Is vaginal atrophy caused by testosterone (exogenous testosterone) use reversible if testosterone is discontinued?

Vaginal Atrophy from Testosterone Use is Generally Reversible Upon Discontinuation

Vaginal atrophy caused by exogenous testosterone is typically reversible when testosterone is discontinued, though the timeline for recovery varies and symptoms may persist for months. This parallels the reversibility seen with other forms of hormone-induced vaginal atrophy, where restoration of normal hormonal milieu allows vaginal tissue to recover 1, 2.

Mechanism and Reversibility

• Exogenous testosterone causes vaginal atrophy through decreased estrogen in the vagina and subsequent atrophic changes to vaginal tissue, similar to postmenopausal estrogen deficiency 2
• When testosterone is discontinued, the suppression of endogenous estrogen production typically resolves, allowing vaginal tissues to regenerate 1
• The recovery process mirrors what occurs in postmenopausal women who receive estrogen therapy—vaginal tissue can restore its normal architecture when adequate estrogen becomes available 1, 3

Evidence from Treatment Studies

• Studies demonstrate that vaginal atrophy responds well to hormonal interventions, with treatment leading to restoration and maintenance of vaginal function and vaginal health 4
• A 12-week treatment trial showed significant improvement in vaginal trophism with both testosterone and estrogen therapy, demonstrating the tissue's capacity for regeneration 3
• Treatment with vaginal estrogen results in relief of symptoms in 80-90% of patients, indicating that atrophic changes are not permanent structural damage 1

Timeline and Clinical Considerations

• The recovery timeline after testosterone discontinuation is not well-defined in the literature, but likely requires several months for complete tissue restoration 1
• During the recovery period, symptoms of vaginal atrophy (dryness, dyspareunia, discomfort) may persist and require symptomatic management 1, 2
• Over 60% of transgender men on testosterone experience vulvovaginal pain during sexual activity, highlighting the significant impact of testosterone-induced atrophy 2

Management During and After Testosterone Discontinuation

• Non-hormonal first-line approach: Apply vaginal moisturizers 3-5 times per week (not just the typical 2-3 times) to the vagina, vaginal opening, and external vulva, combined with water-based lubricants during sexual activity 1
• If symptoms persist after 4-6 weeks: Consider low-dose vaginal estrogen therapy (tablets, creams, or sustained-release rings), which is the most effective treatment for vaginal atrophy 1
• Alternative options: Vaginal DHEA (prasterone) is FDA-approved for vaginal dryness and dyspareunia, improving sexual desire, arousal, pain, and overall sexual function 1
• Adjunctive therapies: Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, orgasm, and satisfaction 1

Important Caveats

• While the atrophic changes are reversible, the timeline for complete recovery is variable and may take months after testosterone discontinuation 1
• Some individuals may require active treatment (vaginal estrogen or DHEA) to accelerate recovery rather than waiting for spontaneous resolution 1, 3
• The multifactorial nature of vulvovaginal pain in testosterone users (physiological atrophy plus psychological factors related to gender affirmation) means that discontinuing testosterone alone may not resolve all symptoms 2