Taking testosterone has been transformative for me. I remember talking to my husband during my first week on T, and likening my experience to getting glasses for the first time: not realizing what it would feel like to actually see, not realizing that how I saw before wasn’t as crisp.

That was more than nine years ago.
 

If you’ve ever taken T for gender-affirming care—or if you’re considering it—you’ll likely know the typical list of effects: your voice drops, you may grow facial and more body hair, your clit grows into a T-dick, you probably want to hump everything and everyone around you in the beginning.
 

One less favoured effect of T, though, is the potential to develop genitourinary symptom of menopause (GSM), formerly known as vaginal atrophy. Much like cis women going through menopause, the drop in estrogen associated with taking T can induce dryness and thinning in front-hole tissues, making them more prone to tearing, which can hurt.

This may or may not be an issue for you.
 

The latest findings from 2022 U.S. Trans Survey (USTS), the largest trans-led survey of trans people in the country, indicate that about 1 percent of respondents assigned female at birth have had a vaginectomy—surgery to remove the vagina, after which there is only smooth, flat skin where the opening once was. Another 9 percent want to have a vaginectomy someday and 28 percent aren’t sure if they might one day. Among trans men specifically, the 2022 USTS found that 2 percent have had a vaginectomy while another 16 percent want to someday—the discrepancy highlights persistent barriers to accessing gender-affirming care.
 

Additionally, keeping your front hole doesn’t mean you necessarily want or need to use it for sex, alone or with partners. If that’s the case, you may be less concerned with changes in lubrication or texture.

That said, if you do keep your front hole and are concerned about possible irritation or atrophy, symptoms are easily manageable. To walk me through the basics, I reached out to Sarah Fraser, MD, MSc, CCFP, queer family physician and founder of Coastal Gender Affirming Care in Halifax.
 

What is vaginal atrophy for folks on T?

“The vaginal tissues are estrogen-dependent, so as testosterone lowers estrogen, the tissue gets thinner, drier and more easily irritated,” says Fraser. “People notice dryness, burning, itching, pain with penetration, sometimes small tears and a higher chance of bacterial vaginosis, yeast [infections], and UTIs [urinary tract infections].”
 

Why can T cause front hole atrophy?

Long story short, “it’s the same mechanism as menopause, low estrogen at the tissue level. Changes often start within three to six months of T and peak around one to two years,” says Fraser.
 

Basically, when estrogen decreases, the pH of the front hole changes along with the composition of the front-hole microbiome. The resulting irritation is a common menopausal symptom for folks on T, regardless of age or menopausal history.
 

How common is front-hole atrophy on T?

“A high proportion of folks on T get symptoms,” says Fraser. “A study put painful sex alone around 60 percent, and most people on sustained T show some degree of atrophic change.” Not enough research exists to confirm whether people on “full” doses of T experience atrophy differently than those taking “microdoses.”
 

How can I manage symptoms?

Fraser recommends local, topical estrogen as the primary course of treatment: it might seem counterintuitive to take estrogen, but the most common formats—the tablet and the cream—are designed for local-only effects. This type of intervention is also low-dose, “so it won’t interfere with testosterone or its effects,” Fraser says. “Simple intervention, great results and it also helps prevent recurrent UTIs.”

In other words, localized estrogen can soothe your hole without messing with your T. Fraser says the tablet and cream preparations are “usually nightly for two weeks then twice weekly,” and do not have any systemic effects.
 

Some people also use a low-dose estrogen ring, “which can lead to more systemic absorption but [is] still unlikely to overpower [the] effect of T,” says Fraser.
 

One caveat: if you have any history of hormone-dependent cancer (such as breast or ovarian cancers), tell your doctor first. For many years, care guidelines advised against any kind of hormone therapy with this history. However, more recently, researchers have begun looking to low-dose vaginal estrogen as a way to treat vaginal atrophy in breast, endometrial, uterine and other cancer survivors. The results look promising so far: a recent study found vaginal estrogen safe for those with a history of genitourinary cancers, and another found the same for those with a history of breast cancer.
 

What else helps?

Lube, lube and lube! As a sex educator, I can’t emphasize enough how much using lube your body likes can help to both promote pleasure and reduce bad pain. Any time you’re inserting a hand or toy or dick or anything else into your front hole for sexual play, use lube.

Water-based lube is a great default and is compatible with condoms and gloves and toys; silicone-based lube feels incredible and lasts longer and works with condoms and gloves but degrades silicone toys; oil-based lubes last a long time but degrade latex condoms.
 

If you’re not sure what kind of lube your body likes, or if you have very sensitive skin, consider getting a small sampler pack of various types and do spot tests on your skin. Feminist sex toy shop the Smitten Kitten produced a comprehensive guide to lube pH and osmolality and irritating ingredients in 2015 that we sex educators still swear by—check it out for a user-friendly way to find what’s right for you.

Also, the same idea, but for your outer skin around your front hole: consider a gentle moisturizer. Sometimes the skin irritation folks experience on T extends from inside your front hole to the surface of your genital skin. Be gentle with yourself and moisturize if you need it.