Testosterone HRT & Front Hole / Vaginal Atrophy: What to Know & How to Treat

Introducing testosterone to a body can affect estrogen-dependent parts, and may sometimes cause some unpleasant sensations.

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Those who start testosterone HRT usually experience some changes to their front hole/vagina. This is called vaginal atrophy. This is a super common experience and can often change how people use or relate to this part of their body, which can lead to frustration or discomfort. We’re here to demystify these changes, open up dialogue about this issue, and help you navigate treatments. 

Estrogen-dependent tissues can change with the introduction of testosterone HRT.

It's important to know that vaginal/front hole tissues are estrogen-dependent, and testosterone suppresses estrogen in the body. With low levels of estrogen, the body isn’t as good at making lubrication or keeping the tissues as thick, supple, and stretchy as they may have been prior to testosterone.

On testosterone, your tissues can become thin and easily irritated: they can feel dry, burning, painful or itchy, and can become especially sensitive to internal friction, such as different types of penetration. Traditionally, this is called “atrophy." Some will 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 good bacteria that keep everything healthy. This is important to know because it can make the front hole more prone to bacterial vaginosis (BV) and yeast infections. The tissues of the urethra (your pee hole) are also affected and can cause some people on testosterone to be more susceptible to urinary tract infections (UTIs) or bladder infections.

Every person is different, but generally, these changes usually start within 3-6 months of T and reach maximum effect around 1-2 years.

The good news is that there are easy treatments for these types of irritation.

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The main treatment options for front hole irritation are estrogen tablets, estrogen cream, or an estrogen ring that stays inside the body. Each of these options provides low dose estrogen replacement directly to the front hole tissues, and do not interfere with the other changes testosterone is creating in the body. The estrogen helps improve internal tissue lubrication and alleviate discomfort.

Treatments for vaginal/front hole irritation will not interfere with testosterone HRT.

Since the estrogen is used topically, it 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 go for the estrogen cream, one study from Israel showed that those using the estrogen tablet were able to tolerate the treatment long-term. Each option has its own pros and cons. It may take a week or two to notice a difference.

Estrogen cream (Premarin)

Estrogen cream is inserted into the vagina/front hole using a reusable applicator. The cream is usually prescribed for daily use for the first 1-2 weeks, then used twice weekly after that. 

PROS CONS
  • Can be used internally and on some of the more 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 are estrogen tablets. These are small (approximately 6mm in diameter) tablets inserted with an applicator* inside the vagina/front hole daily for two weeks, and then twice weekly after that. Once inside, the tablet slowly dissolves and releases estradiol into the body. 

*The applicators are included with the prescription and are disposable.

PROS CONS
  • No mess as it’s a very small pill inserted
  • Applicators are not reusable
  • Can take hours to dissolve internally
  • Can weaken condoms, diaphragms, and cervical caps if used within 72 hours after a dose

And don’t forget lube!

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We also highly recommend lube. Replens is a lubricant that can rebalance the pH of the vaginal/front hole tissues and creates a moisture film on the tissues. Other types of lubricants can help with general comfort, especially with penetration. 

There are some other common front hole/vaginal issues & complications to be aware of:

Atrophy can lead to some other conditions that FOLX doesn’t currently treat, but it’s important to be aware of 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.

Be on the lookout for these symptoms:

  • Bacterial Vaginosis (BV): Similar to atrophy, BV can cause irritation and a different type of discharge. Foul-smelling discharge is more likely to be BV, and people often have this chronically, sometimes triggered by sexual activity (especially penetration). 
  • Yeast Infection: Itchiness with clumpy white discharge. Sometimes people will have raw, red, irritated genital tissues.
  • Urinary Tract Infection (UTI): Both atrophy and UTI can cause frequent need to pee or a need to pee right away (feelings of urgency), sometimes even 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, 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), or sores or rashes.

Obviously this isn't not the most fun subject, but we hope this helps clear up some some confusion and shed light on some trans specific health issues that don't get talked about often.

FOLX is not yet able to prescribe treatment for vaginal atrophy, so we currently recommend you contact your primary care provider. If you don't feel comfortable speaking to your primary care provider or don't have one, you can find a local LGBTQIA+ friendly clinic through this list. Members are welcome to reach out to their clinician with any further questions related to the effects of their testosterone prescription.