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A journal club style critical review of current publications in evidence-based transgender medical care.

Thursday, October 27, 2011

Microflora of the Penile Skin-Lined Neovagina of Transsexual Women

     In a study of the penile-inversion neovaginal microbiome of 50 transsexual women,  vaginal irritation and discharge was not correlated with the presence or absence of leukocytes or specific organisms on gram stain.  No cases of candidal colonization were identified, and only one woman had lactobacilli. (1)

     Transsexual women often present with a variety of vaginal symptoms after penile-inversion vaginoplasty.  The authors aimed to identify colonizing flora of the neovagina, and determine if any correlation existed between vaginal cleansing habits, specific flora or the presence of leukocytes and symptoms of irritation or discharge.  They also aimed to evaluate any correlation between sexual orientation (i.e. presence or absence of receptive penetrative sex with a penis) and presence of particular microbiologic species.

     50 post-vaginoplasty transsexual women (mean time since surgery: 6.3 yrs) were studied through a combination of pelvic examination, gram stain and culture/PCR, and self-report survey.  Almost all were on estrogen HRT (94%),  44% were heterosexual, 22% homosexual, 28% bisexual and 6% asexual.  Regular episodes of vaginal irritation occurred in 22% of the women and 18% experienced frequent dysuria.  Only 34 women answered questions about foul smelling discharge;  Of these, 23.5% had frequent foul smelling discharge.   No correlation was found between vaginal rinsing habits and vaginal pH or vaginal discharge, and no correlation was found between vaginal pH and complaints of irritation or malodorous discharge.  No correlation was found between the presence of leukocytes and reported malodorous discharge. 

     Mean vaginal pH was found to be 5.88.  On exam, clinicians reported a foul smelling discharge in “most patients”.  Microbiological studies revealed a mixed vaginal flora with typical skin and intestinal organisms.   Lactobacilli were found in only one woman, and candida were notably absent from all women.  Notably, colonization with E. faecalis was correlated with both heterosexual orientation and regular receptive coitus with a male partner.  Mobiluncus (a genus typically resistant to metronidazole) was found in higher numbers than in natal vaginal flora.  All participants were negative for Chlamydia and gonorrhea.  Twelve novel, untypable species were identified.  No strong correlation was found for any specific flora species and symptoms.

     The authors conclude that they are unable to explain the high rates of vaginal discharge and irritation in transsexual women through microbiologic analysis or analysis of vaginal rinsing habits. 


     This article highlights the fact that postoperative symptoms of irritation, odor, discharge, and dysuria are common complaints in transsexual women, even years after surgery.  It also reminds providers to take a different approach to penile-inversion neovaginas than they would for natal vaginas in the setting of vaginal complaints.  Also of interest is that the neovagina is colonized (not surprisingly) with a variety of skin and intestinal flora, and in heterosexual transsexual women active in receptive coitus is more likely to be colonized with the UTI-causing coliform E. faecalis. 

     No correlations with symptoms were found between symptoms and cleansing habits, pH, a particular microbial species, or the presence of leukocytes.  Only one woman was colonized with lactobacilli, and no candida was found.  Hopefully this will help lay to rest the notions that neovaginas are (or should become) colonized with a usual vaginal microbiome, that lactobacilli are important for neovaginal health, that neovaginal candidiasis is a common entity, and that pH effects microbial outcomes in neovaginal health. 

     The authors are unable to draw any conclusions on neovaginal symptomatology from a microbial perspective; It is likely that while colonization occurs, most neovaginal symptoms are not infectious in nature and instead relate to the constant production of sebum, sweat, and cellular and keratin debris that occurs in a skin-lined vagina.  Also likely to contribute is the presence of semen, lubricating gels and other foreign substances and the constant “skin-on-skin” irritation which may occur.  Treating neovaginal symptoms with antimicrobials is likely only treating colonization.  It is curious that cleansing habits did not improve or worsen symptoms.  More outcome-based research is needed to explore risk factors and curative interventions for neovaginal symptomatology.

Several additional points of interest in this paper:
- The range of reported sexualities in the study population supports the notion of diversity of sexual orientations among transsexual women

- A metronidazole-resistant microorganism was commonly found in neovaginas, suggesting that clindamycin should be used if one does decide to treat with antibiotics

- Heterosexual transsexual women are at higher risk of E. faecalis colonization.  Weather specific recommendations for preventive measures against UTI should be given to tramssexual women, and what measures should be taken are areas for future study.

- The fact that none of the 50 women were positive for gonorrhea or Chlamydia suggests that the neovagina itself is resistant to infection with these organisms;  Providers may consider obtaining swabs for these organisms from the urethral meatus for a higher yield.  It also may simply suggest that there are populations of transsexual women who have a low incidence of these (and perhaps other) STI’s.


1) Weyers S, Verstraelen H, Gerris J, Monstrey S, Santiago G dos SL, Saerens B, et al. Microflora of the penile skin-lined neovagina of transsexual women. BMC Microbiol. 2009;9:102. 

Tuesday, October 18, 2011

Incidence of Thrombophilia and Venous Thrombosis in Transsexuals Under Cross-Sex Hormone Therapy

     Retrospective cohort study of 162 MTF patients on transdermal estradiol + cyproterone acetate with an 8% prevalence of baseline thrombophilic conditions showed no incidents of venous thromboembolism over an average 49.6 months. (1)

     Venous thromboembolism (VTE) is a common concern for providers providing cross gender hormone therapy (cHRT) for male-to-female (MTF) transgender persons.  Additional concern may exist for patients with pre-existing prothrombotic mutations, and the question arises as to weather or not it is important to pre-screen MTF persons for hypercoagulability prior to initiation of cHRT.

     Researchers conducted a retrospective review of outcomes in a cohort of 162 MTF women who had a baseline prevalence of 8% (13/162) prothrombotic mutations, which is consistant with the baseline prevalence in non-transgender caucasian persons.  All 13 patients exhibited activated protein C (aPC) resistance and four were smokers.  No cases of antithrombin III or protein C deficiency were found the study population.  Only one patient (a smoker) was on anticoagulation therapy.  161/162 patients received either transdermal estradiol monotherapy (if post-op) or transdermal estradiol + cyproterone acetate + finasteride (if pre-op).  One patient with multiple cardiovascular risk factors and aPC resistance (not on anticoagulation) was given cyproterone acetate monotherapy.  60/162 patients had reported prior self-directed cHRT use, all had been off cHRT for a minimum of 4 weeks prior to treatment at the study site.

     Over a mean duration of 49.6 months on cHRT (range 12-135 months), no incidents of VTE were observed in the study cohort.  The expected incidence of VTE in 0.43/18 patients with a prothrombotic mutation did not differ significantly from the observed incidence of 0/18.  The authors concluded that cHRT in transgender persons with a prothrombotic mutation is safe, and that routine pre-cHRT screening for prothrombotic mutations is not recommended if there is no family or personal history of VTE.


     Venous thromboembolism is a commonly feared outcome of cross gender hormone therapy, but a growing body of recent evidence has shown that the use of transdermal estradiol (or oral estradiol as opposed to conjugated equine or synthetic estrogens) minimizes this risk.  The authors chose to look at the risk of VTE in a cohort of MTF women who were pre-screened for the presence of a prothrombotic mutation.  None of the women, with or without a mutation had a VTE during the study period of an average 49.6 months.  Since most incidents of VTE occur in the first year of HRT in non-transgender contexts, their conclusions that cHRT with respect to thrombophilia is safe seems reasonable.  This study should help reassure the clinician that the use of safe cHRT such as transdermal estradiol minimizes VTE risk in the general population and in those with minor prothrombotic mutations such as aPC resistance / factor V Leiden.

     Shortcomings include the relatively small number of patients, retrospective nature and the lack of any patients in the cohort with more serious prothrombotic mutations such as antithrombin III or protein C deficiency.

     Of note, the study also looked at an FTM cohort and found similar results.  While the authors cite several basic science articles suggesting testosterone increase thrombotic risk in lab animals, this is not congruent with publications in trauma research which suggest that testosterone leads to a hypocoaguable state. (2)


1) Ott J, Kaufmann U, Bentz E-K, Huber JC, Tempfer CB; Incidence of Thrombophilia and Venous Thrombosis in Transsexuals Under Cross-Sex Hormone Therapy; Fertil Steril 2010;93:1267-72

2) Gee AC, Sawai RS, Differding J, Muller P, Underwood S, Schreiber MA; The Influence of Sex Hormones on Coagulation and Inflammation in the Trauma Patient; Shock 2008;29:334-41