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Testosterone HRT and Front Hole Irritation 101: Vaginal Atrophy Symptoms and Treatment Options, Explained by FOLX

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FOLX Health

Feb 23, 2022

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Those who start testosterone gender-affirming hormone therapy (GAHT) usually will experience some changes to their vaginal area or front hole*, particularly with vaginal atrophy. Vaginal atrophy (also known as atrophic vaginitis, genitourinary syndrome of menopause/GSM, or vulvovaginal Atrophy) is described as vaginal dryness, thinning, and inflammation of the vaginal walls when your body has less estrogen.

*Front hole refers to the vaginal opening and area surrounding it. In this article, we will be opting for this gender-affirming term, since the treatment and symptoms of vaginal atrophy are the same for front hole irritation.

Most medical research about vaginal atrophy/front hole irritation revolves around the experiences of cisgender women undergoing the many changes, such as changing estrogen levels, that menopause and/or breast cancer treatment brings.

However, front hole irritation is an extremely common experience for trans masculine people, transgender men, non-binary and intersex people on T. This health condition can often change how people use or relate to this part of their body and can lead to frustration or discomfort during sex. We’re here to demystify these changes, open up dialogue about this issue, and help you navigate the treatment options available. While there is a growing body of work within the fields of gynecology and endocrinology about this topic, we at FOLX also rely on community knowledge to properly address topics such as this.

Estrogen-dependent tissues can change alongside hormone levels with the introduction of testosterone HRT (including topical testosterone/androgen gel) into the body. Front hole tissues are dependent on estrogen production. On testosterone HRT, rising testosterone levels suppress estrogen levels in the body. Low levels of estrogen decrease the body’s ability to make lubrication to keep the tissues as thick, supple, and stretchy as they may have been prior to testosterone. 

On T, the tissues around your front hole can become thin, easily irritated, and especially sensitive to internal friction, such as different types of penetration during sexual activity. As a result, this area can feel dry, burning, painful, and/or itchy. Traditionally, the medical term for this experience is called “atrophy." Some might even have small tears in the tissue with internal friction that can cause small amounts of bleeding from the tears.

Testosterone can also cause shifts in the pH and beneficial bacteria that keep everything healthy and balanced. Due to this hormonal change, front holes can be more prone to bacterial vaginosis (BV) and yeast infections. The tissues of the urethra (the urinary pee hole) are also affected and can cause some people on testosterone to be more susceptible to urinary tract infections (UTIs) or bladder infections. While everyone's body reacts differently to this hormonal shift, these changes can start within three to six months of T and reach maximum effect around one to two years.

In addition to dryness, thinness, and irritation, front hole irritation can also cause urinary incontinence, or an inability to hold in your pee, leading to feelings of urinary urgency or the need to pee quickly and/or more frequently. 

Fortunately, there are treatments for front hole irritation.

Medications to treat front hole irritation

Front hole irritation can be treated with topical or oral estrogen and improve a person's overall quality of life. The main hormonal treatment options include estrogen tablets, estrogen cream, or an estrogen vaginal ring that stays inside the body. Each of these options provides low-dose estrogen replacement directly to the front hole tissues. Treatments for front hole irritation will not interfere with testosterone HRT. The estrogen purely helps improve internal tissue lubrication and alleviate discomfort.

For those on testosterone, the thought of taking estrogen might feel scary or uncomfortable. However, these low estrogen treatment methods do not interfere with the other changes that testosterone HRT creates in the body. Since the estrogen treatments are used topically, it only affects the tissues it comes in contact with directly with little to no absorption through the rest of the body. Because of how low the dose of estrogen is and how it is applied, there should not be any noticeable change in the effects of testosterone.

Although more people tend to opt for the vaginal estrogen cream as their treatment of choice, a 2017 study showed that those using the estrogen tablet were able to tolerate the treatment long-term. While not optimal, Replens is also a personal lubricant that can be purchased over the counter and is a good option for those who can’t afford estrogen cream (more on that below). Each option has its own pros and cons. It’s important to note that it may take a week or two to notice a difference.

Estrogen cream

Estrogen cream is inserted into the front hole using a reusable or disposable applicator. The cream is usually prescribed for daily use for the first one to two weeks, then used twice weekly afterward.

PROS CONS
  • Can be used internally and on some of the external tissues for relief

  • Can be messier than tablets 
  • Can weaken condoms, diaphragms, and cervical caps if used within 72 hours after a dose
  • Reuse one applicator with each tube; need to keep it clean for repeated use

Estrogen tablets

Another option for treatment is estrogen tablets. These are small (approximately 6mm in diameter) tablets inserted with a disposable applicator—which are included with prescription—inside the front hole daily for two weeks, and then twice weekly afterward. Once inside, the tablet slowly dissolves and releases estradiol into the body.

PROS CONS
  • No mess as it’s a very small pill inserted
  • Can take hours to dissolve internally
  • Can weaken condoms, diaphragms, and cervical caps if used within 72 hours after a dose

If you believe you’re experiencing side effects from either treatment, please contact your healthcare provider.

Don’t forget to use lube!

Gel for treating front hole irritation

Whether you choose to pursue topical estrogen treatment or not, we highly recommend lube when or if you engage in sexual activity. Replens is a personal daily lubricant that can rebalance the pH of the front hole tissues and create a moisture film on the tissues. Please ignore the highly gendered branding of the product (sigh). Other types of lubricants help with general comfort, especially during sex when penetration is involved. Unlike estrogen treatments, lubes can be purchased over the counter, meaning they don't require a prescription nor need to be purchased in a pharmaceutical setting.

There are some other common front hole issues and complications to be aware of. Atrophy can lead to some other conditions that FOLX doesn’t currently treat, and it’s important to know the symptoms. Conditions and symptoms described below may be simple and easily treated and others may need an exam, testing, and treatment by a primary care clinician in person. Look out for these symptoms:

  • Bacterial Vaginosis (BV): Similar to atrophy, BV can cause irritation and a different type of vaginal discharge. Foul-smelling discharge is more likely to be BV. Additionally, some often have chronic BV, sometimes triggered by sexual activity, especially penetration. 
  • Yeast Infection: Yeast infections are characterized by itchiness with clumpy white discharge. Sometimes, people will have raw, red, irritated genital tissues.
  • Urinary Tract Infection (UTI): Both atrophy and UTI can cause urinary symptoms, including a frequent need to pee or a need to pee right away, sometimes accompanied by burning during urination. This symptom is more likely to be a UTI if you also notice pain over your bladder area, cloudy and/or foul-smelling urine and/or blood in the urine.
  • Sexually Transmitted Infections (STIs): STIs commonly don’t cause symptoms, but when they do, they can cause large amounts of yellow or greenish discharge, pelvic pain, abnormal bleeding/spotting (with no changes to your dose of T), and/or sores or rashes.
  • Dyspareunia: Dyspareunia is characterized as persistent or recurrent genital pain that occurs just before, during, or after sexual intercourse that includes penetration. This pain can also show up with other types of penetration, such as inserting a tampon.

Since FOLX isn’t yet able to prescribe treatment for front hole irritation/vaginal atrophy, we recommend you contact your healthcare provider. If you don't feel comfortable speaking to your primary care provider or don't have one currently, you can find a local LGBTQIA+ friendly clinic through this list. Existing FOLX members are welcome to reach out to their clinician with any further questions related to the effects of their testosterone prescription as well as sexual health.

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