Gender Identity Service

Transmasculine individuals on testosterone-based gender- affirming hormone therapy report high levels of symptoms of genital and pelvic pain (up to 64–78%).  This is likely to be under-recognised and under-reported by patients and clinicians alike. In those who use testosterone as gender-affirming hormone therapy, this may trigger symptoms of vaginal atrophy and vulvovaginitis, via a variety of proposed mechanisms including changes to vaginal microbiome.  It can occur at any point during testosterone therapy but is more common with accumulative use.

Symptoms may include dryness, itching/irritation, bleeding, discharge, discomfort or pain, pain with intercourse, vaginal discharge or urinary symptoms including recurrent Urinary Tract Infections. As a result, vaginal examinations can be distressing not just due to dysphoria but also due to discomfort and pain.

Physical examination is recommended but this may not be acceptable to patients and empirical treatment may be preferred.  Examination may also not always correlate with the severity of symptoms, and a normal examination does not exclude the diagnosis of testosterone associated vulvovaginitis. If TAVV is suspected and the individual is unable to tolerate a full examination, we would suggest treatment for 4-6 weeks before another attempt at vaginal examination is made.

Management includes basic information on maintain vulval dermatological health Vulval skincare.

Initial treatment with a vaginal estrogen is recommended such as (but not limited to)

• Vagifem/Vagirux: 10mcg pessary daily for 2 weeks then 1 pessary twice per week (if still symptomatic at 2 weeks it would be appropriate to continue with application for 4-6 weeks before titrating down to 1 pessary twice per week).
• Ovestin cream 0.1%: 1 application per day for 2-4 weeks then reduction based on symptoms down to a maintenance dose of one application twice per week.

Systemic absorption is limited and there is no increased risk of VTE or systemic complications of estrogen therapy.  It will not effect masculinising changes from testosterone, nor will it feminise.

Topical estrogens may damage condoms.

In severe symptoms, precluding an individuals ability to insert treatments into the vagina, creams should be commenced for external use initially and adding internal estrogen once introital atrophy has been treated.  Symptoms may take 3 months of consistent use to be fully effective and it is suggested to use for 3 months before switching to an alternative preparation if symptoms continue.  It can be used in the longer term and for as long as testosterone is continued.

In some severe cases it may necessitate more frequent and prolonged application of topical Estradiol than in post-menopausal cis females.

Occasionally a combination of a vaginal preparation and a vulval preparation are also required along with vaginal moisturisers such as coconut oil. We would also recommend lubricants for penetrative intercourse.

If infective symptoms are present or features suggestive of desquamative vaginitis a treatment of 5-7 days of nightly topical clindamycin may be offered alongside or instead of vaginal estrogen.

If vaginal bleeding is a problem, please see our separate advice above on: How to Approach Vaginal Bleeding for Transmen and Non-Binary Individuals on Testosterone Treatment.

For further support please access: BASHH best practice statement on the management of testosterone-associated vulvovaginitis

Please see Testosterone-associated vulvovaginitis (TAVV) Patient information leaflet for more information.