What Happens to the Vagina on Testosterone?

Testosterone therapy causes the vaginal lining to thin and lose moisture in a process that resembles what happens during menopause, driven by the same underlying shift: a drop in the estrogen that normally keeps vaginal tissue thick, elastic, and well-lubricated. These changes can start within weeks of beginning treatment and affect everything from the tissue’s microscopic structure to its bacterial ecosystem. For many transmasculine and nonbinary people on testosterone, the effects are manageable or even unnoticed, but for others they bring discomfort that deserves attention and has real solutions.

How the Tissue Changes at a Cellular Level

In the presence of estrogen, the vaginal wall is made up of multiple layers of cells packed with glycogen, a sugar that feeds the beneficial bacteria living on the surface. Testosterone suppresses circulating estrogen, and the vaginal lining responds by losing those upper cell layers. In biopsied tissue from transmasculine people on long-term testosterone, the intermediate and superficial layers of the vaginal epithelium were completely absent and glycogen stores were depleted.¹ What remains is a thinner, more fragile surface that looks and behaves much like the vaginal tissue of postmenopausal cisgender women.²

Lab models comparing estrogen-exposed and testosterone-exposed vaginal tissue help clarify what is different rather than simply what is missing. Testosterone-exposed tissue was thinner with changes in cornification (the hardening of the outermost cell layer), but researchers found no actual breakdown in the epithelial barrier itself. Testosterone also upregulated genes related to tight junctions, which help cells seal together, while dialing down certain inflammatory signaling molecules.³ So the tissue is thinner and drier, but it is not defenseless. It adapts to a different hormonal environment rather than simply deteriorating.

The Bacterial Ecosystem Shifts

The glycogen that disappears from vaginal cells is not just structural filler. It is the primary food source for Lactobacillus, the group of bacteria that dominates a healthy premenopausal vaginal environment and keeps pH low. When glycogen dwindles, Lactobacillus populations collapse. In their place, bacteria more commonly associated with the intestinal tract move in, including species like Prevotella, Anaerococcus, Dialister, and Campylobacter.⁴ The resulting microbial profile closely resembles what researchers see in menopausal cisgender women, reinforcing that the shared factor is estrogen deprivation rather than testosterone itself.⁵

These shifts happen fast. A prospective study that tracked vaginal samples before and after starting testosterone found that after just 12 weeks, participants had a lower likelihood of Lactobacillus dominance, higher bacterial diversity (which in vaginal ecology is actually a marker of disruption, not health), and measurably higher vaginal pH.⁶ Higher pH means a less acidic environment, which can make the tissue more hospitable to opportunistic infections and more prone to irritation.

Common Symptoms and When They Start

The clinical term for what people actually feel is “vaginal atrophy,” and it shows up as dryness, itching, irritation, and pain during penetrative activity. The 12-week study mentioned above found that after testosterone treatment, participants reported more symptoms overall and higher atrophy scores on clinical exam.⁶ Not everyone develops bothersome symptoms, but the tissue-level changes are nearly universal, so a degree of dryness is the norm rather than the exception.

Genital pain during sexual activity is strikingly common. In a large survey of over 1,000 sexually active transmasculine and gender-diverse people, roughly two-thirds reported genital pain or discomfort during sex in the preceding month, most often located at the vaginal opening. Current testosterone users were more likely to report vaginal pain than those who had never used testosterone, though pain at the vaginal opening specifically was reported by about 52% of sexually active participants overall.⁷

There is an interesting wrinkle in that same data, though. Current testosterone users also reported higher interest in sexual activity and were more likely to achieve orgasm than those who had never used testosterone. They were also less likely to report difficulty with lubrication than non-users.⁷ So the picture is not uniformly negative. Testosterone increases desire and orgasmic capacity even as it makes the tissue more prone to discomfort. The two effects coexist, and for many people the net result is a tradeoff rather than a simple loss.

Pelvic Pain and Cramping

Beyond the localized genital symptoms, a broader pattern of pelvic pain shows up in a surprisingly high proportion of people on testosterone. In a study of nearly 500 transmasculine participants, about 72% reported pelvic pain after starting testosterone therapy. The most common description was cramping concentrated in the lower abdomen.⁸

The pain was strongly associated with two things: ongoing menstrual bleeding (testosterone usually stops periods, but not always right away) and pain during orgasm. The association with orgasm-related pain was especially strong, suggesting that pelvic floor muscle dysfunction could be playing a role. The pelvic floor muscles can tighten or spasm in response to hormonal changes, pain avoidance, or emotional stress, and this kind of chronic tension can create its own cycle of discomfort. Pelvic floor physical therapy, which is well established for similar conditions in cisgender women, is increasingly being offered to transmasculine patients, though research in this specific population is still limited.⁸

Does Testosterone Raise Urinary Tract Infection Risk?

Because vaginal atrophy in postmenopausal cisgender women is linked to higher rates of urinary tract infections, it seems reasonable to expect the same in transmasculine people on testosterone. But the data so far do not support that assumption. A study comparing UTI rates between gender-diverse people on testosterone and cisgender women found no meaningful difference: both groups averaged about 0.09 to 0.10 UTIs per year, and about 7% of each group had at least one UTI during the study period.⁹ This is one area where the menopause analogy breaks down. The reason may have to do with age-related differences in immune function or anatomy, or it may simply be that the UTI-atrophy connection in older women is driven by factors beyond estrogen depletion alone. Either way, testosterone therapy does not seem to be a UTI risk factor on its own.

Androgen Receptors in Vaginal Tissue

One important piece of context for all these changes is that vaginal tissue is not just passively responding to the absence of estrogen. It is actively responding to testosterone through its own androgen receptors. These receptors are found throughout the vulvovaginal region, including in the labia, the clitoris, the vestibule, and in all three layers of the vaginal wall (the surface lining, the connective tissue beneath it, and the muscle layer).¹⁰

This means testosterone is not just removing estrogen’s influence; it is actively shaping the tissue in its own right. Research on the role of testosterone in vaginal function (largely studied in the context of cisgender women with low androgen levels) indicates that it helps maintain smooth muscle thickness, supports nerve fiber density, and plays a role in the neurovascular processes that drive arousal-related blood flow and lubrication.¹¹ This dual role helps explain why the picture is complicated: testosterone is simultaneously thinning the epithelium (by suppressing estrogen) and supporting deeper tissue structures (through its own receptors). It is doing two things at once that partially work against each other.

What Pap Tests Look Like on Testosterone

If you are on testosterone and get a cervical screening, your provider should know that the results can look unusual even when nothing is wrong. The atrophic tissue produced by testosterone creates distinctive patterns under the microscope. In one study reviewing Pap tests from transmasculine patients, about 92% of samples showed at least mild atrophy, and the tests had a much higher unsatisfactory rate than usual, reaching nearly 14% when rereviewed by cytopathologists (compared to the standard unsatisfactory rate of under 4% on the original reports).¹² An “unsatisfactory” result does not mean cancer; it means the sample was too thin or dry to read properly, and the test needs to be repeated.

A separate study found that testosterone-treated patients had characteristic cell changes including something called transitional cell metaplasia, seen in about 88% of cases, and unusually small cells, seen in about 82% of cases. These features are not seen in atrophic cisgender samples and appear to be specific to testosterone exposure.¹³ Without awareness of these patterns, a pathologist unfamiliar with testosterone’s effects could flag the sample as abnormal when it is actually a predictable result of the hormonal environment. This is a concrete reason to make sure your provider knows you are on testosterone before ordering a Pap.

Surgical Considerations

Testosterone-related tissue changes have practical implications for anyone undergoing gynecological surgery, particularly hysterectomy. The thinner, less elastic vaginal and cervical tissue can make procedures more technically challenging. In a case series of transmasculine patients undergoing laparoscopic hysterectomy, intraoperative complications included vaginal lacerations, cervical avulsion (tearing of the cervix from surrounding structures), and bladder injury, with contributing factors identified as cervical atrophy, cervical stenosis (narrowing), and reduced vaginal elasticity from long-term testosterone use.¹⁴

Recovery can also look different. In a study of transgender adolescents and young adults who underwent hysterectomy while on testosterone, over half reported postoperative vaginal bleeding concerns. These were most often traced to atrophy and granulation tissue (a type of fragile healing tissue), suggesting that the thinned vaginal lining may be more susceptible to trauma during surgery and more prone to this kind of incomplete or bumpy healing process afterward.¹⁵ None of this means surgery is unsafe, but it does mean surgical teams benefit from experience with testosterone-treated tissue, and patients benefit from knowing that some post-surgical bleeding may be related to atrophy rather than a complication requiring alarm.

Managing Vaginal Dryness and Discomfort

The most effective intervention for testosterone-related vaginal atrophy is topical estrogen applied directly to the vaginal tissue. This is a low-dose, locally acting treatment that restores thickness and moisture to the vaginal lining without meaningfully raising systemic estrogen levels, which means it generally does not interfere with testosterone’s masculinizing effects. Many transmasculine people use it successfully, though some understandably have concerns about using any estrogen-based product, and the conversation with a prescribing provider is worth having openly.

For those who prefer to avoid estrogen entirely, intravaginal DHEA (a precursor hormone that converts locally into both estrogen and androgens) is another option. Randomized trials in postmenopausal cisgender women found that vaginal DHEA improved sexual dysfunction and atrophy symptoms at least as effectively as vaginal estrogen.¹⁶ Whether DHEA performs identically in testosterone-treated transmasculine people has not been tested in a dedicated trial, but the mechanism is plausible given the shared underlying cause of atrophy.

Beyond prescription treatments, over-the-counter vaginal moisturizers (used regularly, not just before sex) and water-based or silicone-based lubricants during sexual activity can make a significant difference in day-to-day comfort. These are not treating the tissue changes, but they are addressing the symptom most people care about most, which is dryness and friction.

What the Menopause Comparison Gets Right and Wrong

Clinicians and researchers frequently compare testosterone-related vaginal changes to menopause, and the comparison is genuinely useful: both states involve estrogen deprivation, both produce a similar-looking thinned epithelium, and both shift the vaginal microbiome away from Lactobacillus dominance. But the comparison has limits. People on testosterone are typically young, with all the vascular health and healing capacity that comes with youth, which may explain why UTI rates do not rise the way they do in older postmenopausal women. The tissue’s response to testosterone itself, through androgen receptors in all layers of the vaginal wall, adds a variable that does not exist in menopause. And the cellular appearance under a microscope is not identical: the transitional cell metaplasia and small-cell patterns found on Pap tests from testosterone-treated individuals do not show up in atrophic postmenopausal samples.¹³ So while “like menopause” is a helpful shorthand for understanding the broad strokes, the testosterone-exposed vagina is its own distinct biological state, not a copy of an older one.

Clitoral Growth and External Changes

While most of this article has focused on the internal vaginal environment, testosterone also causes visible changes externally. Clitoral growth (sometimes called “bottom growth”) is one of the earliest and most consistent effects of testosterone therapy. The clitoris enlarges, sometimes substantially, and the tissue becomes more sensitive. This is generally experienced positively, but increased sensitivity can also mean increased vulnerability to irritation from clothing or friction. The clitoral pain reported by about 29% of sexually active participants in the large survey discussed earlier may partly reflect this heightened sensitivity in combination with atrophic changes in the surrounding vulvar tissue.⁷ Unlike vaginal atrophy, clitoral growth is permanent and does not reverse if testosterone is stopped.

The labia may also change in texture and moisture over time, becoming somewhat thinner and less cushioned as local estrogen effects diminish. These external changes tend to get less clinical attention than the internal ones, partly because they are less likely to cause medical problems and partly because the research has focused on the vaginal canal and cervix. But for people navigating these changes in their daily lives, the external shifts can be just as noticeable and worth understanding as part of the full picture.

1
PubMed Central. Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-α and -β expression of young women
2
Europe PMC. The Effect of Gender-Affirming Medical Care on the Vaginal and Neovaginal Microbiomes of Transgender and Gender-Diverse People
3
Europe PMC. Epithelial Changes in the Testosterone-Dominant Vagina: Implications for Menopause, Transgender Care, and Beyond
4
Nature. The vaginal microbiome of transgender men receiving gender-affirming hormonal therapy in comparison to that of cisgender women – Section: Results
5
Nature / Scientific Reports. The vaginal microbiome of transgender men receiving gender-affirming hormonal therapy in comparison to that of cisgender women
6
CrossRef. Characteristics of the Vaginal Microbiome Before and After Testosterone Treatment in Transgender Men – Section: Results
7
American Journal of Obstetrics and Gynecology. Testosterone Use and Sexual Function among Transgender Men and Gender Diverse People Assigned Female at Birth – Section: Results
8
PubMed Central. Pelvic Pain in Transgender People Using Testosterone Therapy – Section: Results
9
PubMed Central. Urinary Tract Infections Among Gender Diverse People Assigned Female at Birth on Testosterone
10
PubMed Central. Expression of androgen receptors in the structures of vulvovaginal tissue
11
PubMed Central. Testosterone and Vaginal Function
12
Wiley Online Library. Cervicovaginal Papanicolaou tests in transgender men: Cytomorphologic alterations, interpretation considerations, and clinical implications – Section: RESULTS
13
Wiley Online Library. Cytomorphologic findings of cervical Pap smears from female-to-male transgender patients on testosterone therapy – Section: RESULTS
14
BioMed Central. Intraoperative complications during gender-affirming laparoscopic hysterectomy in transgender men receiving testosterone: a case series – Section: RESULTS
15
Elsevier. Postoperative Vaginal Bleeding Concerns after Gender-Affirming Hysterectomy in Transgender Adolescents and Young Adults on Testosterone – Section: CONCLUSIONS
16
Elsevier / Maturitas. Efficacy of intravaginal dehydroepiandrosterone (DHEA) for symptomatic women in the peri- or postmenopausal phase