A few articles back, we discussed transdermal testosterone. We’re back to discuss transdermal estrogen: why might we want to apply estrogen directly to the skin?
The short answer is: for the effects!
We’re going to be talking about genitals in this article and about transdermal use of estrogen. We do use the term vagina.
What Do You Mean By “Direct Contact Estrogen”?
What’s transdermal? Why not topical?
Topical substances lie on top of the skin, or are only very shallowly absorbed into the skin. If the substance can be absorbed into the tissues and bloodstream past the skin layers, it’s transdermal.
But, on genitals?
Yep. Genital skin is thin, and the tissues just under genital skin have lots of blood vessels and hormone receptors, so we can target those tissues with direct application. When using hormones, this won’t stop hormones from getting into the bloodstream and potentially to other parts of the body, but, MORE of the “oomph” of the hormone is absorbed locally. And in correct doses you won’t notice much or any whole body effects.
In Born-With-It Vaginas
The most common reason we use transdermal estrogen is because genital tissues like vaginal (front-hole,) vulvar, and urethral tissues are very sensitive to hormones. We know that when these tissues go from having more estrogen around to less estrogen around, atrophy can happen. Atrophy’s simple definition is “shrinkage” but it describes when cells become smaller, less efficient at their jobs, or slower to heal. Making new cells to replace old ones may slow down. Vaginal tissues with atrophy become thinner, drier, less elastic, and more likely to become inflamed or damaged. If we say that things can get uncomfortable when taking testosterone, we mean that people may experience painful urination, UTIs, pelvic pain, and pain with receptive sex. This can happen whenever ovarian production of estrogen decreases, to both cis and trans bodies.
How does this work?
Vaginal tissue is epithelial and mucosal.
Epithelial tissue is essentially a covering type of tissue. It lines all of the surfaces of the body, from the outside (the skin) to every single organ and cavity inside the body and all of the blood vessels. Epithelial tissue protects other tissues and can specialize to create and release substances (like lubrication, sweat, or enzymes) and absorb substances (like oxygen, nutrient, and other chemical movement back and forth in the lungs, intestines, and from blood to the cells and back.) A lot of epithelial tissues do all three things. Other types of body tissues include nervous tissue, muscular tissue, and connective tissue.
Collagen is a big player in epithelial and connective tissue and helps tissue mobility and stretchiness. Collagen is sensitive to hormones. For people starting new hormones, the risks/benefits include changes to thickness and softness of the skin. This is largely due to hormonal effects on collagen. Collagen gets less stretchy on testosterone and more stretchy on estrogen. These changes happen everywhere in the body.
Mucosal tissue is a type of epithelial tissue that secretes lubricating substances that protect and cushion other tissues or help movement within the body. We have mucosal tissues everywhere in our bodies. Both born-with-it and after-market via peritoneal pull-through or intestinal/sigmoid surgery vaginal tissue is mucosal.
In people who take testosterone, the amount of lubrication produced by vaginal tissue decreases. The tissues themselves may also become less bendy and stretchy when in a testosterone-dominant environment compared to an estrogen-dominant environment. This can result in dryness and discomfort like itchiness or burning feelings, plus less stretch or size-accommodation for receptive sexual practices. For people using the front hole for receptive sexual activity, this can make the experience a lot less fun. Adding targeted local direct contact estrogen can help those cells produce more lubrication and get a little stretchier again.
So, if you came pre-installed with a vagina, you might want to consider estrogen while on testosterone therapy. At QueerDoc, we recommend vaginal estrogen for everyone with a vagina and on T. It can help prevent atrophy from starting or slow it down when present. We prefer to use bioidentical estradiol (meaning like the stuff the body produces rather than created in a lab.) We like to prescribe oral estrogen tablets to be used vaginally because it is much less expensive than estradiol creams, which can be messy. Creams come most often in a tube with an applicator (which can be hard to clean!) A small amount of cream or an estrogen tab is applied/inserted regularly, and maintained on the schedule that keeps everything comfy. Transdermal estrogen cream can also be compounded (important things to know about compounding!)
For After-Market Vaginas
From a small study of people with peritoneal tissue vaginas, we know that estrogen can be efficiently absorbed into the bloodstream via peritoneal vaginal tissue. (1) We also know that some providers and surgeons do prescribe vaginal estrogen after vaginoplasties of all types, including peritoneal pull-through, penile inversion, and colovaginoplasties. We don’t have data about how local estrogen could affect lubrication or the existing biome in neovaginas.
When considering transdermal estrogen for neovaginas, we would include any locally applied estrogen in the individual’s total estrogen dose. After all, it does get into the body, so it should be included in the individual’s hormone equation.
Other Uses of Direct Contact Estrogen
We’re aware of people using or requesting direct application estrogen for use on facial skin as a hair management tool. This may help soften skin, but we don’t know of any data showing that direct application of estradiol to skin would thin or soften hair. (The opposite can be true with testosterone: we sometimes see increased hair growth on skin that is regularly exposed to direct contact with testosterone–for example, when using testosterone gel.)
There is some buzz around using transdermal estrogen as an anti-aging treatment and for targeted estrogenic effects, and there are studies showing that applying estrogen products designed for skin care directly to the skin reduces some of the structural skin changes that happen around the time of cis perimenopause and menopause. These changes happen both locally and across the body.
Would it similarly work to achieve targeted changes in bodies that used to be testosterone-dominant? It seems likely, but, again, there’s very little data. With informed consent about how much we don’t know about risks and benefits, and calculating any estrogen applied directly to skin in a cream, oil, or gel as part of the total estrogen dose, we’d consider it.
We are going to spend a little time on a literature search for any studies about estrogen use on facial skin, and we’ll write up what we find.
References
- Willemsen WN, Mastboom JL, Thomas CM, Rolland R. Absorption of 17 beta-estradiol in a neovagina constructed from the peritoneum. Eur J Obstet Gynecol Reprod Biol. 1985 Apr;19(4):247-53. doi: 10.1016/0028-2243(85)90036-x. PMID: 3924675
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