In this 2009 study, 50 trans women with penile-inversion vaginoplasties had their microbiome sampled and it was revealed that nearly all of them had a microflora similar to bacterial vaginosis in natal vaginas, making them more likely to have UTIs and resulting in malodorous discharge.
Bacterial vaginosis (BV), for those not familiar, is when a wide variety of diverse microbes grow in the vagina. A healthy natal vagina typically has a monoculture of Lactobacillus spp. which grow and excrete lactic acid, which acidifies the environment and prevents other microbes from being able to grow. When lactobacilli are unable to form a monoculture, the microbiome can diversify and problematic bacteria are able to grow, which can cause irritation, urinary tract infections (UTIs), and unpleasant odors.
Typical advice for a person with a natal vagina is to avoid douching and to allow the vagina to "self clean" - basically the vagina already creates the conditions that promote lactobacilli dominance, and in bad cases of BV, a course of antibiotics usually will clear it up.
The way this works in a natal vagina is that the cervix and the special kind of skin that lines the vagina both secrete glycogen (think of it as a kind of sugar) that feed the lactobacilli, and the estrogen also triggers the vaginal lining to acidify the environment, helping create conditions ideal for lactobacilli to grow in.
Unlike in a natal vagina, neo-vaginas are lined with scrotal skin or colon grafts, neither of which respond to estrogen the same way that natal vaginal skin lining does, and there is no cervix - so there is nothing that produces glycogen to feed the bacteria. There is also no regular production of mucus like the cervix creates which acts to regularly flush or clean-out the vagina, and the skin used to line the neo-vagina does not regularly cast off and replace itself like natal vaginal skin does.
So as you might imagine, my surgical team told me that I would never have a normal vaginal microbiome, and that for the rest of my life I will have to douche with vinegar every other day.
I continue to follow those instructions (I douche with a 1:1 solution of vinegar and water, every other day), especially because I still have bleeding and healing wounds from wound separation complications that happened (basically the dilator regularly rips the skin back open every time I dilate, and I don't want those wounds to become infected).
Meanwhile, I've began to explore ways to improve my microbiome.
First step: acidify.
Lactobacilli don't generally grow without a supportive, acidic environment to kill off other bacteria. Vinegar is great because it's acidic, but acetic acid (which is what vinegar is made up of) apparently doesn't help lactobacilli to grow, what they need is lactic acid.
My first attempt to help my microbiome was to find a lubricant that would have lactic acid and promote lactobacilli growth, and I found one!
Before I share what I found, I want to be clear this isn't an advertisement and I'm not suggesting you buy this product. In fact, by the end, I'll share why you shouldn't buy it.
But the only lubricant I found that has lactic acid and promotes a healthy microbiome is from Good Clean Love, they have several products but any of the water-based lubricants or the "moisturizing gel" product would work (avoid all silicone lubes).
OK, great - so I found a way to acidify my vagina!
Except, when I tested my discharge even when just using Good Clean Love's lube, I consistently had a pH of around 5.0, which is too basic ... Additionally, the cost of the lube was too much for how much I needed to use to dilate - it's not a workable solution financially.
So I thought I could make my own! Turns out, you can buy medical and food grade lactic acid online. My pump bottles of Slippery Stuff lube would inevitably have some leftovers that I collected in jars and awkwardly tried to use up, so I already had a "waste" source of base lube to test with.
Next step: feed.
So I could acidify the environment, but it didn't seem like it was promoting lactobacilli enough, and I put together that the Good Clean Lube didn't have any kind of fuel for the lactobacilli to eat, basically nothing was replacing the glycogen that the cervix was releasing in natal vaginas (and that makes sense, the makers of Good Clean Lube probably assume their customers are using the lube with a natal vagina providing its own glycogen, so for a natal vagina acidifying was probably sufficient).
So I did a little research on what kinds of fuel lactobacilli can eat, and I kept finding that FOS (fructooligosaccharide) powder is used as a prebiotic to promote lactobacilli growth. So for my first batch, I combined Slippery Stuff lube with 1% lactic acid (by weight) and 1% FOS powder, and started using it as a lubricant when dilating, and using a lube syringe to insert some of the stuff into my vagina on the nights I wasn't douching. And again, I found my pH wasn't dropping, still tested around 5.0.
For context, FOS is a carbohydrate - and it turns out lactobacilli can sort of feed on it it through anaerobic fermentation, but ... that is usually happening in the digestive tract, not in the vaginal canal (FOS powder is a common prebiotic ingredient in oral probiotic pills, and is used similarly to inulin prebiotics) - and, it's not clear it promotes the kind of metabolism and growth the way glycogen does.
So I wondered what would make a better substitute for glycogen? Well, duh - glucose, sugar. But how much sugar should be added to the lube, it would need to be the right amount so it doesn't promote the wrong bacteria or, god forbid, fungi.
So it turns out sugar has about the same caloric value per gram as glycogen, so I reasoned a 1:1 substitute would be sufficient, and samples of genital fluids of natal vaginas show that glycogen made up 3% of the fluid, so that's a good starting place.
Another problem I ran into was the way the lactic acid turned my Slippery Stuff base lubricant from a stretchy lube gel into a very runny liquid, basically unusable as a lubricant and even worse, it would run out of me when I tried to insert it to feed lactobacilli in the canal overnight - I needed something like a gel that would stay in place and be able to feed the lactobacilli overnight. I noticed Good Clean Love uses agar agar and aloe in their water-based lubricants, so I tried the same.
For my second batch, I used 3% powdered sugar, 1% lactic acid, 0.5% agar agar powder, and 0.5% FOS (just in case it might still be helpful), and this time I had to boil the solution and allow it to set into a gel.
The 0.5% was maybe too firm of a gel, but I was able to break it up enough to suck it into a lube syringe and deposit it into the canal with the syringe.
For clarity, both batches with 1% lactic acid tested around a pH of 3.0.
Once a month or so, I had been inserting a vaginal suppository which contains lactobacilli, and once I had my second batch, on a night between douching, I inserting the vaginal suppository, and then deposited some of my second batch gel.
The next morning, eureka - my discharge tested at a pH of 4.0, and smelled heavenly - sweet and sour, a little bit like a kind of yogurt or sourdough.
I think it worked, I found a way to promote lactobacilli in my vagina!
Next steps: once healed and infecting wounds is no longer a concern, I can figure out how frequently I would need to feed the lactobacilli so they remain dominant (every other day? twice a week?), and also how to occasionally douche without nuking the microbiome, perhaps with a lactic acid solution rather than a vinegar solution?
(It would also be nice to eventually find a more objective way to test my microbiome than just pH and smell; unfortunately the study that examined the microbiome of trans women used methods like gene sequencing, though I might be able to try their method of gram staining and then examining under a 1000x microscope. I'm not sure if swabs being cultured on agar dishes would be a reasonable method of examining the microbiome, but that's at least within the realm of possibility compared to gene sequencing.)
Douching would still be necessary because as mentioned there is no "self-cleaning" process happening naturally, old lube and stuff will collect without occasionally irrigating the canal.
But at least I have a decent lead on how to avoid BV!
Disclaimer: Just to be clear, I'm doing weird stuff and taking risks I wouldn't recommend others take - none of this is medical advice, I have no medical training, and probably a lot of this is very stupid and potentially risky.
I wanted to share in case anyone else found it interesting (or better, if they know more than me and can provide critique), and in case others have been tinkering with their microbiome as well and may have notes.
EDIT: It should also be noted that a study published in 2014 found 75% of 63 trans women they swabbed were found to have lactobacilli in their microbiome, and their microbiomes were comparable to those of postmenopausal cis women.
Also, the Good Clean Love vaginal suppository I linked to contains pseudo-science homeopathic ingredients which is cause for some concern, and I would like a better vaginal suppository that just has the bacteria and none of the homeopathic ingredients.
And it should also be mentioned that I also take a daily, oral probiotic called Soaking Wet (I chose that one because it has Lactobacillus crispatus in particular). My surgical team indicated taking these oral probiotics will not help with my vaginal microbiome (likely for the reasons above on why my vaginal microbiome will never be like a natal one), but they did recommend Align probiotics in particular to help recover from surgery (you take a lot of antibiotics in the first few weeks post-op, so they recommended switching to Align probiotics once I was finished with my antibiotics) - that was for my gut microbiome, not for the vaginal microbiome. Needless to say, I haven't noticed any dramatic improvement from taking the Soaking Wet probiotic - though it does also contain vitamin D, vitamin E, and zinc, which is probably helpful for some people.
ah, my lovely Schrödinger's forehead
it's not too bad, tbh - I'm just dysphoric about it, but most people probably won't notice (it's a subtle difference). My hairline bothers me more, and my nose, and my lips, and my jaw, and my chin ... etc. 🙈