report symptoms rather than waiting for your next appointment.

Frequently asked questions

Can you get vaginal cancer if you have no cervix and no uterus?

Yes, because the vagina remains after a hysterectomy. For women who had a hysterectomy for a benign reason it is extremely rare, about 2 cases per 100,000 women per year in the Swedish national study.^[4]

I had a hysterectomy for fibroids. Should I ask for a vaginal Pap test anyway?

Not if your cervix was removed and you have never had high-grade cervical precancer. Guidelines advise against it because it almost never finds cancer in this group and can lead to unnecessary biopsies.^[6][7] Our guide to fibroid treatments covers the operation itself. If you are unsure what your pathology showed, ask before deciding.

My vaginal test after hysterectomy came back abnormal. Does that mean cancer?

Very rarely. In studies of women after a hysterectomy, most abnormal vaginal results turned out to be minor changes or HPV rather than cancer.^[5][6] Depending on the result, your doctor may suggest a repeat test or a colposcopy. Follow the plan you are given, especially if you have a history of CIN.

How long after a hysterectomy can vaginal cancer appear?

It can appear many years later. In the Swedish study, the risk for women with CIN at the time of surgery was still high after 15 years of follow-up, and in the 2024 review most of the cancers after a benign hysterectomy were found more than 10 years after surgery.^[4][15] That is why the 25-year testing period for women treated for precancer matters.

Is bleeding after a hysterectomy a sign of cancer?

In the first weeks it is usually part of normal healing. Months or years later it is most often caused by dry, thin tissue, granulation tissue at the cuff or an infection, but it should always be examined. Heavy bleeding, fever or bad-smelling discharge in the weeks after surgery need urgent medical attention. Our week-by-week recovery guide describes what is normal while you heal.

Sources

1. American Cancer Society. Key statistics for vaginal cancer.
2. American Cancer Society. What is vaginal cancer?
3. American Cancer Society. Risk factors for vaginal cancer.
4. Alfonzo E, Holmberg E, Sparén P, Milsom I, Strander B. Risk of vaginal cancer among hysterectomised women with cervical intraepithelial neoplasia: a population-based national cohort study. BJOG. 2020;127(4):448-454.
5. Cao D, Wu D, Xu Y. Vaginal intraepithelial neoplasia in patients after total hysterectomy. Current Problems in Cancer. 2021;45(3):100687.
6. Pearce KF, Haefner HK, Sarwar SF, Nolan TE. Cytopathological findings on vaginal Papanicolaou smears after hysterectomy for benign gynecologic disease. New England Journal of Medicine. 1996;335:1559-1562.
7. US Preventive Services Task Force. Cervical cancer: screening (2018).
8. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. Journal of Lower Genital Tract Disease. 2020.
9. American Cancer Society. Signs and symptoms of vaginal cancer.
10. American Cancer Society. Tests for vaginal cancer.
11. National Cancer Institute. Vaginal cancer treatment (PDQ), patient version.
12. American Cancer Society. Vaginal cancer survival rates.
13. American Cancer Society. Can vaginal cancer be prevented?
14. Centers for Disease Control and Prevention. HPV vaccine.
15. Qian J, Gracious K, Chen L, Xu S. Primary vaginal cancer after hysterectomy for benign conditions: a systematic review of the literature. Frontiers in Oncology. 2024;14:1334778.

This article is for general information and is not a substitute for medical advice. Always discuss your own risk and follow-up plan with your gynecologist or doctor, and have any vaginal bleeding, lump or unusual discharge after a hysterectomy checked promptly.