Blood tests, other screenings and neovaginal health

All you need to know about what and when to test for a safe HRT. What blood values should I test? When is it best to run blood work? What about hormono-dependant cancers? How do I take care of my neovagina? Answers in the pages linked below.

1: Blood tests
2: Cancer screenings and navigating healthcare
3: Neovaginal health

1 - Blood tests

Why, when and what blood test should I run when taking HRT?

Note

When reading blood test results, always pay attention to the measurement units. According to countries and lab, the prefered unit can change.

Estradiol is usually expressed in pg/ml or pmol/L (the transfem target level of 200pg/ml equates 734.25 pmol/L)
Testosterone is usually expressed in ng/ml or nmol/L (the transfem target level of 0.50 ng/ml equates 1,73nmol/L)

You can refer to this converter if need be.

Why?

Doing regular blood test are essential for two reasons:

Making sure your levels of hormones are correct. If the definition of “correct” regarding hormone levels varies from individuals, having a number makes you more able to estimate if you are underdosed or overdosed. Taking a blood test when you feel at your best and experience the changes you seek lets you know what levels of hormones are good for you.
Preventing potential problems, that have to do (or not!) with your new hormonal balance. These includes:
Blood clots
Liver and kidney problems
Polycythaemia/erythrocytosis (high red cells in blood)
Prolactinoma
Liver dysfunction
Heart disease
High blood pressure

When?

Below is a general guideline, however, if your dose and hormone levels aren’t stabilized, get a blood test every three months until it is, before reducing the frequency.

Baseline test before starting hormone treatment: an initial blood test before starting HRT is beneficial for establishing your baseline hormone levels and screening for morbidity (illnesses)
Three months: after three months of hormone treatment, get your second blood test
Six months: after six months, get your third blood test
Twelve months: after twelve months of hormone treatment, get your fourth blood test
Every year after: get a blood test every six to twelve months for as long as you take hormone treatment
Change in dosage and administration route: get a blood test one to three months after any change in dosage to monitor the effects, and after changing administration route calibrate dosage. Wait at least a month after changing to a new route of administration before taking the test.

Timings for blood tests vary depending on the way in which your medication is administered.

Estradiol injections: have the test carried out immediately before your next injection, and 1 month at least after the 1st injection
Testosterone undecanoate injections: have the test carried out immediately before your next injection
Testosterone enanthate/cypionate injections: have the test carried out midway between injections
Patches: have the test carried out the day after a patch change
Gels: have the test carried out 4-6 hours after gel application (to avoid contamination don’t apply gel on the lower arms for at least a week before your blood test)

What?

A complete blood work should include these. Other values might be added depending on your own health profile, and medication.

Full blood count
Blood biochemistry: Glycemy, Plasma aspect, Creatinine…
Ionogram: Sodium, Potassium…
Lipids: Cholesterol, Triglycerides
Liver enzymes: ALAT, ASAT, GGT
Sex hormones and affiliated: FSH, Testosterone, Estradiol, Progesterone, Prolactin
Possibly, thyroid hormones: TSH

Refer to our description of each medication to know which values are particularly important to monitor for you.

Total, free, and bioavailable testosterone

Note that when measuring testosterone, the standard measurement is usually total testosterone, as it is easier and cheaper to measure. As explained in the section on SHBG, testosterone binds itself to albumin and SHBG, which makes it unable to bind to the androgen receptors, and blocks its effect. The rest - a tiny portion of around 1-2% - is “free” and biologically active. You can ask for measuring the “bioavailable” testosterone, which is the addition of the free testosterone and the albumin bound testosterone, since the binding with albumin is loose enough that testosterone can easily unbind and become biologically active. However, especially for transfeminine people, the total testosterone value is usually a good indicator of the efficacy of your treatment, and a total testosterone under 50 ng/dl corresponds to nearly nothing in bioavailable testosterone. You can also ask to measure your SHBG levels, especially if your treatment gives you good levels of sex hormones, but still no effects after a while. Abnormally high SHBG levels could be a cause. You can refer to our page on SHBG for more details.

2 - Cancer screenings and navigating healthcare

Some cancer are hormono-dependant. What should I be vigilant about? What does HRT change in terms of risk factors?

Cancer screenings

We should recall the obvious here: a trans person who is not on HRT should be screened for the same affections as for people of their assigned gender at birth. More specifically, transfeminine people not on HRT should be screened for prostate cancer after 55, and transmasculine people not on HRT (and without mammectomy) for breast and cervix cancer.

Breast

Transfeminine people on HRT usually trade their risks of prostate cancer for risks of breast cancer. Getting screened for breast cancer hence becomes important for transfem people on hormones, and even more after 45 and if you have family history of breast cancer.
The lowered risks of breast cancer that masculinizing therapy comes with should not dispense transmasculine people who haven’t got mammectomy to also get screened.

Prostate (before and after SRS)

Similarly, the lowered risks of prostate cancers in transfem people on hormones should not be read as an invitation to completely disregard the risks. There are many other risk factors to prostate cancer. Androgens mainly play a role on maintaining and aggravating prostate cancer, other factors can start it.

Note

Clinical prostate cancer screening (touch) should be performed differently depending if you had or not a vaginoplasty (with vaginal cavity). If you didn’t, the rectal examination remains the way to go. But post-SRS (with vaginal cavity), it makes more sense to examine the prostate through the vagina, as the vaginal cavity is created between the rectum and the prostate. An examination through the neovagina will reduce the amount of tissue walls, and hence be more precise. Many practitioners will not be aware of this, and an explanation will probably be required from you.

Cervix (pap-smear)

Pap-smear and screening for uterine and cervical cancers should also be performed on transmasculine people on testosterone who have not undergone hysterectomy.

So, to sum up, your hormonal treatment will rebalance your risks for hormone-dependent cancers, but since there are many other risk factors, you should never consider yourself immune to these cancers because of your HRT.
As opposed to what many practitioners seem to forget, your general health continues to be an intricate combination of many factors, and can never be solely reduced to your HRT. It seems silly to recall, but trans people still have affections that have nothing to do with their HRT and them being trans.
The tendency of many practitioner to immediately accuse the HRT for all affection you come with, or to assume that a trans person can only seek trans-related care is sometimes called the “broken arm syndrome”: a trans person comes to seek care because they broke their arm in a fall, and the doctor would be like “your hormone levels are wrong”. Or, as another example, the author of this section has nearly been denied an appointment with a urologist who happened to also performed SRS, because she was not believed to be seeking care in urology and not for SRS.

3 - Neovaginal health

You have had transfem SRS (vaginoplasty), but you’re unsure how to take care of your new vagina? You’re not alone! Here are some relevant info that might come in useful.

“Bio-vagina” functioning: hormones, glycogen and probiotics

In order to look at neovaginal health, it is important to understand how biovaginas work. (Note that I call biovaginas the vaginas of cis-women and AFAB people only for writing convenience, acknowledging that the term might not be ideal. Neovaginas are in many ways biovaginas as well.)

We are probably all aware of the vaginal flora and of its importance for vaginal and cervix health. What is less known is the evolution of this flora, and its relationship to hormonal balance.

Vaginal flora, or vaginal microbiota/microbiome, are microorganisms (mainly bacterias and yeasts) that colonize the vagina. If the right mix of species form a good balance, they will provide defense against pathogenic species (responsible for infections, such as Candida Albicans…). The bacterial world is a world of survival, of constant fight for food and space. It is only natural that, if a colony is strong enough, it will not leave enough food and space for other colonies to spread. But if the good bacteria were to be weakened (by a topical or systemic antibiotic, for example, or extra cleaning…), it leaves room for the pathogenic species to take over, and start an infection.

The lactobacillus: yogurts, sauerkraut and vaginas

The main bacterias of the healthy vaginal microbiome is a group called Lactobacillus (sometimes referred to as “Doderlein’s flora”, from the name of the German dude who figured it out). Most of the vaginal bacterias come from a transfer from the colon microbiome: they move from the anus, to the perineum, the labias, and hop, in the vagina! Gross? Maybe, but healthy. And also, first, they come from the stomach flora, and from what you eat. Actually, the lactobacillus are the same bacterias that make yogurt, cheese, or fermented vegetables like pickles, kimchi, or sauerkraut. This yogurt in your fridge, or this juice in your jar of sauerkraut is very similar, in terms of bacterial presence, to what’s inside a healthy vagina. And the same fermentation process also happens in your vagina.

The idea, when making sauerkraut for exemple, was to be able to keep this huge amount of cabbage we harvested from going to waste - that is, being colonized by pathogenic bacterias. The fermentation process consists in making sure that the natural bacterias present on the cabbage - the lactobacillus - develop. As they develop, they need food, and start eating and digesting the sugars naturally present in the cabbage. The result of this bacteria feast is lactic acid. It is sour, and the pH balance it provides keeps pathogenic bacterias at bay. The cabbage - now sauerkraut, or kimchi, can then be kept for a long time. The same thing applies for yogurts and cheese: how to keep all this nutritious milk over the winter: remove the water and ferment it; you can now keep your “milk” (cheese) for months.

Back to the vagina. The lactobacillus, that came from this kimchi you ate (and, originally, from you licking the vaginal walls of the person who gave birth to you - if you were not born through C-Section), and went all the way down to your vagina, will eventually have the chance to be fed on the spot by… the vagina itself! Indeed, under the effect of estrogens, the vagina starts producing glycogen, that is, sugar. The lactobacillus will eat and digest this glycogen, and produce lactic acid as well as hydrogen peroxide (among others), who will both keep pathogenic agents at bay. The biovagina is a self-sufficient protective device: it feeds and keeps alive the good bacterias that will protect it from pathogenic agents.

This is why the vaginal flora is also quite different in its composition in prepubertal and post-menopausal vaginas, since glycogen is produced under the influence of estrogens. Less or no estrogen means less or no vagina-made sugar, which means a different macrobiotic balance. It results that postmenopausal individuals can be more vulnerable to vaginal infections. This is also true for prepubertal individuals, who can be exposed to pathogenic agents because of lack of hygiene.

What care for neovaginas?

So, what does this mean in regard to your neovagina? Actually, knowledge is extremely limited on this matter. A team of researchers in France is currently leading one of the first research project on neovaginas’ microbiome to try to figure it out, and examine the vaginal flora of post-SRS transfeminine people. The project is called Transbiome.

What we can infer, however, is that a neovaginal flora is more likely to be closer to the one of a prepubertal or postmenopausal biovagina. Indeed, despite all the estrogens you can take, your neovagina tissue (former penile tissue in most cases) will not be able to secrete glycogen to feed the lactobacillus. This is true to all surgery techniques (penile inversion, colon graft or peritoneum graft). You may take all the topical prebiotic capsules you can find at your pharmacy, if the new colony you installed can’t be fed, it will fade away.

An idea is to add glycogen as well. Such medication exists, which combines both prebiotic (lactobacillus) and glycogen. Theoretically, once the lactobacillus colony is well established, all you would have to do is to feed it regularly; do manually what the biovagina does by itself. Reinstalling a healthy flora is quite important after taking antibiotics (oral or local). But how often, how much, and with what sugars? Until proper research is published, we do not have the answers to this, and many post SRS transfem people are left experimenting in order to figure out what works best for them.