Vaginal estrogen therapy among transgender and nonbinary assigned female at birth individuals: use, effectiveness, and hesitations

Gender affirming hormone therapy is a crucial part of gender affirming care for transgender and nonbinary individuals (TGNB). For TGNB individuals assigned female at birth (AFAB), masculinizing therapy with testosterone suppresses circulating estrogen, which can result in changes to the vaginal epithelium similar to those seen in post-menopausal cisgender women.1 As a result, testosterone use may be associated with vaginal atrophy. Existing research demonstrates that many TGNB-AFAB on testosterone have reported dyspareunia.2,3 There are also reports of vaginal dryness, irritation, and bleeding with penetration.2 Although vaginal estrogen has been recommended for TGNB-AFAB that experience symptoms of vaginal atrophy as a result of testosterone use,3 there are very few studies that evaluate its utilization in these individuals. In fact, much of the existing literature on the impact of vaginal estrogen use on serum testosterone levels is in postmenopausal cisgender women4 and demonstrate no change in the level. The goal of this study is to determine counseling patterns, utilization, hesitations, and barriers to vaginal estrogen use in this population.