What vaginal atrophy is, who it affects and how it is treated

Perimenopause, menopause and testosterone-based hormone replacement therapy can all lead to vaginal atrophy, a condition linked to falling estrogen levels.

The medical issue affects people regardless of gender identity. For cisgender women, it often appears during menopause. For transmasculine, nonbinary and gender-diverse people, it can also develop after testosterone treatment. It may also occur after an oophorectomy, when the ovaries are removed.

Vaginal atrophy is increasingly known by the broader term genitourinary syndrome of menopause, or GSM. The condition can involve vaginal thinning, dryness and inflammation, and can also bring burning, itching, spotting, microtears, pain during sex and recurrent urinary tract infections.

Dr. Amira Bhaiji, a sexual health expert and a medical board member for Daye, said the condition can have “a significant impact on quality of life.” Lasara Firefox Allen, an accredited menopause educator and author of Gender Queer Menopause, said symptoms can also include urinary issues, more UTIs, VB infections, yeast infections and pH-related problems.

Jericho Feng, a therapist who has provided LGBTQ-affirming therapy for 12 years, described the sensation as painful and difficult to pin down. Feng said it can feel like an unexplained problem between the belly button and vagina, similar to a UTI but not quite the same.

The condition is common during perimenopause and menopause, when the ovaries produce less estrogen. Firefox Allen said the genital tissues can enter “estrogen starvation mode.” Bhaiji said vaginal atrophy affects at least half of women during perimenopause and menopause, yet remains under-recognized, under-treated and under-researched.

Testosterone can be life-saving for trans people and is linked to better mental health outcomes, including lessening depression, anxiety and suicidal ideations. But Bhaiji said it can also cause vaginal atrophy in trans men receiving gender-affirming hormone therapy because testosterone suppresses estrogen production and reduces tissue thickness, elasticity and lubrication.

Research on how testosterone dose affects vaginal health remains limited. Bhaiji said more evidence is needed to understand how best to prevent and manage the symptoms.

Feng said the condition disrupted his own sex life after he began taking testosterone. He said the first time he experienced the symptoms, he sat on the toilet unable to move because something felt wrong. Firefox Allen also said trying estrogen in menopause treatment was difficult at first because of previous experiences, but that a low-dose, steady-state option brought relief.

Available treatments are largely the same for cis women and transmasculine people, though gender dysphoria can affect what a person is willing to use. Options include topical estrogen creams, vaginal tablets, vaginal rings, moisturizers, lubricants and pelvic floor physical therapy. Systemic hormone replacement therapy may also help with hot flushes, brain fog and anxiety alongside vaginal symptoms.

Firefox Allen said topical estrogen can be prescribed as a cream, a tablet in an applicator or an Estring ring. Bhaiji said common options include low-dose creams such as Estrace or Premarin, vaginal tablets like Vagifem, and vaginal rings that deliver localized estrogen.

For some trans people, choosing a treatment can involve balancing symptom relief with concerns about dysphoria. Feng said he chose the pill form and felt back to normal within two weeks. Firefox Allen said that for genitally applied estrogen, “there is no risk of feminization with this kind of use.”

Experts also say communication matters. Bhaiji noted that partners may not understand the condition because public education is limited. Feng recommended talking to a gender-affirming care doctor, speaking with sexual partners, watching for symptom patterns and reducing friction with extra lube, softer clothing and position changes.

Firefox Allen said lubricants should be pH-safe so they do not worsen symptoms. They said the right lube can reduce the risk of tears and irritation and make sex more comfortable.

For LGBTQ communities, the issue also highlights a broader gap in health care access and education. Because GSM is still often framed around cisgender women, transmasculine and nonbinary people can be left without clear information about symptoms, diagnosis and treatment.

What the experts say

• Dr. Amira Bhaiji said vaginal atrophy affects at least half of women during perimenopause and menopause.
• Lasara Firefox Allen said estrogen can help and that genitally applied estrogen is not systemic.
• Jericho Feng said better education and clearer materials would help people recognize symptoms sooner.

What treatments are available

• Low-dose topical estrogen creams such as Estrace or Premarin
• Vaginal tablets like Vagifem
• Vaginal rings that deliver localized estrogen, including Estring
• Moisturizers and lubricants
• Pelvic floor physical therapy
• Systemic hormone replacement therapy for broader menopausal symptoms

As estrogen falls and vaginal tissue becomes thinner and drier, sex can become painful. Experts say the condition does not have to define a person’s sex life, but it may require patience, communication and medical care.