Gender Identity Service

From: BASHH best practice statement on the management of testosterone-associated vulvovaginitis

What is testosterone-associated vulvovaginitis?

Some trans gender masculine and non-binary people who were assigned female at birth may notice changes to their vulva (outside area) and vagina/front hole after starting testosterone. These changes can happen at any age. Symptoms might start soon after beginning testosterone, or only after several years.

Testosterone-associated vulvovaginitis (also called vulvovaginal atrophy) can cause

• Dryness
• Itching
• Changes in discharge
• Thinner skin
• Stinging when peeing
• More infections
• Pain or swelling inside the vagina/front hole

These symptoms might also make sex or medical examinations feel uncomfortable.

What causes testosterone-associated vulvovaginitis?

Testosterone lowers the amount of estrogen your body makes. Estrogen helps keep the skin and lining of the vulva and vagina soft and moist. When estrogen levels drop, the skin can become thinner and drier.

Testosterone can also change the pH (acidity) inside the vagina and the balance of normal bacteria. These changes can cause irritation or inflammation.

Other conditions, like infections or skin problems, can cause similar symptoms, so it’s important to speak to a healthcare professional. They may suggest an examination or tests.

If you are worried about being examined or having tests, because of physical discomfort or because of anxiety or dysphoria, talk to your healthcare provider: they may be able to suggest options such as extra appointment time, extra lubrication, self-insertion of the speculum, using a smaller speculum, self-swabbing, or delaying examination until after treatment has begun.

How can it be treated?

There are not many studies on testosterone-associated vulvovaginitis in transmasculine people, but treatments used for cisgender women with similar symptoms often help.

The main treatment is topical estrogen, which puts a small amount of estrogen directly on the affected tissues.

Options include:

• Vaginal pessaries (small tablets you insert)
• Estrogen cream or gel
• A vaginal ring that stays in place for up to 3 months

These give low-dose estrogen straight to the tissues that need it.

All of these treatments are used “off-label” for trans masculine people. This is very common in healthcare and does not mean the treatments are unsafe.

Topical estrogen can take time to work. You may need to use it for at least 3 months before deciding whether to continue or try another option. You can keep using it long-term if it helps.

Some people may find that trying a few different for mulations, setting alarms/reminders, and asking for support from partner/friends/family can help with sticking to a treatment plan.

Will topical estrogen affect my transition goals?

No. These treatments do not interfere with testosterone or stop the changes testosterone causes in your body. The estrogen stays mainly in the area where it is applied and is absorbed very little into the rest of the body. It will not cause (re-) feminisation.

Are there any risks to my general health?

The risk of health problems from topical estrogen is very small. Package information often lists risks linked to full-body estrogen, but these do not apply to low-dose topical products.

A very small amount of estrogen may enter the blood stream. If you have had breast cancer or another hormone- dependent cancer, or if you take medicines called aromatase inhibitors, speak to your clinician before using it.

Topical estrogen does not increase:

• The risk of blood clots
• The risk of womb-lining overgrowth

Avoid receptive vaginal sex for 1 h after applying estrogen cream or gel.

Topical estrogen is not a contraceptive and may damage condoms. Use another form of protection if you need to prevent pregnancy.

If you are pregnant, chestfeeding, or planning to be, speak to your clinician first.

You can safely use lubricants along with topical estrogen.

Are there other options?

Yes. Moisturisers and lubricants can help ease dryness and irritation. Your clinician can suggest safe brands. Check whether products are condom-safe if needed.

Using gentle, non-irritating skin cleansers and emollients instead of strong soaps can also help.

Vulval skincare

What should I do if problems continue?

Contact your clinician if symptoms continue or get worse despite treatment, or if you notice:

• New vaginal bleeding
• New or unusual discharge
• New or increasing pain

You may need other tests, treatments, or a referral to another specialist (for example, sexual health, dermatology or gynaecology).

Your healthcare team will work to make sure your needs and dignity are respected.

Please see the vaginal atrophy page for more information about Testosterone Associated Vulvovaginitis (TAVV).