How you can have better, less painful sex with vaginal atrophy

Is vaginal atrophy part of perimenopause and menopause?

At the same time you're dealing with hot flashes, memory changes, and loss of libido, you might also be suffering from vaginal atrophy. GSM occurs during perimenopause and menopause when the ovaries start producing less and less estrogen. “The genital tissues go into a kind of ‘estrogen starvation mode,” says Firefox, who is also the founder and facilitator of the Gender-Affirming Menopause Care Certification course for care providers.

These symptoms are common and not only cause pain but also sexual dysfunction, and yet while there are some treatments available, the condition hasn’t been widely studied, Bhaiji says.

“Despite affecting at least half of women during perimenopause and menopause, vaginal atrophy remains significantly under-recognized, under-treated, and under-researched,” she says.

How does vaginal atrophy impact the transgender community?

Testosterone can be life-saving for trans folks — taking HRT is linked to better mental health outcomes, including lessening depression, anxiety, and suicidal ideations — but like any medicine, it can come with side effects.

“Vaginal atrophy often affects trans men who undergo gender-affirming hormone therapy (GAHT),” Bhaiji says. “Testosterone suppresses the body's estrogen production, meaning the vaginal tissues are no longer able to naturally maintain their thickness, elasticity, and lubrication. This can mimic many aspects of the vaginal changes experienced by cisgender women during menopause.”

And just like GSM caused by menopause, this side effect of taking T is understudied. “Unfortunately, this is yet another area where research is limited,” she says. “We still need more evidence to understand how different testosterone doses affect vaginal health and how best to prevent and manage these kinds of symptoms.”

For Feng, he was used to menstrual pain, but experiencing GSM after taking T was a whole new ball game. “Being in the driver’s seat of this new side effect of being on testosterone meant feeling a new — and frankly awful — road of ouch,” Feng says. “The first time I just sat on the toilet, gripping my legs, unable to move, knowing something was wrong.”

But HRT isn’t the only thing that can cause reduced estrogen leading to GSM. Anyone who undergoes an oophorectomy — where the ovaries are removed — could also experience GSM.

Getting information about the symptoms of GSM and what can be done to treat it is even more complicated for the trans community because the condition is usually framed around cis women. Feng says more needs to be done to educate people because he was left in the dark.

“We need it described in detail to understand what exactly that could feel like,” he says. “Give me a pamphlet, an infograph, or video about what I can expect. Because when the unexpected happened, it sucked, and there was a delay in linking the symptoms with the diagnosis and the diagnosis with the treatment and the treatment with the doctor appointment. That’s a lot of time in pain.”

What treatments are available if you’re trans?

For transgender men and transmasculine people experiencing GSM symptoms, the treatments are largely the same as the ones available to cis women, but the option you choose may be influenced by your gender identity and whether taking estrogen gives you dysphoria.

“Trans men often face not only the stigma surrounding vaginal health, but also the additional barrier of gender dysphoria, which can make accessing vaginal care particularly confronting and difficult,” Bhaiji says.

This is exactly what Feng was worried about when presented with the treatment options after he started having symptoms. “I was worried how it would affect my transition — yes — but the pain was so excruciating and all-encompassing that I felt like even if there were side effects, I’d suck it up,” Feng recalls. “I chose the pill form, started using it, and within two weeks I felt back to normal. When I forget to take the pill and am exercising, the torturous sensations get me back on track to taking the pill. The estrogen pill feels like a lifesaving drug — I don’t know how I could function properly with the pain caused by vaginal atrophy.”

Firefox had a similar experience when they finally decided to bite the bullet and try estrogen because the symptoms of GSM were so severe. “I had had terrible experiences with estrogen over the years, and was loath to try it in menopause treatment,” Firefox says. "But what I have found is that a low-dose, steady-state estrogen has been a revelation. It's nothing like my ‘natural' experience of estrogen, which was incredibly dysphoria-inducing.”

For other people in the trans community who are worried about the same thing, Firefox recommends finding an estrogen option that works for you because it can be life-changing. “Some trans folx shy away from estrogen. To that, I want to say: hormones have no gender,” they say. “All bodies need all the sex hormones, just in different proportions. Estrogen is really the answer to GSM, and using genitally applied estrogens is not systemic, so there is no risk of feminization with this kind of use.”