Vaginoplasty FAQs


Pre-op insurance requirements?

  • Insurance companies generally follow WPATH guidelines. WPATH guidelines currently require 2 letters from providers, one can be your primary care or hormone specialist and the other from a mental health specialist.

  • However, many insurance companies follow the previous WPATH recommendations of 3 letters: 1 from your hormone specialist and 2 from mental health providers (1 provider needs to be a PhD or MD). Please check with your insurance carrier for their specific requirements.

California sterilization state law requirements:

  • Non-Federally funded (not Medi-cal or Medicaid) patients, must be 18 years old to undergo elective sterilization surgery (orchiectomy, removal of the testes). Exceptions to this rule include the following: under 18 years of age and have entered into a valid marriage OR is on active duty with the U.S. armed services OR received a declaration or emancipation OR is at least 15 years of age, live apart from your parents or guardians, and manage your own financial affairs.

  • Federally funded (have Medi-cal or Medicaid) patients, must be 21 years of age to undergo elective sterilization surgery (orchiectomy, removal of the testes).

Hair removal requirements? 

  • Hair removal is required prior to undergoing most forms of vaginoplasty procedures. This can be done with either laser hair removal or electrolysis. Hair removal can take 6-12 months depending on genetics and response of hair follicles.

  • What hair needs to be removed? One inch around the base of the penis, all hair on the scrotal skin, and 2.5 inches on the perineum. Please download the hair removal guides and take to a local hair removal specialist.

  • Insurance coverage for hair removal? We provide a letter with our initial consult for patients to submit to their insurance to facilitate coverage, if insurance covers hair removal. If you have not had a surgical consultation and would like to start on hair removal,  ask your hormone or primary care specialist to write a letter stating that hair removal is medically necessary for surgery.

  • Starting hair removal prior to your initial consultation may facilitate shorter wait times for surgery. If the 6-12 months of hair removal is already completed and you have the appropriate letters stated above, surgery can be scheduled within 3 months. 

How long do I have to be in the area?

  • We recommend patients stay in our area for 4 weeks. A pre-op visit can be up to 1 week prior to surgery and then 3 weekly routine post-operative visits are required. Everyone needs to be seen in person pre-operatively. This cannot be done over the phone. A physical exam is needed. 

Does my place of recovery have any distance requirements?

  • We require that you stay in San Francisco County and within 30 traffic minutes from our office for a minimum of 2 weeks post surgery.

  • Reason- the first 2 weeks is the time when some emergencies can happen. If 911 is called, they will take you to the closest emergency room which may not be equipped to see our post-operative patients and where we may not have facility privileges to treat patients.

Traveling: Why am I so swollen after my short flight?

  • Even a short flight can cause swelling. I recommend ice packs, motrin and rest after any flight.

Support Person

  • Your support person is required to be in the area minimum from the day of discharge from the medical facility until after your 2 week post operative visit. 

  • Ideally your support person is with you for your entire stay.

  • There can be a team of support people, but make their must be someone continuously available and no gaps in coverage.

  • Your support person does not have to have a medical background.

  • Your support person will be responsible for making sure you get from the medical facility to your place of recovery, that you are fed, taking your meds, emptying your foley/urine bag the first week, ensuring you are getting to your appointments, and call if there is an emergency.

Is there a BMI (body mass index) cutoff for vaginoplasty?

  • Yes, it is 35. If you are not sure what your BMI is, you can input your height and weight from any BMI website. 

  • This is a safety precaution for anesthesia, post-op recovery and complications.

Affidavit letters for Gender Affirmation?

  • Can I get a letter saying I’ve had my surgery, so I can get legal documents changed to reflect my true gender?  Yes, letters from our office verifying you have undergone vaginoplasty surgery can be requested after your surgery. These letters are usually required to be notarized by a Notary Public. Please allow 14 business days from date of request to receive your documents. Physician declaration letters or other documents requiring notarization will incur the cost of the services rendered by a notary republic.


Why is my perineum opening up?

  • Very commonly, after your bandages have been removed, the skin has a lot of rebound swelling. This can cause tension on the perineum which is the area at the bottom of the vagina that connects the vagina and anus. Separation will happen more than 50% of the time, so don't be nervous if this area opens up. This is one of those expected aspects of your recovery and healing process. This area will take time to heal and we want it to heal naturally. If we put this area back together immediately, there is an increased risk of infection, which can lead to prolonged healing, more scarring, and discomfort.  You should continue to cleanse the area using a squirt or spray bottle with one of our recommended cleansing solutions (Dakin’s Solution or 1 cup water with 1 tbsp of Hydrogen Peroxide). This should be done twice daily and after every trip to the restroom.

  • Swelling typically is maxed at post op week 2 ( recommendation is to limit walking to 2 blocks 3 times/day). If someone is walking more than 4 blocks 3 times/day on the 3rd post operative week ie going on a long hike, then swelling can increase further. Continuing ice packs, non-steroidal anti-inflammatory meds like ibuprofen (as long as you can take this medication), and over the counter arnica can also help with swelling.

  • Air travel and prolonged car rides will also increase swelling in the immediate postoperative period. Once your travel has been completed, please go home, lay down, apply ice packs, non-steroidal anti-inflammatory meds like ibuprofen (as long as you can take this medication), and over the counter arnica.

My catheter is not emptying; what should I do?

  • If you notice your catheter is not emptying please call the office for further instructions. If our office is closed please go to the nearest Emergency Room (ideally CPMC Davies Campus or Saint Francis Memorial Hospital).

Is it ok that I have small blood clots in my catheter/tubing?

  • Very commonly, small flecks or clots of blood appear in the catheter, especially toward the end of the week.

  • Also it is common to feel urethral irritation and burning with a catheter in place.

  • The catheter irritates your urethral lining, which can cause both of the above.

  • The antibiotics that are prescribed will cover any possible urinary tract infection, but call the office or after hours triage nurse if you have a fever of 101.0 or greater.

Why am I bleeding?

  • If you are having blood soaking through your first-week dressing, please call the office, we need to assess you. If you call after office hours, please go to the nearest Emergency Room, (ideally CPMC Davies Campus or Saint Francis Memorial Hospital).

  • If you are having bleeding after the first week, make sure you are dilating the vagina and not the urethra. If you are dilating correctly, please call the office or after hours nurse.

  • If you are bleeding after the second to third month, it is commonly from benign scar tissue called granulation tissue. Granulation tissue is common during the first year of healing. It is vascular tissue and can resemble a bloody polyp or flat red/pink tissue. It may resolve on its own, but seeing your surgeon can help expedite healing. We either excise or cauterize the area. Sometimes applying Medi-Honey and Betamethasone cream (50:50 ratio) over the affected area helps over the course of 1-2 months. 

  • Please refer to the picture on Common Post Op Issues for Examples of Normal and Abnormal Bleeding.

What is a normal and abnormal amount of bleeding?

  • Please refer to the picture on Common Post Op Issues for Examples of Normal and Abnormal Bleeding.

  • Immediately Post Operatively: in first two weeks, oozing is expected onto the hygiene pads that cover your bolster.

  • First 3 months: Intermittent bleeding can occur postoperatively as part of healing within the first 3 months after surgery. Please make sure you are dilating the vagina and not the urethra. Also check for signs of a bladder infection ( see FAQs and Videos on Bladder Health/ Gyn 101)

  • Within the first year after surgery, occasional bleeding or dark brown discharge can be seen on pads. This is usually due to granulation tissue which commonly occurs within the first year after surgery. While scary, it's benign bleeding. This will be taken care of on your post-operative visits at 3, 6, 9, and 12 months. If unable to return to our office, please see a local provider like a gynecologist. Again, please make sure you are not accidentally dilating your urethra and also check for signs of a bladder infection ( see FAQs and Videos on Bladder Health/ Gyn 101)

What are the pads that I should buy for post vaginoplasty recovery?

  • 2 types:

  • First is a feminine hygiene pad geared for vaginal bleeding. You will need maxi-pads for heavy bleeding initially then with time you can move to the daily pantyliners when discharge lightens up- somewhere between 2-3 months.

  • Immediately post-operatively it will be nice to have a pad to protect your bedsheets. They are usually called medical "chucks" pads but exactly the same & less expensive are puppy pee pads. 


How often should I change my pads? 

  • Whenever you go to the restroom

  • Whenever they are covered with discharge

  • Whenever they start having an odor


What brand pads should I buy?

  • Does not matter, as long as it's economical and does the job


How do I clean my incisions post-operatively?

  • Common solution of dilute hydrogen peroxide: obtain hydrogen peroxide from store and dilute 1 tablespoon of hydrogen peroxide in 1 cup of tap water

  • Spray or Squirt bottle: place solution in bottle and spray or squirt minimum 3x/day or whenever you use the restroom. Pat dry.

How do I douche?

  • There are many over the counter brands- it doesn't matter which one. Follow their instructions

  • Generally, you insert the nozzle just in the opening of the vaginal and squirt the bottle

  • Alternatively, once you get comfortable, there are many home kits you can use. Google options. Insert the nozzle or end of the catheter/tube into the vagina and squirt the solution.


What solution do I use to douche?

  • There are many brands or over the counter versions- it doesn't matter which one

  • Home solutions involve vinegar, apple cider, or diluter hydrogen peroxide (1 table spoon in 1 cup of water)

  • All of these solutions are acidic which help flush out bacteria that build up with skin grafted vaginal lining

Why do I need to douche? I heard douching was bad.

  • For skin grafted vaginas vs natal vaginas, there is a lack of lubrication, self cleaning oven effect, and natal acidic pH which keeps the flora in check.

  • Skin grafted vaginas tend to be more basic with a pH of 7 vs natal vaginas with an optimal pH of 4.4

  • To compensate for the above, douching is needed to flush out skin cells, dried up lube, and overgrowth of bacteria that like to hang out in basic pH vagina.

  • This is why douches are acidic


How often do I douche?

  • First week post op - douche every day

  • Second week post op - douche every other day

  • Third week and ongoing - 1-2x/week

  • If you start having a fishy odor - commonly this is from bacterial overgrowth and you can increase your douching regimen to cleans out the overgrowth and re-acidify your vagina


Why am I numb and also having sharp zinging pains throughout my pelvis, vulva and clitoris?

  • Nerves can initially be numb or super sensitive and while they heal very slowly, while they are "waking up", they can produce sharp zingy pains anywhere you have had surgery. This does not mean something has gone wrong, this is part of the normal nerve healing process.

  • Nerves regenerate and heal very slowly, typically it can take up to one year post operatively to see what the final results of sensation are, and sometimes even up to eighteen months.

  • Risks of surgery are that certain areas remain numb or with decreased sensation, these are typically the actual scar sites or incision sites. For instance, scars where you have had a cut or accident before, feel a little different than the surrounding skin once the area heals.

Post Operative Period 1-4 months

Why is Dilating becoming harder?

  • Remember that depth is more important than width or size of the dilator. If it is starting to hurt, go down in size and increase in frequency until you can go back up to the larger sized dilator. This may take several weeks to months. 

  • Between month 2-4 after surgery, the body goes through a healing process that stiffens the muscles, ligaments and scar tissue around the vagina. Patients commonly have a period of time which dilating becomes more difficult. We recommend taking more time, going down in size of dilator ( if you have increased size), dilate more frequently from at least 3x/day to 4-5x/day. Once dilation becomes easier, you can decrease to your baseline number of times of dilation and increase your dilator size.

Why do I feel suture poking out and or tender hard red spots?

  • ​All sutures will be eventually absorbed or the body will push them out. Sutures dissolve at varying times from 10 days to 4months. The sutures used in areas of most tension, along clitoral hood, labia minora and the perineum near the bottom of the vaginal opening; will have delayed absorption of up to 4 months. Typically, at 3 months after surgery, these suture knots are causing redness and tenderness points which will heal with time.

  • If the areas of redness and tenderness are getting bigger, more tender, have any discharge, of fever- please contact our office for evaluation for possible infection. If unable to come into our office due to distance, please be evaluated for possible infection.

Post Operative Period 1-12 months

When should I be able to orgasm?

  • There is a range of as little as a few months to as long as a year for having a clitoral orgasm. On average, most patients tend to have their first clitoral orgasm around 9 months. Remember, nerves take longest to heal, so be patient and if at first you do not succeed, try, try again.

  • G-spot orgasm: post-operatively the other erogenous zone is the prostate, which is approximately 4 cm inside the vagina on the top wall. Patients can also experience an orgasm with stimulation of this area. This also may take time but can happen sooner than the clitoral orgasm. Range is as little as a few weeks to as long as a year.

How do I go about having an orgasm?

  • Unfortunately there is not one set of instructions that would work for everyone. This is an experimentation type of process because everyone is different and also as the nerves heal, different stimulations may feel better. Be patient during the first year since it does take time for the nerves to heal, as well as time for you to learn your body and what you like stimulus-wise.

  • There are 2 erogenous spots: the clitoris and the G-spot ( where the prostate is located) approximately 4cm inside the vagina on the top/anterior/bladder side of the vagina. Gently rubbing these spots separately or together will help you find your way to an orgasm.

  • Experimenting with either touching these spots directly, gently at first since these areas may be extremely sensitive (or numb depending when you are trying during your first year of nerve regeneration), or gently touching, rubbing massaging the areas around the clitoris and the G-spot may work for you.

  • Be patient, experiment, have fun.