Characterization of Neovaginal Epithelial Microstructures and Evaluation of the Nugent Score as a Dysbiosis Diagnostic Tool for Transfeminine Individuals Post-Vaginoplasty

Transfeminine individuals (tF) often elect to undergo vaginoplasty — surgically creating a neovagina, often using penile and scrotal tissue. While cisgender genital mucosae and their impact on genital health are well characterized, the neovaginal microenvironment remains poorly understood. Through quantitative microscopy, this study demonstrated that unlike natal vaginal epithelia, neovaginal epithelium lacks glycogen and retains many penile-like characteristics, including a thinner epithelium, a cornified outer layer, and low expression of mucosal markers. However, it also exhibits reduced cornification structural protein expression compared to natal foreskin. These differences likely drive the uniqueness of the neovaginal microbiome, impacting the utility of current diagnostics. We demonstrated the Nugent score, a gold-standard tool for assessing natal vaginal bacterial dysbiosis, is ineffective in the neovagina, as targeted bacterial morphotypes do not correlate with inflammation or symptoms. These findings highlight the need for trans-specific diagnostics and treatments to address the unique neovaginal microenvironment.