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Atrophy on Testosterone: Everything You Need To Know

Trans_catdad
August 31, 2022
8:15 am

Atrophy is more than just feeling dry. It’s a chronic and progressive condition affecting the genitourinary system, which includes not just the front hole, but the urinary tract, bladder, and uterus as well. In this article, we’ll go over everything you need to know about atrophy: its cause, symptoms, and treatment options. Even in the absence of PIV sex, the effects of atrophy can negatively affect a person’s health and quality of life.

Content Warning!

Reproductive organs and genitals will be mentioned by name, for the sake of accuracy. I will always correct exclusionary and cisnormative language where possible, and I’ll do my best to avoid potentially dysphoria-inducing imagery without a warning. Primary sources tend to be cisnormative – please keep that in mind when clicking any links!

Genitourinary Syndrome of Menopause

Jumping right into the dysphoria-triggering language, the first thing you should know about atrophy is its real name: Genitourinary Syndrome of Menopause (GSM). It was officially renamed from Atrophic Vaginitis and Vulvovaginal Atrophy in 2014 (source). This is important for a number of reasons:

For one, knowing the current terminology makes it much easier to find accurate information. Searching for “FTM atrophy” can get you some decent results, but it’s also a good way to end up on Buck Angel’s fearmongering “educational” videos on the subject (for the love of god, do not listen to a word that man says). And two, the term “vaginal atrophy” only describes one of GSM’s many possible effects. Testosterone replacement therapy affects the entire genitourinary system, which includes not just the vagina, but the vulva, urethra, bladder, cervix, and uterus as well. To put it plainly, “GSM” is medically accurate and “atrophy” is not. Knowing the proper name of the condition can help you communicate with health care professionals. A doctor who is hesitant or confused at the idea of treating a trans guy’s atrophy might be less flustered if you explain it’s the same condition that cis women experience due to menopause.

And lastly, because the term is less stigmatizing. Transphobes assert that atrophy is dangerous, disabling, irreversible, and exclusively inflicts trans people. This is false. In reality, the condition is very common and highly treatable. In recent surveys, 45% to 63% of postmenopausal cis women reported symptoms of GSM, vaginal dryness being the most common (source). It occurs in younger people due to oophorectomy (removal of the ovaries), medications such as birth controls or E blockers, chemotherapy, or even breastfeeding. Any condition or medication that lowers your estrogen levels can cause atrophy. The atrophy that we experience from T is only as dangerous as menopause. That is to say, it’s more uncomfortable and annoying than it is a genuine risk to your health.

TLDR; atrophy is a colloquial term for GSM (genitourinary syndrome of menopause). In this article, I may occasionally use the term “atrophy” instead of the more proper term, GSM. Oh also TERFs can rot in hell, as a treat.

Why Do Trans Masculine People Experience Atrophy?

The North American Menopause Society defines GSM as “a collection of signs and symptoms associated with estrogen deficiency that can involve changes to the labia, introitus, vagina, clitoris, bladder and urethra.” GSM is caused by hypoestrogenism, a lack of estrogen in the genitourinary system. The vagina, bladder, urinary tract, cervix, and uterus all contain high concentrations of estrogen receptors.

These receptors bind with estrogen to modulate cellular proliferation, the process by which a cell grows and divides. If estrogen is low in supply, your body may fail to replace dying cells in your bladder, urinary tract, vagina, and other bits. In English: atrophy doesn’t just reduce self-lubrication. It thins the tissues in the vagina and urethra, making them more vulnerable to injury and infection. Atrophy tends to increase the pH level of the vagina, making it more alkaline and less acidic. A healthy vagina is moderately acidic with a pH between 3.8 – 5.0 (source). An acidic environment helps serve as a defense against various bacterial and fungal infections such as bacterial vaginosis, yeast infections, and UTIs.

Even if you’re not on estrogen blockers, the administration of testosterone significantly decreases your systemic estrogen levels by suppressing the ovaries. When a person uses testosterone therapy (whether they’re AMAB or AFAB), their hypothalamic-pituitary-gonadal axis (HPG) detects the testosterone in their body and says to their gonads, “Hey, we’ve already got plenty of sex hormones in here! Don’t bother making any more, just take a break :)” In typical AFAB bodies, this means the ovaries are suppressed; menstruation ceases and estrogen production plummets, triggering an early (and sometimes reversible) menopause.

It is not the presence of testosterone that causes the atrophy, but the absence of estrogen. I can feel some of you getting nervous at the mention of testosterone being the cause of trans masculine atrophy and estrogen being the solution to it, so let me be perfectly clear: you do not have to quit testosterone to treat atrophy. And topical estrogens are unlikely to negatively affect your transition due to their very low systemic absorption. However, if topical estrogen therapy is not an option for you, there are some non-hormonal options available to help manage the condition.

Why GSM can sometimes be worse for trans folks

There is an upsetting lack of research specific to trans bodies, to be sure. If menopausal cis women did not experience GSM, we would have little medical understanding of it. Luckily, the testosterone-induced atrophy that trans masc folks experience is in almost every way identical to the very well-researched GSM that cis women experience as a result of menopause. So let’s get down to learning!

GSM is a chronic and progressive disease, meaning it tends to get worse over time and is unlikely to improve without intervention. Due to its chronic and progressive nature, GSM can be more problematic in trans folks than in people who experience it due to menopause. Why? The answer is “time”. Menopause is a mid-life event, with an average onset of age 51. “Given current life expectancies, most people can expect to live almost 40% of their lives after menopause” (source). But for trans masculine people, the onset of GSM can be as early as our teens or twenties, and many folks (including myself) notice symptoms of GSM after only a few months on T. This means that the condition has the potential to worsen over six decades or more — that’s double the amount of time most cis women have to put up with it. After 12 months on testosterone, the lack of estrogen available to my bladder and urinary tract caused me to develop chronic urinary tract infections. I went through several rounds of antibiotics, visited the emergency room a few times, dealt with peeing out blood, itching, burning, and even leaky bladder. It heckin sucked, but I recovered after treating my atrophy with a topical estrogen. I’ve been UTI-free since March 2021. If atrophy gets worse over time, I don’t even wanna know what it’d be like if I left it untreated for sixty years.

Don’t get too freaked out, though. A lot of the things I’m going to mention in this article are going to sound pretty scary, but like I said before, GSM is very treatable. Some folks don’t notice a single sign of atrophy after five years or longer on T. You might be lucky, and you might not. I just happen to be a highly sensitive lad.

Aside from the time factor, another reason GSM can be worse for trans folks than cis folks is access to healthcare. Trans people are impoverished at much higher rates than cis people, which makes access to preventative treatment unlikely. Many doctors lack the knowledge necessary to treat trans patients, and some are downright transphobic. The fear of being disrespected in the doctor’s office is a reasonable one; I’ve personally had to file a grievance due to a doctor treating me like a spectacle rather than a patient. And of course, there’s the dysphoria factor. Talking about these body parts with a stranger and potentially subjecting yourself to an examination of your least favorite body parts is far from a pleasant experience. I highly recommend reaching out to your local trans community to find trans-friendly medical professionals in your area.

Signs and symptoms: how do I know if I have it?

Testosterone-induced GSM is relatively easy to self-diagnose, but because other conditions can manifest in ways that are very similar to GSM (and because GSM can make these body parts more prone to infection), it is very important to see a doctor to ensure that you’re not leaving anything untreated.

Here are some common symptoms of GSM:

Vaginal symptoms:

pain, itching, or burning
pain or difficulty with penetration
bleeding with penetration
dryness/lack of lubrication
change in discharge
change in smell
recurring yeast infections or bacterial vaginosis
increased pH (5.0 or above may indicate atrophy or infection)

Urinary symptoms:

urinary urgency
leaky bladder
recurring urinary tract infections
pain, burning, or itching with urination

Vulval symptoms:

shrinking of the labia
dryness (skin may flake, peel, or crack)
pain, itching
redness, inflammation

*Life Pro Tip: If you live in a shithole country like the United States and have to limit doctor visits for financial reasons, you can buy an over the counter UTI test for around or less than $10. I started keeping AZO test strips at home after I started getting chronic UTI’s. (Here’s a link to the ones I keep at home). You can also keep pH test strips handy to help diagnose atrophy or infection. (Here are some vaginal pH test strips on Amazon).

I knew I had atrophy (and a UTI) when it burned when I peed. And I mean burned. I would wake up feelin’ fine, but after taking my morning piss, I’d be squirming for the rest of the day from the itching and burning. Before developing that first UTI, I was starting to notice less lubrication during arousal, as well as a different and mildly unpleasant smell down there. During PIV sex – and this embarrassed the heck outta me – I started leaking urine. I was not a happy camper.

Happily, these symptoms have resolved since starting Nuvaring. I’ve been UTI-free since March 2021 🙂 Sweet relief.

A pelvic exam is generally not required for an atrophy diagnosis. A good gynecologist will already know that dysphoria can be a barrier to pelvic exams, and can diagnose the condition just by hearing you describe your symptoms. My gynecologist gave me instructions to take a swab sample to rule out various infections, and she left the room to give me privacy. Plenty of gynecologists are wonderful, trans-educated, empathetic people.

“Anatomic changes include reduced collagen content and hyalinization,
decreased elastin, thinning of the epithelium, altered appearance and
function of smooth muscle cells, increased density of connective
tissue, and fewer blood vessels.The labia minora thin and regress, the
introitus retracts, and the hymenal carunculae involute and lose
elasticity, often leading to significant entry dyspareunia. The urethral
meatus appears prominent relative to the introitus and becomes
vulnerable to physical irritation and trauma.” (Source)

How do I treat atrophy?

Alright! So you have atrophy. Now what the heck should you do about it?

Some of you won’t want to hear this but, the most effective and reliable method to treating atrophy is to address the root cause. Remember, atrophy is caused by hypoestrogenism, a lack of estrogen. Providing a steady supply of estrogen to the area will prevent and gradually reverse the damage of atrophy. To give you an idea of how long it’ll take to reverse atrophy with a topical estrogen, I started Nuvaring on September 25, 2020 and had my final UTI on March 14, 2021. Over those six months, the UTIs became less frequent and less severe. In my case, there was a noticeable improvement in dryness during my first two or three weeks on Nuvaring. It’s important to remember that atrophy won’t heal over night. Nuvaring did the job for me, but it still took nearly half a year.

Being hesitant to put estrogen in your body is a reasonable reaction. After all, estrogen-dominant puberty is what caused my dysphoria in the first place. I am painfully aware of the social stigma on trans and gender-nonconforming bodies and of cis/hetero-normative body standards. Guys are expected to be testosterone monsters, and estrogen is branded the laughing stock of hormones, turning men into soy boys or whatever. I get it.

So let me ease your concerns:

Topical estrogen treats atrophy without increasing serum estrogen (E2) levels. (Source)

One month after starting the topical estrogen Nuvaring, my estradiol serum level tested at less than 5.00 pg/mL. In other words, Nuvaring did not increase the amount of estrogen in the rest of my body — the absorption is almost totally limited to those “downstairs” organs.

When postmenopausal women used a vaginal ring for 12 months, their E2 serum levels increased from 13.5 pg/mL to a whopping 15 pg/mL. (“Whopping” is sarcasm. That’s hardly any gotdamned estrogen at all!)

Normal levels for estradiol are: 30-400 pg/mL for premenopausal women. 0-30 pg/mL for postmenopausal women. 10-50 pg/mL for men. (Source)

Topical estrogen won’t feminize your body.

Now here’s what you should be concerned about.

Some topical estrogens (and progesterone) can increase a patient’s sex hormone binding globulin (SHBG). One month after starting Nuvaring, my SHBG was very high at 182 nmol/L.The normal ranges for SHBG concentrations in adults are 10-57 nmol/L in males and 18-144 nmol/L in non-pregnant females (Source). Fun fact: it’s theorized that SHBG rises to astronomical heights during pregnancy in order to protect the pregnant person from exposure to fetal androgens. Excessive SHBG effectively renders testosterone useless, and my SHBG was certainly excessive.

If you’re not interested in biochemistry and endocrinology, I’ll give you the TLDR version of the next few paragraphs:

Your doctor must check your SHBG and albumin in order to accurately measure your testosterone levels. This is especially important if you’re using a topical estrogen and/or progesterone. If your doctor refuses to check these or tells you that it’s unnecessary, find a different doctor.

My primary care physician was unaware of the fact that excessively high levels of SHBG can decrease the bioavailability of testosterone, so I sought out a trans-educated endocrinologist to take over my transitional care. Here’s how it works:

Testosterone and dihydrotestosterone (DHT) bind to the proteins SHBG and albumin. Testosterone can’t do its job (masculinizing your body) if all of it is bound to SHBG or albumin. This is why it’s important to see an endocrinologist and not just a family doctor. If you start a topical estrogen to treat atrophy, it’s very important that you get your levels checked regularly as your body adjusts to the new medication. Make sure that your doctor checks not just your serum testosterone level, but your SHBG and albumin as well, so they can calculate your free and bioavailable testosterone: that is, the testosterone in your body that’s actually free and able to do some work.

To counteract a high SHBG level, your doctor will likely just have to increase your testosterone dose. There is no one-size-fits-all dose when it comes to testosterone. It’s all about calculating the right dose for your body with an experienced endocrinologist!

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