# Bella's Recovery Plan
## Bella's Recovery
Presented by Allene
Bella's Roadmap to Recovery
A detailed, step-by-step guide to post-operative MTF care, navigating New Mexico Medicaid, and managing daily healing with confidence. Made with love for the woman who had the courage to become herself.
Use arrow keys or swipe to navigate
14 slides · Complete care roadmap
## Table of Contents
Table of Contents
Work through these slides in order for the best results. Each section builds on the last.
Use the arrow keys or swipe to move between slides. Your Progress Tracker saves your checkmarks as long as this tab stays open.
| Section Label | Description | Icon | Color Class | Step Number |
| --- | --- | --- | --- | --- |
| Progress Tracker | Interactive checklist — track every step across all 4 phases of recovery | :icon-check-square: | sage | 01 |
| Medical Providers | The 3 vetted providers in NM with experience treating post-op trans women | :icon-stethoscope: | teal | 02 |
| Phone & Email Scripts | 5 word-for-word scripts written in Bella's voice — ready to copy and send | :icon-scroll-text: | pink | 03 |
| Insurance & Records | NM Medicaid MCO numbers, NEMT booking, and surgical records request protocol | :icon-shield-check: | blue | 04 |
| Advocacy in the Clinic | One-page cheat sheet and 4 essential screening questions for new providers | :icon-message-square: | amber | 05 |
| All 10 Questions | Every screening question with pushback strategies and exact responses to give | :icon-list-checks: | purple | 06 |
| Hygiene & pH | Safe douching recipe, pharmacy shopping list, and normal vs. infection signs | :icon-droplets: | green | 07 |
| Dilation & Healing | 7 evidence-based techniques to manage granulation, pelvic floor spasm, and pain | :icon-heart-handshake: | rose | 08 |
| HRT Management | Post-op estrogen recalibration, stopping blockers, bloodwork panel, delivery methods | :icon-flask-round: | violet | 09 |
| Pelvic Floor PT | What PT is, how to find a trans-literate therapist, and 4 at-home exercises | :icon-activity: | emerald | 10 |
| Emergency Protocol | 5 scenarios with urgency levels, ER script to hand staff, and key emergency contacts | :icon-shield-alert: | red | 11 |
## Progress Tracker
Bella's Progress Tracker
Check off each step as you complete it. Your journey, your pace.
Phase 1: Insurance & Records
Phase 2: Finding a Provider
Phase 3: First Appointment
Phase 4: Daily Home Care
| Step |
| --- |
| Locate physical Turquoise Care Medicaid card |
| Identify your MCO (BCBS / Presbyterian / United / Molina) |
| Call MCO Member Services to confirm PCP & referral requirements |
| Call surgeon's Medical Records dept to request Operative Report |
| Complete HIPAA Release of Information (ROI) form |
| Download personal PDF copy of Operative Report & Discharge Summary |
| Fill out One-Page Medical Cheat Sheet for appointments |
| Step |
| --- |
| Call TGRCNM (505-200-9086) for local vetted referrals |
| Send pre-screening email to Planned Parenthood Farmington |
| Contact UNM Truman Health — request telehealth intake first |
| Book NEMT transport if traveling to Albuquerque (2+ weeks ahead) |
| Verify the specific provider (not just the clinic) accepts NM Medicaid |
| Get PCP referral if required by your MCO plan |
| Step |
| --- |
| Bring printed One-Page Cheat Sheet to hand nurse at check-in |
| Ask to update preferred name & pronouns in the EMR system |
| Request silver nitrate treatment for hypergranulation if present |
| Request full hormone blood panel (estrogen, FSH, LH — no blocker needed post-op) |
| Ask for pelvic floor PT referral to have on file |
| Confirm after-hours triage contact for urgent dilation issues |
| Confirm prostate PSA screening plan based on age/history |
| Step |
| --- |
| Gather all pharmacy supplies (see Hygiene slide) |
| Start daily reverse kegel / pelvic drop practice (10 mins) |
| Switch to butterfly pose + hip pillow for dilation sessions |
| Use lube launcher before every dilation session |
| Take daily fiber supplement & drink 64oz water |
| Begin a simple daily healing journal (note pain level, discharge, mood) |
## Medical Providers
Medical Providers & Clinics
Navigating post-operative care—especially specialized gynecological care—requires an affirming, highly literate clinical team. Here are the top vetted resources.
| Name | Details | Location | Contact | Icon | Link |
| --- | --- | --- | --- | --- | --- |
| Planned Parenthood
Farmington Health Center | A highly trans-literate local option. They accept NM Medicaid and can handle routine checkups, hormone management, and act as a gateway to refer out for specific post-op vaginal care if complications arise. | 1308 E. 20th Street, Farmington, NM | (505) 327-0451 | :icon-heart-pulse: | https://www.plannedparenthood.org/health-center/new-mexico/farmington/87401/farmington-health-center-2940-90860 |
| UNM Truman Health Services | The state's premier clinic for transgender healthcare. Providers have extensive experience with MTF post-op anatomy. They accept NM Medicaid and can often work collaboratively with a local primary care doctor or do telehealth. | Albuquerque, NM | Requires NEMT travel booking | :icon-building-2: | https://unmhealth.org/locations/truman-health-services.html |
| Transgender Resource Center of NM | Not a clinic, but the best hub for direct referrals. TGRCNM maintains a private, heavily vetted directory of providers. They offer free case management and know who has a proven track record with neo-vaginas locally. | Statewide / Virtual | (505) 200-9086 | :icon-users: | https://tgrcnm.org |
## Phone & Email Scripts
Scripts Written for Bella
Copy these word-for-word. You are informed, prepared, and your needs are completely reasonable.
| Tab Label | Icon |
| --- | --- |
| Pre-Screening Email | :icon-mail: |
| Phone Script | :icon-phone: |
| TGRCNM Referral Call | :icon-users: |
| Surgical Records Request | :icon-file-text: |
| NEMT Booking Call | :icon-car: |
Subject: New patient inquiry — Post-operative MTF care and provider collaboration
To the Scheduling and Clinical Team,
My name is Bella. I am a fully transitioned transgender woman seeking a new primary care provider and gynecologist for routine and post-operative follow-up care.
Because my anatomy requires specific clinical knowledge (I have had a vaginoplasty), I want to make sure your clinic is a safe and medically appropriate fit before I transfer my records and book an appointment. Could you please check with your clinical staff and let me know:
**1. Experience:** Do you have a provider on staff who is experienced in examining and treating a neo-vagina?
**2. Exam Protocol:** Is the provider comfortable adapting exam tools for my safety — such as using a pediatric speculum, or allowing me to use my own dilators during a pelvic exam?
**3. Collaboration:** If a specific post-op issue arises outside the provider's typical scope, are they willing to consult directly with my original surgeon or specialists at UNM Truman Health?
**4. Insurance:** Are you currently accepting new patients with New Mexico Medicaid Turquoise Care?
Thank you so much for your time. I look forward to hearing whether your clinic will be a good fit.
Best regards,
Bella
[Your Phone Number]
**When the front desk answers:**
"Hi, my name is Bella. I'm looking to establish care as a new patient, but because my medical history is a bit specialized, I have three quick questions before I book anything. Could I speak to a triage nurse or care coordinator who understands clinical requirements?"
**Once connected to the right person:**
"I am a transgender woman who has completed bottom surgery, so I have a neo-vagina. I need to make sure the doctor I see is actually equipped to handle my anatomy.
First — do your providers have clinical experience with post-operative MTF care?
Second — if I need a pelvic exam, are they willing to use adapted tools, like a pediatric speculum or my own dilators, to prevent tissue damage?
Third — if an issue comes up that they aren't familiar with, are they willing to consult with my original surgeon rather than just sending me to the ER?
And finally — I have New Mexico Medicaid Turquoise Care. Are you accepting new patients on that plan?"
**What to say:**
"Hi, I'm reaching out because I need help finding a doctor for my care. I'm a transgender woman living in the Farmington area. I've completed my transition, including a vaginoplasty, and I'm looking for an experienced provider for post-op and routine care.
Since I'm on New Mexico Medicaid, I'm having trouble finding someone local who has real clinical experience with my specific anatomy. Do you have a directory or a case manager who could give me a vetted referral for a provider in the Farmington, Durango, or Albuquerque area?"
**Contact:** TGRCNM — (505) 200-9086 — tgrcnm.org
**Step 1 — Ask for Medical Records specifically:**
"Hi, this is Bella [Last Name], date of birth [MM/DD/YYYY]. I am establishing care with a new provider in my home state and need to request my surgical records and operative report — both for my personal files and to transfer to my new doctor."
**Step 2 — On the ROI form, request exactly:**
• The **Operative Report** (step-by-step surgical notes)
• The **Discharge Summary** (notes from leaving the hospital)
• The **Most Recent Clinical Progress Note** (last follow-up notes)
**Step 3 — Always request a personal copy:**
"In addition to the transfer to my new provider, please also release a secure PDF copy directly to me so I have it saved for future providers."
**Call your specific MCO member services and say:**
"Hi, my name is Bella [Last Name] and my Member ID is [Number]. I have an upcoming specialist appointment at UNM Truman Health Services in Albuquerque that my local area cannot provide. I would like to schedule Non-Emergency Medical Transportation (NEMT) for this appointment."
**Important tips to know before calling:**
• Call at least **2 weeks in advance** for long-distance trips
• The transport service will need to verify that the specialty care is not available locally
• **Gas reimbursement option:** If a family member drives Bella, you can request mileage reimbursement — but it MUST be set up before the trip
**MCO Transportation Numbers:**
• BCBS NM: 1-866-913-4342 (Modivcare)
• Presbyterian: 1-855-774-7737 (Modivcare)
• UnitedHealthcare: 1-877-236-0826
• Molina: 1-844-862-4543
## Insurance & Records
Navigating the System
Insurance routing and retrieving surgical blueprints.
Turquoise Care MCOs
Turquoise Care is the umbrella for NM Medicaid. You must identify the **Managed Care Organization (MCO)** on the card to book NEMT transport or check provider status.
| MCO Name | Member Services | NEMT Transport Line |
| --- | --- | --- |
| Blue Cross Blue Shield NM | 1-866-689-1523 | 1-866-913-4342 (Modivcare) |
| Presbyterian Health Plan | 1-888-977-2333 | 1-855-774-7737 (Modivcare) |
| UnitedHealthcare Community | 1-877-236-0826 | 1-877-236-0826 (same line) |
| Molina Healthcare | 1-844-862-4543 | 1-844-862-4543 → request transport |
Booking NEMT Transport to Albuquerque
For the ~3-hour trip from Farmington to UNM Truman Health, NM Medicaid covers Non-Emergency Medical Transportation. **Call at least 2 weeks in advance.** The transport service will verify that the specialty care is not available locally. If a family member drives, ask about **gas mileage reimbursement** — but it MUST be set up before the trip.
Surgical Records Protocol
| Step Title | Description |
| --- | --- |
| Call Medical Records | Don't just ask the front desk. Ask specifically for the Medical Records department of the original surgeon. |
| Sign the ROI Form | Complete the HIPAA Release of Information form via secure portal or DocuSign. |
| Request Specific Documents | Do NOT ask for 'all records'. Specifically request the **Operative Report** and **Discharge Summary**. |
Always request a personal PDF copy for yourself alongside the direct transfer to the new doctor. This prevents repeating the process if you switch providers again.
## Advocacy in the Clinic
Advocacy in the Clinic
Getting past the front desk and interviewing your provider to ensure safe, literate care.
Why ask:
How to respond:
One-Page Cheat Sheet
Doctors have limited time. Hand the nurse a single piece of paper with all vital info to make the appointment productive:
| Item |
| --- |
| Surgeon's Name & Contact Info |
| Exact Date of Vaginoplasty |
| Surgical Technique Used |
| Current Estrogen & Blocker Doses |
| Exact Dilation Schedule |
Crucial Screening Questions
These 4 questions cover the most critical safety criteria. See the next slide for all 10 with full strategy breakdowns.
Print this sheet double-sided with your Operative Report on the back. Hand it to the nurse at check-in before the doctor enters — this sets the clinical tone immediately.
Continue to **All 10 Questions** for the complete screening strategy with pushback tactics and exact responses.
| Question | Why Ask | Response |
| --- | --- | --- |
| How many post-operative trans women have you treated for routine gynecological care? | Standard speculums or lack of MTF anatomical knowledge can cause harm. A neo-vagina has a different mucosal lining and carries specific risks. | "While they function similarly, my neo-vagina has a different lining. I need a provider who knows my specific healthy baseline." |
| Are you comfortable using my personal dilators or a pediatric speculum for pelvic exams? | Adult speculums can cause micro-tears depending on depth and technique. | "For my safety, are you willing to adapt exam tools, or allow me to guide the insertion?" |
| If I develop hypergranulation tissue, are you equipped to treat it with silver nitrate? | Granulation is a common complication. It causes bleeding during dilation but is easily treated in-office. | "If you are not comfortable doing it, who in this clinic or local area can you refer me to for immediate treatment?" |
| If an issue arises with my anatomy, are you willing to consult with my surgeon? | You want a doctor with the humility to consult an expert, rather than sending you to the ER or rejecting care. | "Because I am on Medicaid, waiting for a new specialist takes months. I need a provider willing to collaborate." |
## All 10 Questions
All 10 Screening Questions
Every question Bella should ask to evaluate whether a provider is clinically safe and a genuine fit. Tap each to expand the strategy.
Why Ask
Potential Pushback
How to Respond
| Category | Question | Why Ask | Potential Pushback | How to Respond |
| --- | --- | --- | --- | --- |
| Anatomy Experience | How many post-operative trans women have you treated for routine gynecological care? | You need their actual baseline of experience — not just if they are 'LGBTQ friendly.' A provider who has never seen a neo-vagina may misread normal anatomy as a complication or miss a real one entirely. | "A vagina is a vagina. We know how to do a pelvic exam." | "While they function similarly, my neo-vagina has a different mucosal lining and carries specific post-op risks like hypergranulation or strictures. I need a provider who knows what my specific, healthy baseline looks like." |
| Exam Equipment | Are you comfortable using my personal dilators or a pediatric speculum for pelvic exams instead of standard clinic equipment? | Standard adult speculums can cause micro-tears or extreme discomfort in a neo-vagina depending on its depth and the surgical technique used. Adapted tools are a standard clinical accommodation, not an unusual request. | "We just use our standard clinic speculums for all patients." | "Using a standard speculum on my anatomy can actually cause tissue damage. For my safety and comfort, are you willing to adapt the exam tools — or allow me to guide the insertion?" |
| Hormone Management | How do you approach HRT for a patient who has completed bottom surgery? | She no longer produces testosterone naturally. Her estrogen needs have dropped significantly and testosterone blockers like Spironolactone are no longer needed. A provider who leaves her on pre-op doses can cause cardiovascular harm or deficiency. | "We will just keep you on the same dosages your previous doctor prescribed." | "Since my bottom surgery, my endocrine system has completely changed. I would like to order a full hormone blood panel today — estrogen, FSH, LH — so we can adjust my dosage safely for my new biology." |
| Granulation Treatment | If I develop hypergranulation tissue, are you equipped to treat it here in-office with silver nitrate? | Granulation is one of the most common post-op complications. It causes bleeding and pain during dilation but is easily and quickly treated in-office. Sending Bella to a surgeon out of state for a 2-minute treatment is unnecessary. | "That sounds like a surgical complication. You would need to go back to your surgeon for that." | "My surgeon is out of state, and silver nitrate application is a standard minor outpatient treatment. If you are not comfortable doing it, who in this clinic or locally can you refer me to for immediate treatment?" |
| Pelvic Floor PT | Do you have a referral network for pelvic floor physical therapists experienced with trans women? | Pelvic floor hypertonia — where the muscles lock in constant spasm — is very common post-vaginoplasty and makes dilation extremely painful. A referral on file means she does not have to wait months if an issue arises. | "You probably don't need PT as long as you are keeping up with your dilation schedule." | "Sometimes the pelvic floor muscles lock up entirely independent of dilation. Even if I don't need it today, I would like a referral on file so I don't have to wait months to get in if an issue arises." |
| Prostate Screening | Are you familiar with how to screen for prostate issues in post-op trans women? | Vaginoplasty does NOT remove the prostate gland. It remains situated against the vaginal wall. She still needs PSA screening based on age and family history. Many providers falsely believe surgery eliminates this need. | "You had bottom surgery, so you don't need to worry about prostate exams anymore." | "The prostate is not removed during a vaginoplasty. While my risk is lower because my testosterone is suppressed, I still need PSA levels checked and routine screening based on my age. How do you handle this?" |
| Infection / Microflora | How do you approach testing and interpreting cultures for UTIs, yeast infections, or bacterial vaginosis in a neo-vagina? | The natural bacterial flora inside a neo-vagina is entirely different from a natal vagina. Standard lab reference ranges may flag her normal baseline as an infection, leading to unnecessary antibiotics that can damage healing tissue. | "We just do a standard swab and send it to the lab like we do for anyone else." | "Because my vaginal lining is made from a different tissue type, a standard culture might flag my normal baseline bacteria as an infection. Will you be able to interpret lab results with my specific anatomy in mind?" |
| EMR & Identity | How does your front desk and medical records system handle preferred names and pronouns? | Being deadnamed or misgendered in a waiting room is humiliating and signals the clinic's overall culture. Most modern EMR systems have a preferred name field. This is a non-negotiable for affirming care. | "We have to use your legal name because of how Medicaid billing works." | "I understand billing requires my legal name, but most modern systems have a Preferred Name and Gender Identity field. Can we take a moment now to update that so your staff addresses me correctly?" |
| Provider Collaboration | If an issue arises with my anatomy that you aren't familiar with, are you willing to consult with my surgeon or UNM Truman Health? | You want a doctor with the humility to call an expert rather than guess. On Medicaid, a specialist referral takes months — a collaborative primary care doctor prevents that delay. | "If it's beyond my scope, we will just refer you out to a specialist." | "Because I am on Medicaid, a new specialist referral can take months. I am looking for a primary provider willing to make a quick phone call to collaborate with an expert, rather than just sending me away." |
| Emergency Protocol | If I have urgent bleeding or extreme pain during dilation after hours, what is your protocol? | Local ERs in Farmington will almost certainly have zero experience with neo-vaginal complications and may cause more harm than good through inappropriate interventions. Knowing Bella's after-hours options is critical. | "If you have a medical emergency after hours, go to the ER." | "Local emergency rooms lack experience with neo-vaginal complications. Does your clinic have an on-call triage nurse I can speak to first, so we can determine if an ER visit is actually safe and necessary?" |
## Hygiene & pH
Neo-Vaginal Hygiene & pH
Establishing the right microbiome and keeping the body feeling healthy without irritating delicate surgical tissue.
| Title | Description | Icon |
| --- | --- | --- |
| The Golden Rule | Soap is for the outside only. Only water and specific diluted solutions go inside. The neo-vagina needs help to establish the correct acidic microbiome to prevent Bacterial Vaginosis (BV). | :icon-droplet: |
| The Recipe | Mix 1-2 tablespoons of plain white vinegar into 32 oz of lukewarm water. The slight acidity mimics a healthy vagina and washes away old fluids and lube. | :icon-flask-conical: |
| Safe Technique | Use a reusable medical squeeze bulb. Do NOT forcefully blast water. Squeeze slowly to let water cascade out. Forceful squirts push bacteria deeper. | :icon-activity: |
| Equipment Care | Wash the bulb/nozzle with hot water and antibacterial soap (like Dial) after every use. Let it air dry completely to prevent mold. | :icon-shield-alert: |
Pharmacy Shopping List
Specific supplies to have on hand for safe, comfortable home care.
| Item |
| --- |
| Water-based lube only — Surgilube or Slippery Stuff (NEVER silicone, warming, or flavored) |
| Needle-less medical syringes / lube launchers (ask pharmacist if not on shelf) |
| Reusable medical squeeze bulb or gravity bag — NOT pre-packaged Summer's Eve douches |
| Plain white vinegar (grocery aisle — no need for expensive specialty vinegar) |
| Unscented mild soap — Cetaphil or CeraVe (facial aisle, gentlest option) |
| Antibacterial soap like Dial — ONLY for washing the douching bulb, never on skin |
| 100% cotton underwear — avoid nylon, spandex, polyester (trap heat and moisture) |
Normal Healing vs. Infection — Know the Difference
| Type | Description | Icon |
| --- | --- | --- |
| Normal | Light spotting or bleeding after dilation (granulation tissue). White or clear discharge with a neutral or slightly vinegary smell. Minor aching for 1–2 hours after a session. | :icon-check-circle-2: |
| See a Doctor | Green, yellow, or cottage-cheese discharge. Strong foul or 'fishy' odor (indicates BV). Severe itching on the outside. A sudden spike in pain, swelling, or fever above 101°F after dilation. | :icon-alert-triangle: |
## Dilation & Healing
Dilation & Mental Fatigue
Managing the exhausting reality of long-term healing, overcoming granulation, and protecting your peace.
The 'Sandy' Feeling: Hypergranulation
If you feel a gritty, spongy texture that bleeds bright red during dilation, you are likely dealing with hypergranulation. This is normal. Do not force larger sizes right now.
| Title | Description | Icon |
| --- | --- | --- |
| Over-Lubricate (Lube Launcher) | Don't just coat the dilator — lube gets wiped off at the entrance, leaving the deep canal dry and causing micro-tears. Use a needle-less medical syringe to push water-based lube (Surgilube or Slippery Stuff) directly inside before insertion. Always water-based. Never silicone. | :icon-syringe: |
| Heat Before You Dilate | 15 minutes before each session, sit in a warm bath or lay with a heating pad on your lower belly. Heat naturally relaxes pelvic floor muscles the way stretching relaxes tight leg muscles. Never skip this step when pain is high. | :icon-flame: |
| The Locked Pelvic Floor | After months of anticipating pain, the pelvic floor locks into constant spasm. Practice reverse kegels daily — push the muscles outward and down, like passing gas, not squeezing inward. Do 3 sets of 10 holds for 5 seconds, without a dilator, every single day. | :icon-lock-open: |
| Adjust Positioning | Lying flat tilts the pelvis in a way that makes insertion harder. Prop hips up on a firm pillow, bend knees, and let legs fall open in butterfly pose. This physically opens the pelvic outlet and reduces the angle of entry. | :icon-expand: |
| Belly Breathing — Time the Push | Never push the dilator in while holding your breath — this automatically tightens the floor. Take a deep slow belly breath (belly expands, not chest). Only push the dilator inward on the slow exhale, when the muscles are at their most relaxed. | :icon-wind: |
| Build a Nest — Distract the Brain | Staring at the ceiling waiting for it to be over creates anxiety that physically tightens the pelvic floor. Dim the lights. Put on a comfort show, an audiobook, or music. Distracting the brain breaks the pain-tension cycle and makes 20 minutes feel much shorter. | :icon-tv: |
| Size Down — Let the Tissue Heal | At 6 months, there is immense pressure to use the largest dilator. But fighting a large dilator for 5 painful minutes is worse than using a smaller size comfortably for 30 minutes. Drop down one size until granulation heals. Depth can be reclaimed — torn tissue cannot. | :icon-minus-circle: |
Daily Recovery Habits
| Task |
| --- |
| Practice reverse kegels / pelvic drops (10 mins without dilator) |
| Drink at least 64 oz of water |
| Take daily fiber supplement to prevent straining |
| Prop hips up and use butterfly pose for dilation |
| Use lube launcher to coat the canal before dilating |
| Practice deep belly breathing during insertion |
Be kind to yourself! This is physically and emotionally exhausting. It is okay to take a mental break if it all feels like too much today.
## HRT Management
HRT After Surgery
Everything changes after vaginoplasty. Your hormones, your dosages, your bloodwork schedule — all need to be recalibrated for your new biology.
The single biggest hormonal change after bottom surgery is that your body is no longer producing testosterone. This means testosterone blockers like **Spironolactone** (or Bicalutamide) are **no longer needed** and should be stopped or tapered under a doctor's guidance. Continuing blockers unnecessarily can cause dangerous electrolyte imbalances, low blood pressure, and fatigue.
| Section Title | Body | Icon |
| --- | --- | --- |
| Estrogen Dosage — Expect a Reduction | Pre-surgery, estrogen doses are often kept higher to counteract testosterone production. Post-surgery, your estrogen needs drop significantly. A dose that was correct before surgery may now cause hyperestrogenism — symptoms include headaches, breast tenderness, nausea, mood swings, and increased clotting risk. Your new provider MUST run labs before adjusting, not just guess. | :icon-activity: |
| The Essential Blood Panel — What to Ask For | At your first post-op appointment, request: **Estradiol (E2)** — target range post-surgery is typically 100–200 pg/mL, though this varies. **FSH & LH** — these confirm whether your body's own feedback loop is functioning. **Comprehensive Metabolic Panel (CMP)** — checks liver, kidneys, and electrolytes. **Complete Blood Count (CBC)** — screens for clotting risk. **PSA** — prostate screening, still needed post-op. | :icon-test-tube: |
| Delivery Method Matters | Oral estrogen (pills) carries a higher clotting risk than transdermal patches or injections. Post-surgery, many clinicians prefer to switch to patches or injections because oral estrogen also produces higher levels of estrone (a less effective form of estrogen) rather than estradiol. If you are currently on pills, this is a great time to discuss switching delivery methods. | :icon-syringe: |
| Progesterone — Still Being Studied | Some trans women report benefits from bioidentical progesterone (Prometrium) post-surgery — including improved sleep, mood, and breast fullness. Others do not respond. There is no definitive consensus yet. If interested, ask your provider about 100mg oral micronized progesterone (Prometrium) at bedtime. Avoid synthetic progestins like medroxyprogesterone (Provera), which carry cardiovascular risks. | :icon-moon: |
Critical Post-Op Change
Always bring labs to your appointment. Never let a provider change your hormones without current bloodwork.
Reference Resources
| Label | URL |
| --- | --- |
| UCSF Transgender Care — HRT Guide | https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy |
| Endocrine Society — Transgender Clinical Practice Guidelines | https://www.endocrine.org/clinical-practice-guidelines/gender-dysphoria |
| WPATH Standards of Care v8 (Full PDF) | https://www.wpath.org/publications/soc |
## Pelvic Floor PT
Pelvic Floor Physical Therapy
The single most underprescribed tool in post-op recovery. A specialist can resolve pain in weeks that months of solo dilation cannot.
Pelvic Floor PT is performed by a specially trained physical therapist who works with the internal and external muscles of the pelvic floor — the hammock-shaped muscle group that cradles the bladder, bowel, and vaginal canal. After vaginoplasty, these muscles often become **hypertonic** (locked in constant contraction) due to post-surgical inflammation, pain avoidance, and anxiety around dilation. A hypertonic pelvic floor is like trying to push a dilator through a clenched fist.
Sessions are always conducted with full consent and explained step by step. A typical session includes an **external assessment** of posture, hip alignment, and lower back tension; gentle **internal assessment** (with a gloved finger) to locate and release trigger points in the muscle; **biofeedback training** using surface sensors to teach you to consciously release muscles; and a **customized home exercise program** of reverse kegels, diaphragmatic breathing, and hip openers.
Ask your provider explicitly for a referral to a pelvic floor PT with transgender or post-surgical experience. You can also self-search at **pelvicrehab.com** (the APTA's Pelvic Health Academy directory) using the filter for 'pelvic pain' and 'gender-affirming care.' When calling, ask: "Do you have experience with post-vaginoplasty patients or neo-vaginal anatomy?"
| Sign |
| --- |
| Dilation feels like hitting a wall even with plenty of lubrication |
| Pain persists for more than 2 hours after a dilation session |
| Leaking urine when laughing, sneezing, or coughing |
| Feeling of pressure or heaviness in the pelvic area at rest |
| Lower back pain that accompanies dilation difficulty |
| Inability to fully relax pelvic muscles even when consciously trying |
What to Expect in a Session
How to Find One
What Is It?
Signs You Need PT Now
At-Home Exercises to Start Now
| Exercise | How To Do It | Icon |
| --- | --- | --- |
| Diaphragmatic Belly Breathing | Lie on your back. Place one hand on your chest, one on your belly. Inhale so only the belly hand rises. On a slow exhale, feel the pelvic floor drop and soften. Repeat 10 times, twice daily. | :icon-wind: |
| Reverse Kegel (Pelvic Drop) | Instead of squeezing inward, gently push outward and downward — like the beginning motion of passing gas. Hold for 5 seconds, release fully. Do 3 sets of 10, daily. Never force or bear down hard. | :icon-arrow-down-circle: |
| Happy Baby Pose | Lie on your back, bring knees to chest, hold the outsides of your feet, and let your knees fall open toward your armpits. Breathe deeply and hold for 60–90 seconds. Do before every dilation session. | :icon-baby: |
| Supine Hip Opener (Butterfly) | Lie on your back with a pillow under your hips. Bring the soles of your feet together and let your knees fall outward. Hold for 2 minutes with slow belly breathing. Best done with a heating pad on the lower belly. | :icon-expand: |
Find a Therapist
| Label | URL |
| --- | --- |
| APTA Pelvic Health Academy — Find a PT | https://www.pelvicrehab.com |
| UCSF Post-Op Pelvic Floor Guide | https://transcare.ucsf.edu/guidelines/surgery-vaginoplasty-aftercare |
## Emergency Protocol
Emergency Protocol
Knowing when to call, what to say, and how to protect yourself if you must go to a local ER with no trans-care experience.
Know Before You Go
Local ERs in Farmington will almost certainly have **zero clinical experience with neo-vaginal anatomy**. An uninformed provider performing a pelvic exam or inserting a standard speculum without guidance can cause serious tissue damage. You have the right to refuse any exam and to educate your ER team before they touch you. Your voice is your protection.
| Scenario | What to Do | Urgency | Icon |
| --- | --- | --- | --- |
| Light spotting after dilation | This is almost certainly granulation tissue. Apply gentle pressure with a clean cloth. Do not dilate again today. Call your provider's office the next business day. Do NOT go to the ER. | Monitor at home | :icon-droplets: |
| Heavy, soaking bleeding that does not slow in 15 minutes | Apply firm pressure. Call your surgeon's emergency line first — most practices have one. If you cannot reach them and bleeding continues, go to the ER. Bring your Operative Report PDF and the ER script below. | Urgent — call surgeon first | :icon-alert-triangle: |
| Fever above 101°F with pelvic pain | This may indicate an infection in the surgical site. Call your provider immediately. If after hours, go to the ER. Bring your records. Request IV antibiotics and insist on consulting a specialist before any internal exam. | Go to ER with records | :icon-thermometer: |
| Sudden inability to insert any dilator size | A sudden complete blockage may indicate significant stenosis (narrowing). Do not force it. This is not an ER situation unless you also have a high fever or cannot urinate. Call your provider or surgeon the next morning. | Call provider next day | :icon-x-circle: |
| Pain or burning when urinating with no other symptoms | Likely a UTI, which is common post-op due to anatomy changes. Call your provider for a urine culture. Drink extra water, avoid caffeine. Request a sensitivity test alongside the culture so antibiotics are targeted correctly. | Call provider — not ER | :icon-flask-conical: |
ER Script — What to Say When You Arrive
Print this and keep it in your wallet or phone.
**"My name is Bella. I am a transgender woman who has undergone a vaginoplasty. I have a neo-vagina, which has different anatomy from a natal vagina and requires specialized care.**
**Before any internal pelvic exam is performed, I need you to:**
1. Contact my surgeon's office or UNM Truman Health Services for guidance.
2. Use a pediatric speculum or my personal dilator — NOT a standard adult speculum.
3. Have the most experienced provider available conduct any examination.
**I am providing my Operative Report for reference. Please review it before proceeding.**"
Add your surgeon's number
Key Emergency Contacts
| Name | Phone | Notes |
| --- | --- | --- |
| My Surgeon's Office | [Fill in] | Call their main line and ask for the on-call emergency line after hours |
| UNM Truman Health Services | (505) 272-2811 | Ask for the on-call provider for established patients |
| Planned Parenthood Farmington | (505) 327-0451 | During business hours only — not an after-hours emergency line |
| TGRCNM Crisis Support | (505) 200-9086 | Navigation help and guidance — not a medical emergency line |