Experiences and evidence of transfeminine people’s challenges with chronic, recurrent neovaginal malodor: a cross-sectional qualitative study

Experiences and evidence of transfeminine people’s challenges with chronic, recurrent neovaginal malodor: a cross-sectional qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Experiences and evidence of transfeminine people’s challenges with chronic, recurrent neovaginal malodor: a cross-sectional qualitative study Ainslie C. Shouldice, Reeya Parmar, Hannah Wilcox, Aleena Ghafoor, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7348971/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Penile inversion vaginoplasty, which uses penile and scrotal skin to surgically create a neovagina, is a medically necessary gender-affirming surgery for some transfeminine individuals. Much like cisgender women, roughly a third of transfeminine individuals who have undergone vaginoplasty report having experienced bothersome neovaginal malodor in the past 30 days. However, sources of neovaginal malodor remain unclear. This study sought to collect data on odour quality and characterize the experiences of transfeminine individuals with neovaginal malodor. Methods Participants (n = 20) completed a cross-sectional questionnaire answering semi-structured interview questions on malodor experiences, exacerbating factors, and attempted reduction methods. Participants were mailed scent test kits containing samples of known malodorous compounds, and rated sample resemblance to their own malodor on a Likert scale. Results were evaluated by Spearman’s correlation. Participant comments were analysed using a thematic analysis and organized into key themes. Results Twenty-nine different scents were reported by 20 participants. Sixteen participants completed semi-structured interview questions, providing sixty-four total comments. Three key themes were identified: (i) odor and malodor diversity, ii) lifestyle and physiological factors, and iii) preventative hygienic practices. Participants often described both nonbothersome, desirable neovaginal odor, as well as unpleasant and undesirable neovaginal malodors. Scent test results revealed three malodor typologies, characterized by i) trimethylamine, ii) isovaleric acid, and iii) a diverse combination of the polyamines spermine, cadaverine, putrescine, as well as acetic acid. Participants engaged in diverse malodor management strategies, which were differentially effective. Conclusions The identification of three unique malodour typologies and varying success of treatments and hygienic practices in reducing neovaginal malodour suggests that different microbial communities may underlie each odour type. Further, the diversity of malodor reduction methods and douching substances reported highlight the lack of standard care guidelines for neovaginal malodor, demonstrating the need for further research aimed to develop evidence-based treatments. Bacterial vaginosis vaginoplasty post-operative care transgender transfeminine Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Transfeminine individuals (TF) are those assigned male at birth but who have a non-masculine gender identity ( 1 , 2 ). Many communities, including transgender women and non-binary or other gender-diverse individuals, fall under this umbrella term ( 3 , 4 ). Many TF pursue gender-affirming medical care, may involve the use of feminizing hormone therapy ( e.g. , estrogen, progestin, androgen blockers) and/or surgeries ( 1 , 2 ). These interventions are life-saving medical care, reducing the risk of gender dysphoria, depression, and/or anxiety ( 5 ). 97% of people who access gender-affirming surgery report improved quality of life ( 6 ). Vaginoplasty is a gender-affirming surgery involving reconstruction of the penis, perineum, and scrotum to create a vulva, vaginal canal, shortened urethra, and sensate clitoris capable of sexual function ( 7 , 8 ). Penile inversion vaginoplasty, the most common technique performed globally, lines the vaginal canal with penile and scrotal skin ( 9 – 11 ). Many cisgender females (CF) (30–50%) experience bothersome vaginal symptoms over their lifetimes that may be secondary to infection (bacterial vaginosis, candidiasis, trichomoniasis, sexually transmitted infection or vaginal atrophy ( 12 , 13 ). A recent study of 56 Canadian TF reported similar neovaginal symptoms, with neovaginal malodor the most frequently reported symptom, affecting 27% of participants in the past month ( 14 ). In cF, vaginal malodor has significant psychosocial impacts including malodor-associated shame and embarrassment, adoption of hypervigilant hygienic routines, increased cognitive load, and decreased quality of life ( 15 ). Despite the well-documented and significant impacts of vaginal malodor in cF, the behavioural, psychological, and physical impacts of neovaginal malodor in TF have received little attention. In reproductive-age CF (rCF), vaginal malodour is caused by microbial metabolites associated with a dysbiotic vaginal microbiome ( 16 – 20 ). Optimally, the rCF vaginal microbiota is dominated by Lactobacillus spp., which inhibit colonization by opportunistic and pathogenic species via lactic acid production. Lactic acid lowers vaginal pH (~ 4) and has direct microbicidal and anti-inflammatory effects ( 8 , 21 – 23 ). However, roughly a third of North American women harbor microbiota with low Lactobacillus abundance and a diverse array of strict and facultative anaerobes, some of which produce malodorous compounds ( 24 – 28 ). Species such as Trichomonas vaginalis , Prevotella micra , Peptostreptococcus anaerobius , Leptotrichia spp., Gemella spp., and Mobiluncus curtisii produce trimethylamine, a volatile fishy-smelling metabolite ( 19 , 20 , 29 , 30 ). Other gram-negative and gram-variable bacteria, such as Pseudomonas spp., Escherichia coli , Prevotella spp., and Dialister microaerophilus , produce polyamines like agmatine, cadaverine, putrescine, and spermine that have musty, rotting flesh, putrid, or semen-like odors, respectively ( 19 , 30 , 31 ). The fungi Candida albicans can also cause vaginal malodor through the production of carbon dioxide, creating a scent akin to brewing beer ( 17 , 18 ). The TF neovagina supports distinct microbiota than the rCF vagina, with differing potential capacities to produce odorous metabolites ( 32 , 33 ). Bacterial metabolism is responsible for many body odors: isovaleric and acetic acid from the skin commensal Staphylococcus epidermidis cause foot odor ( 34 ), sweat odour is the result of sulfanyl compounds produced by Corynebacterium , Propionibacterium , yeasts, and Micrococcaceae ( 35 – 39 ); and oral malodor is caused by a complex interplay of many bacteria ( 31 ). Understanding the sources of neovaginal malodor is necessary for effective treatment. For example, metronidazole effectively reduces fishy odor from gram-negative anaerobes in the cF vagina by targeting of T. vaginalis and trimethylamine-producers, but is not effective against aerobic skin commensals responsible for foot malodor. Though the impact, causes of, and treatments for vaginal malodor are well characterized in cF, there is a paucity of information on neovaginal malodor in TF. We use thematic analysis to gain insight into the experiences of transfeminine people with neovaginal malodor. Genital odor reporting is highly variable – individuals do not perceive odor in the same way, leading to a lack of consensus on what constitutes “normal” genital odor ( 40 ). Here, we employ a scent test, which normalizes malodor reporting by providing scent vials and prompting participants to report vial resemblance their own neovaginal odor, regardless of whether participants consider the odor bothersome. This provides a more consistent and standard system for odor reporting. Methods Participant cohort Participants were recruited from the TransBiota study (2021–2022), which included n = 56 adult TF from across Canada who had received vaginoplasty at least one year prior ( 14 ). TransBiota participants who indicated previously experiencing neovaginal malodor, and who had consented to be recontacted for future research, were offered participation by email. Consenting individuals (n = 23) were mailed a scent test to their homes and asked to provide feedback through a secure online questionnaire in REDCap ( 41 ). Of those 23 participants, 20 completed study activities. Scent Test Kit Malodorous chemicals putrescine, cadaverine, spermine, isovaleric acid, acetic acid, and trimethylamine were purchased from Sigma-Aldrich. Each sample was diluted to a concentration commonly found in the environment (Table 1 ) ( 29 , 42 – 46 ). 1 mL/chemical was absorbed onto a small cotton ball and placed in a 10 mL glass vial (ThermoFisher) and labelled with a number to blind participants to the chemical contents. Table 1 Malodorous chemical concentrations and volumes in mailed scent test kit Chemical Concentration (in H 2 O) Amount Added Putrescine 0.16% 200 µL Cadaverine 0.3% 500 µL Spermine 273 µg/mL 500 µL Trimethylamine 8.8 µg/ mL 500 µL Isovaleric Acid 4 µg/mL 500 µL Acetic Acid 8% 500 µL Scent test kits comprised of one vial of each chemical (six per kit), two pairs of nitrile gloves, and a booklet providing instructions for conducting the scent test ( Additional File 1 ). Vials were wrapped in bubble wrap and placed into individual plastic bags with absorbent sheets. Scent test kits were mailed to consenting participants by Canada Post and arrived in 2–5 business days. Data Collection Study participants were provided a link to a two-part questionnaire ( Additional File 2 ) in REDCap ( 41 ). The first part of the questionnaire prompted participants to describe their malodor, its duration and impact, exacerbating factors, and attempted reduction methods. Questions were framed in Likert scales with descriptors, text boxes, or “other” options for participants to write in responses. Participants were asked to report additional symptoms experienced during their most recent occurrence of malodor. The second part of the questionnaire collected data from the scent test kit. Participants were instructed to remove the lid of the first scent test vial, waft air from the vial towards themselves, and rate the proximity of the scent to their own odor on a Likert scale from zero to four. Participants were also provided the option to indicate if they did not detect a scent from the vial. To capture the potential diversity of odors, participants were able to report multiple previously experienced malodours: after completing the scent test, participants were then asked to indicate if they had ever experienced a second odor that was distinct from the first. If they indicated yes, they were asked to repeat the scent test, describing this second odor. Participants were asked to complete this to a maximum of three unique odors. After completing the scent test, participants were sent an email with a second questionnaire link and asked to repeat the scent test if malodor returned. Thematic Analysis Thematic analysis was applied to the open-ended questions about neovaginal symptoms, odor-exacerbating factors, and general experiences surrounding neovaginal malodor. Thematic analysis is flexible and can be tailored to the dataset, allowing production of a specific and robust account of qualitative data; this method has been successfully used in the analysis of vaginal malodor described by cF ( 15 ). Thematic analysis was conducted in alignment with the six stages proposed by Braun and Clarke ( 47 ). In stage 1, participant comments were reviewed to promote familiarity with the content. In stage 2, codes and subcodes were assigned to participant comments to the granularity of a sentence clause. Codes were reviewed and re-assigned by a second team member to reduce bias and then reviewed and refined by all research team members to better reflect participant comments. A code tree was synthesized assigning definitions to each code. In stage 3, codes were categorized into themes intended to describe the experiences of TF with neovaginal malodor. Themes were reviewed, synthesized, and modified by all members of the research team to accurately reflect participant comments. In stage 5, data were reviewed and analyzed to create specific definitions and names for themes. In stage 6, participant comments were reviewed, and specific representative examples were chosen to represent each theme and aid in theme communication. Quantitative Analysis A two-sided Fisher’s exact test was performed to evaluate potential associations between discharge color and texture (GraphPad Prism version 8 for Windows, GraphPad Software, Boston, Massachusetts, USA, www.graphpad.com ). Participants’ scent test ratings were binned into three groups: no resemblance (Likert scale 0), low resemblance (Likert scale 1–2), and high resemblance (Likert scale 3–4). A Shapiro-Wilk test of normality was performed. Spearman’s correlation test was performed on all scent study response reports to examine for correlation between each reported scent (GraphPad Prism version 8 for Windows, GraphPad Software, Boston, Massachusetts, USA, www.graphpad.com ). Data storage Data were deidentified prior to data analysis. All data were encrypted, password-protected, and stored on secure institutional servers. Results Malodor experiences and related concerns Sixteen participants responded to semi-structured interview questions. Half (50.0%) of participants were experiencing neovaginal malodor at the time of participation. Approximately half reported experiencing additional symptoms when they have malodour (45.0%), which included abnormal discharge (100.0%), neovaginal pain (33%), itching/burning (22%), and pelvic pain (11%). Reported discharge colours included white (66.7%), clear (22.2%) and yellow (11.1%), while two participants (22.2%) were unsure. Discharge consistency included runny (55.6%), thick (33.3%), clumpy (22.2%) and cottage cheese-like (11.1%). Discharge texture and color were not significantly associated (p = 0.85). Malodour duration varied: 60.0% reported < 1 week, 25.0% reported that malodour typically lasts for weeks, and 11.1% reported less than a day ( e.g. , minutes). Participant experiences with malodor are summarized in Table 2 . Table 2 Transfeminine participant malodor self-reports (n = 20 unless otherwise stated) Characteristic Self-reports (n, %) Currently experiencing bothersome malodor Yes 10 (50.0%) No 10 (50.0%) When you experience malodor, how much are you bothered by it? Not at all (I do not think about it) 1 (0.5%) A little bit (It is easy to put it out of my mind) 5 (25.0%) A moderate amount (I occasionally think about it) 12 (60.0%) A lot (I think about it frequently) 2 (1.0%) An extreme amount (It prevents me from participating in activities) 0 (0.0%) When you experienced malodor, did you experience any other symptoms? a Yes 9 (45.0%) No 11 (55.0%) Other symptom reports with malodor a n = 9 Abnormal discharge 9 (100.0%) Itching/burning 2 (22.2%) Pelvic pain 1 (11.1%) Neovaginal pain 3 (33.3%) Abnormal discharge color a,b n = 9 White 6 (66.7%) Clear 3 (33.3%) Grey 0 (0.0%) Yellow 1 (11.0%) Unsure 2 (22.0%) Abnormal discharge texture a n = 9 Clumpy 2 (22.2%) Thick 3 (33.3%) Cottage cheese-like 1 (11.1%) Runny 5 (55.6%) Typical length of time of malodor Minutes 2 (11.0%) Hours 0 (0.0%) Days 12 (60.0%) Weeks 5 (25.0%) a Data reported for most recent malodor instance only b Multiple descriptions may be selected Participant Self-Reports Reveal Three Distinct Malodor Typologies Twenty-nine unique odor reports were submitted, and one report out of three provided by a single participant was excluded as they reported the scent test odours were undetectable. Three participants repeated the scent test when their malodor returned, and three participants reported multiple odor types. Scent tests revealed that neovaginal malodors are diverse: of the six sample scents provided, all except acetic acid were identified as having high resemblance by at least 3 participants (Fig. 1 ). Given that an individual instance of malodor may be the result of a mixture of multiple volatile compounds, participants were able to select multiple scents and a similarity rating for each (Likert). For each instance of malodor, a correlation matrix was generated to assess the frequency with which different scents were observed together (n = 28 instances reported by the 20 participants). Results reveal three distinct malodor typologies characterized by ( 1 ) isovaleric acid, ( 2 ) trimethylamine, and ( 3 ) multiple scents (polyamines cadaverine, putrescine, and spermine, alongside acetic acid) (Fig. 2 ). Malodor Management Strategies Most participants (75.0%) reported attempting malodor reduction methods. The most common reduction method was exterior washing (neovulva, 60%), followed by douching (50.0%), yeast infection treatments (30.0%), hygienic wipes (25.0%), and prescription medication (15.0%). One participant (5.0%) used Vagisil, two (10.0%) reported probiotic use (oral “Renew Life Ultimate Flora VS 50 billion” and vaginal “Probaclac”), and one used soap inside the neovaginal canal. Of those who reported douching, douching substances included water (81.8%), soapy water (27.3%), saline (18.2%), vinegar solution (18.2%), and betadine 9.0%). Malodour reduction methods are summarized in Table 3 . Table 3 Neovaginal malodor reduction methods (n = 20) Malodor Reduction Method Characteristics Self-reports (n, %) Ever attempted malodor reduction method n = 20 Yes 15 (75.0%) No 5 (25.0%) Odor reduction method attempted n = 20 Douching 11 (55.0%) Washed exterior 12 (60.0%) Prescription medication 3 (15.0%) Over-the-counter medication 1 (5.0%) Hygienic wipes 5 (25.0%) Yeast infection treatment 6 (30.0%) Deodorant product 0 (0.0%) Other 2 (10.0%) Douching substance n = 11 Water 9 (81.8%) Betadine 1 (9.0%) Saline 2 (18.2%) Diluted vinegar solution 2 (18.2%) Soapy water 3 (27.3%) Over-the-counter medication Vagisil 1 (5.0%) Yeast infection treatment Canesten 4 (20.0%) Monistat 1 (5.0%) Unknown 1 (5.0%) Other malodor reduction method Probiotic use 2 (10.0%) Efficacy, defined as participant-reported lasting reduction or elimination of malodour, varied. Equal numbers of participants reported exterior washing with soap was effective and ineffective (n = 5 and n = 5 respectively, 42.0%). Douching was effective for 60.0%, while 40.0% reported no or an inconsistent/transient benefit. Vagisil and Betadine were each used by one participant and reported to be effective. Of those that used prescription medications (n = 2 metronidazole; n = 1 could not recall), two (66.7%) found them effective, and one (33.3%) reported that it was sometimes or briefly effective. Equal numbers of participants reported that over-the-counter yeast infection treatments were and were not effective (n = 3 each, 50.0%). Efficacies are reported in Table 4 . Table 4 Self-reported neovaginal malodor reduction method efficacy Malodor Reduction Method a Efficacy self-reports Douching, n(%) n = 11 Effective b 6 (60.0%) Not effective 2 (20.0%) Briefly/sometimes 2 (20.0%) Washing exterior n = 12 Effective 5 (42.0%) Not effective 5 (42.0%) Briefly/sometimes 2 (17.0%) Prescription medication n = 3 Effective 2 (66.0%) Not effective 0 (0.0%) Briefly/sometimes 1 (33.0%) Vagisil n = 1 Effective 1 (100.0%) Yeast infection treatment n = 6 Effective 3 (50.0%) Not Effective 3 (50.0%) Probiotic use n = 2 Effective 1 (50.0%) Did Not Report 1 (50.0%) Boric Acid n = 1 Effective 1(100%) Betadine n = 1 Effective 1 (100.0%) a Participants reported all strategies previously used, multiple strategies could be reported b Interventions were considered effective if they reduced or eliminated malodor Participant descriptions of neovaginal malodor Sixteen participants responded to open-ended questions about neovaginal symptoms, odor-exacerbating factors, and general experiences surrounding neovaginal malodor (Fig. 3 ). Comments were reviewed and organized into codes ( Additional File 3 ), which were then organized into themes describing participant experiences with neovaginal malodour. The most common theme was exacerbating factors, accounting for 34.4% (22/64) of the total comments. Among these, intravaginal exposures (dilating, penetration with toys or flesh genitals, lubricant use) and neovaginal physiology (internal hair growth, urine stream diversion resulting in urine entering the neovagina) were most frequently discussed (7/22 and 4/22, respectively). Participants provided the fewest comments on unsuccessful management, intermittence, and delayed onset (2/64). Under intermittence, participants reported that reduction methods are sometimes effective. Two participants reported instances in which a diagnosed yeast infection was initially unsuccessfully managed by over-the-counter treatment, requiring three rounds of over-the-counter treatment for resolution, and that odor could not be controlled by washing externally. One participant reported that hygienic practices provided temporary relief. Thematic Analysis of Participant Comments Thematic analysis revealed three key themes: ( 1 ) preventative hygienic practices, ( 2 ) lifestyle and physiological factors, and ( 3 ) odor diversity (Fig. 4 ). Preventative hygienic practices Participants described routine use of preventative hygienic practices as critical for malodor management (Table 5 ). Four of the 16 participants who commented (25.0%) reported that regular hygienic practices resulted in successful malodor management. Hygienic practices varied considerably; three participants (18.8%) reported douching, one participant (6.3%) reported using hygienic wipes, and two (12.5%) reported washing the neovulva as effective management strategies. Participants often mentioned that malodor would return in the absence of these practices. Table 5 Representative participant comments relating to each identified theme Theme Participant comment Preventative hygienic practices • “This odor returns unless I am douching daily” [P6] • “I have been using boric acid for vaginal use and it has been working amazingly, even better than canesten [sic]” [P9] Lifestyle and physiological factors • “…only noticeable after dilation or penetration” [P16] • “Internal hair growth most significant factor” [P5] Odor diversity • “…there are different "smells" depending on time/area of the neovagina” [P16] • “The second smell is not something I would describe as malodors/unpleasant” [P23] Lifestyle and physiological practices Many participants reported that lifestyle and sexual practices – including dilation, penetrative intercourse, exercise, stress, clothing, hygiene, and rest – exacerbated their observed malodor (expanded in Fig. 3 ). Intravaginal exposures were the most common exacerbating factors discussed (insertive sex, dilation, lubricant use, masturbation), mentioned in 10.9% (7/64) of comments and reported by 37.5% (6/16) of participants. Some participants reported noticing the malodor on the inserted item (e.g. dilators). Neovaginal physiology (internal hair growth, bleeding, urinary stream direction resulting in urine entering the neovagina) was the second most common, accounting for 6.3% (4/64) of comments and reported by 18.9% of participants (3/16). Stress and rest were mentioned by one participant. Three participants (18.9%) cited exercise, two participants (12.5%) cited form-fitted clothing including underwear and workout tights, and two participants (12.5%) cited specific hygiene practices (e.g. soap, douching) as exacerbating factors. Some participants reported that the exacerbating factors did not initiate the malodor, but rather intensified it. Odor diversity Many participants described experiencing multiple distinct odors. Five participants (31.3%) reported a non-bothersome odor, with one participant expressing “I wish I knew how to encourage it!” [P18] (Table 5 ). Many participants reported a second or third odor that they described as abnormal, and that a few participants specifically described as unpleasant. Diverse descriptors, including “musk”, “salty”, “acidic”, “decay”, “bad breath”, “fishy”, and “pre-cum”, were used to describe malodors. Participants reported that these bothersome odors could not be easily managed through hygienic practices, with some participants stating that these practices were intermittently effective, and others describing multiple courses of treatment prior to resolution. Three participants reported malodor as being persistent (18.8%), and three reported it as recurrent (18.8%). One participant attributed their malodor to a persistent yeast infection (6.3%), and two others described malodor as being connected to other symptoms, including pain and itching (12.5%). One participant reported diversity of both malodor type and location within the neovagina (6.3%). Discussion Principle Results TF experiences of neovaginal malodor were classified into three key themes: ( 1 ) preventative hygienic practices, ( 2 ) lifestyle and physiological factors, and ( 3 ) odor diversity. Three distinct neovaginal malodor typologies were identified, defined by resemblance to isovaleric acid, trimethylamine, and a combinatorial odor resembling multiple polyamines (cadaverine, putrescine, and spermine) and acetic acid. Preventative Hygienic Practices TF reported using varied hygienic practices and self-reported effectiveness of hygienic practices varied substantially. Post-vaginoplasty care guidelines differ significantly between institutions, which may explain the diversity in reported practices ( 48 – 51 ). For example, Women’s College Hospital recommends daily or as-needed douching to treat symptoms (e.g. discharge and odor), providing multiple solution options including betadine, saline, vinegar solution, and soap and water, but strongly advises against douching in the first three months after surgery ( 48 ). In contrast, Vancouver Coastal Health recommends douching with betadine solution for the first two weeks post-vaginoplasty, saline following six weeks, and warm water starting two months postoperatively ( 50 ). Variability in participant experiences and provider guidance provide strong rationale for appropriately powered clinical trials to evaluated the role of hygienic practices in reducing symptoms like neovaginal malodor ( 8 ). Provider recommendations for douching contradict guidelines for CF, for whom douching and hygienic wipe use are associated with increased risk of malodor and decreased Lactobacillus ( 52 – 57 ). However, penile inversion vaginoplasty uses keratinized and soft-cornified penile skin, and preliminary evidence suggests that Lactobacillus dominance is rare in the neovagina ( 8 , 32 , 33 , 36 ). This finding aligns with a previously published case study of one TF patient experiencing bacterial vaginosis (BV)-like symptoms and malodor, where douching, rather than administration of metronidazole or doxycycline, was effective in long-term malodor elimination ( 58 ). Lifestyle and Physiological Factors Most participants reported that lifestyle or physiological factors including sexual exposures, exercise, clothing, internal hair growth, and diverted urinary stream impacted and/or exacerbated neovaginal malodor. Depending on the availability of penile skin and desired neovaginal depth, varying amounts of scrotal skin is used in the back of the canal. Scrotal skin contains hair follicles and previous studies of post-vaginoplasty complications have described internal hair growth as associated with malodor ( 59 , 60 ). Both scrotal and penile skin contain apocrine (sweat) glands, which produce secretions that are metabolized by skin-colonizing bacteria into malodorous compounds ( 31 , 34 , 35 , 61 ). Participants reported that exercise and the use of specific tight-fitting clothing exacerbated malodor, which may be due to increased sweating. Though underwear type is associated with Candida infection in the natal vagina, it is not associated with bacterial vaginosis in cF ( 62 ). Some participants reported odor associated with sex (insertion of a natal penis, lubricants, ejaculation into the neovagina, or neovaginal secretions during sex). Roughly 30% of TF report secretions with orgasm ( 63 ) and the bulbourethral gland, seminal vesicle, and prostate are not removed in vaginoplasty. Prostate secretions contains high concentrations of putrescine, spermine, and spermidine ( 64 ), and may contribute to neovaginal malodor in some study participants. Odor Diversity Surprisingly, many participants described experiencing multiple distinct malodor types that varied across time and region of the neovagina. Specifically, one participant reported a unique malodor type that they observed only towards the apex of the neovaginal canal, and that this decay-like malodor could be observed on inserted objects. This may reflex a gradient in oxygen availability – and anaerobe density – in the neovaginal canal. Prevotella are strict anaerobes that produce metabolites with a decay-like odour ( 42 ), and are common in the neovagina and uncircumcised penis. The diversity of reported malodor types and differential efficacy of attempted treatment methods suggest that there are multiple bacterial and chemical sources of malodor. Malodor State Types Scent test results revealed three distinct malodour typologies: ( 1 ) isovaleric acid, ( 2 ) trimethylamine, and ( 3 ) polyamines with some acetic acid. Isovaleric acid is responsible for foot malodor ( 34 , 35 ) and results from the incomplete bacterial degradation of skin lipids by species belonging to Staphylococcus , and Bacillus , and Corynebacterium ( 34 ), all common in the penile-skin lined neovagina ( 32 , 33 , 36 ). Trimethylamine is a volatile small molecule, in part responsible for the fishy odor associated with BV and trichomoniasis in rCF ( 16 , 29 ). In rCF, trimethylamine can be produced by Prevotella or M. curtisii , which are also prevalent in TF ( 32 , 32 , 36 ). The third odour typology included high resemblance to polyamines – putrescine, cadaverine, and spermine – and moderate resemblance to acetic acid. Putrescine and cadaverine are responsible for decay-like malodors associated with bacterial metabolism of organic material, and contribute to wound, skin fold, and rCF vaginal malodor ( 31 ). Spermine occurs in high concentrations in seminal fluid, and spermine carries a similar odor profile to spermidine, another related polyamine expressed by all cell types ( 45 , 65 , 66 ). Participants specifically described malodor as smelling like “pre-cum” and “decay”, further supporting the role of these polyamines in the etiology of neovaginal malodor. The multiple, distinct odor types identified suggest multiple chemical sources, which aligns with the diversity of self-reported exacerbating factors and discrepancies in efficacy of prevention/treatment methods. These findings provide rationale for larger studies, powered to stratify by malodour type. Strengths and Limitations This is the first study to examine potential neovaginal malodor sources using a standardized scent test. Use of scent test vials eliminates the need for participants to be familiar with scent descriptions (e.g., rotting flesh vs. garbage) and reduces subjectivity introduced by asking participants to describing odours as normal, unpleasant, etc. Allowing participants to augment the structured questionnaire with write-ins provided a more comprehensive understanding of participant experiences. However, specific prompts (such as on malodor exacerbating factors) may have led to overrepresentation of specific codes. Additionally, self-enrolment may have biased participation to those experiencing particularly challenging cases of neovaginal malodor. Conclusions The presence of multiple, different malodor types caused by different bacterial communities may explain the differential success of treatments and hygienic interventions in reducing neovaginal malodor. The prevalence of scents associated with non-vaginal malodour underscore the need to assess the efficacy of treatments intended for the natal vagina. The diversity of malodor reduction methods reported, including douching substances, reflects the lack of care guidelines for neovaginal malodor and highlights the need for further research aimed to develop evidence-based treatments. Abbreviations TF Transfeminine CF Cisgender female rCF reproductive-aged cisgender female Declarations Ethics approval and consent to participate Ethics approval was obtained from the research ethics board at Western University (REB #121787). Informed consent was obtained for all participants. This study adhered to the Declaration of Helsinki. Research was conducted in accordance with all applicable guidelines and regulations. Consent for publication Not applicable. Availability of data and materials Due to the sensitive nature of this research and potential for compromising individual privacy, data is not available. Competing Interests The authors declare no competing interests. Funding This study was supported by a Collaborative Research Seed Grant (0000055231) from the Schulich School of Medicine and Dentistry (Western University). JLP received salary support from the Canada Research Chairs Program (Canadian Institutes of Health Research, CRC-2020-00175). ACS was supported by a Canadian Graduate Scholarship from the Canadian Institutes of Health Research. Authors’ contributions ACS and JLP conceived of the study. ACS created and distributed study materials with support from HW and AG. ACS and RP analysed survey data. ACS analysed scent test data with support from JRV. EP, DP, and JR assisted in developing study materials, and directing data analysis strategies. All authors read and approved the final manuscript. Acknowledgements We would like to acknowledge Jason Hallarn for providing guidance on the ethics approval process and design of REDCap questionnaire. We also wish to acknowledge the participants of this cohort for their time, energy, and effort. References Ellis SA, Dalke L. Midwifery Care for Transfeminine Individuals. J Midwifery Women’s Health. 2019;64(3):298–311. Unger CA. Hormone Therapy for Transgender Patients. Transl Androl Urol. 2016;5(6):877–84. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgender Health. 2022;23(sup1):S1–259. James SE, Herman J, Keisling M, Mottet L, Anafi M. 2015 U.S. Transgender Survey (USTS): Version 1 [Internet]. 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J Biol Chem. 2018;293(48):18693–701. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Apr, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers agreed at journal 10 Apr, 2026 Reviewers agreed at journal 24 Mar, 2026 Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers invited by journal 16 Sep, 2025 Editor assigned by journal 10 Sep, 2025 Editor invited by journal 20 Aug, 2025 Submission checks completed at journal 19 Aug, 2025 First submitted to journal 19 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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06:33:15","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77981,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/e5bd35039ba39ac8473a2a33.png"},{"id":92231263,"identity":"644e8f76-0a39-4912-9a58-91270051d6e9","added_by":"auto","created_at":"2025-09-26 06:33:14","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111049,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/82d5b4d1d5afb28a8d744766.png"},{"id":92231262,"identity":"da8c3d54-7676-4ea7-843e-1c8dbb6dc650","added_by":"auto","created_at":"2025-09-26 06:33:14","extension":"png","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97960,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/95ceb20e92a1bd77c66bee5e.png"},{"id":92231092,"identity":"86d42c94-4056-45ee-9414-63c1a5d0e3f0","added_by":"auto","created_at":"2025-09-26 06:25:15","extension":"xml","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":170272,"visible":true,"origin":"","legend":"","description":"","filename":"6e6fcfed703246c193cde3df90844a821structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/f399d1ef104d2a0bbaca3143.xml"},{"id":92231074,"identity":"5e0ae334-d3db-4c17-b2dd-9a3700e8ce01","added_by":"auto","created_at":"2025-09-26 06:25:14","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":190728,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/cae7ba8fb4a27e5c90297103.html"},{"id":92231078,"identity":"a2968059-a299-467b-8f04-54ba16777bed","added_by":"auto","created_at":"2025-09-26 06:25:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13212,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipant reports of metabolite resemblance to experienced malodor. \u003c/strong\u003eParticipants (n=20) rated the resemblance of sample scents to their own experienced malodor on a Likert scale of 0-4 (no resemblance to high resemblance). Ratings of 0 indicated no resemblance; ratings of 1-2 were considered low resemblance, and 3 or 4 were considered as high resemblance (n=28 malodor reports).\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/71a2a5c719240dde124d0007.png"},{"id":92231071,"identity":"b24deaf9-d600-4113-aaa5-5cac884e8136","added_by":"auto","created_at":"2025-09-26 06:25:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26316,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNeovaginal odours fall into three different scent typologies.\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;Spearman correlation was used to assess how frequently different scents were observed together in the same instance of neovaginal malodour. \u003c/strong\u003eParticipants (n=20) rated the resemblance of each provided scent vial to their own malodor(s) (n=28) on a Likert scale of 0-4. *p\u0026lt;0.05, ** p\u0026lt;0.01.\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/836e9903fd82dcb2909a9127.png"},{"id":92231084,"identity":"7c5427b1-ad9a-41ce-8797-8e54a60a2d9c","added_by":"auto","created_at":"2025-09-26 06:25:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":65390,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNeovaginal malodor descriptions, symptoms, and exacerbating factors by code. \u003c/strong\u003eTransfeminine individuals with vaginoplasty (n=20) completed an online survey and the majority (n=16) answered at least one of the following questions: “Please describe the factors that seem to worsen the odor”, “Please specify the other symptom”, “If other, please describe”, and “Is there anything else you would like us to know”. Codes were developed by two independent members of the research team and assigned to participant comments (n=64).\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/4b9021a0b76d7699cdf591fe.png"},{"id":92231076,"identity":"915233ae-7c31-4b1a-b44f-1bcddad838ba","added_by":"auto","created_at":"2025-09-26 06:25:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":24101,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThemes describing the experiences of transfeminine people with neovaginal malodor\u003c/strong\u003e. TF participants with vaginoplasty (n=20) completed an online survey and the majority (n=16) answered at least one of the following questions: “Please describe the factors that seem to worsen the odor”, “Please specify the other symptom”, “If other, please describe”, and “Is there anything else you would like us to know”. Codes were developed and assigned to participant comments (n=64). Themes to describe participant responses (preventative hygienic practices, lifestyle and physiological factors, and odor and malodor diversity) were synthesized by two independent research team members.\u003c/p\u003e","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/fbc5ce9e07402d6d838ee4c2.png"},{"id":92231268,"identity":"73cafc7c-5fd3-4fd5-b444-b3a0368398a2","added_by":"auto","created_at":"2025-09-26 06:33:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1771712,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/2e98e5d0-c8c1-4c19-941b-1fe8a93cea0f.pdf"},{"id":92231260,"identity":"583e0f21-0d8a-4e32-8f7f-df449d1ba8bb","added_by":"auto","created_at":"2025-09-26 06:33:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21703673,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-7348971/v1/1d58cb657ff33323eeba759b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experiences and evidence of transfeminine people’s challenges with chronic, recurrent neovaginal malodor: a cross-sectional qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eTransfeminine individuals (TF) are those assigned male at birth but who have a non-masculine gender identity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Many communities, including transgender women and non-binary or other gender-diverse individuals, fall under this umbrella term (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Many TF pursue gender-affirming medical care, may involve the use of feminizing hormone therapy (\u003cem\u003ee.g.\u003c/em\u003e, estrogen, progestin, androgen blockers) and/or surgeries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These interventions are life-saving medical care, reducing the risk of gender dysphoria, depression, and/or anxiety (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). 97% of people who access gender-affirming surgery report improved quality of life (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eVaginoplasty is a gender-affirming surgery involving reconstruction of the penis, perineum, and scrotum to create a vulva, vaginal canal, shortened urethra, and sensate clitoris capable of sexual function (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Penile inversion vaginoplasty, the most common technique performed globally, lines the vaginal canal with penile and scrotal skin (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMany cisgender females (CF) (30\u0026ndash;50%) experience bothersome vaginal symptoms over their lifetimes that may be secondary to infection (bacterial vaginosis, candidiasis, trichomoniasis, sexually transmitted infection or vaginal atrophy (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A recent study of 56 Canadian TF reported similar neovaginal symptoms, with neovaginal malodor the most frequently reported symptom, affecting 27% of participants in the past month (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In cF, vaginal malodor has significant psychosocial impacts including malodor-associated shame and embarrassment, adoption of hypervigilant hygienic routines, increased cognitive load, and decreased quality of life (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Despite the well-documented and significant impacts of vaginal malodor in cF, the behavioural, psychological, and physical impacts of neovaginal malodor in TF have received little attention.\u003c/p\u003e\u003cp\u003eIn reproductive-age CF (rCF), vaginal malodour is caused by microbial metabolites associated with a dysbiotic vaginal microbiome (\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Optimally, the rCF vaginal microbiota is dominated by \u003cem\u003eLactobacillus\u003c/em\u003e spp., which inhibit colonization by opportunistic and pathogenic species via lactic acid production. Lactic acid lowers vaginal pH (~\u0026thinsp;4) and has direct microbicidal and anti-inflammatory effects (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, roughly a third of North American women harbor microbiota with low \u003cem\u003eLactobacillus\u003c/em\u003e abundance and a diverse array of strict and facultative anaerobes, some of which produce malodorous compounds (\u003cspan additionalcitationids=\"CR25 CR26 CR27\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Species such as \u003cem\u003eTrichomonas vaginalis\u003c/em\u003e, \u003cem\u003ePrevotella micra\u003c/em\u003e, \u003cem\u003ePeptostreptococcus anaerobius\u003c/em\u003e, \u003cem\u003eLeptotrichia\u003c/em\u003e spp., \u003cem\u003eGemella\u003c/em\u003e spp., and \u003cem\u003eMobiluncus curtisii\u003c/em\u003e produce trimethylamine, a volatile fishy-smelling metabolite (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Other gram-negative and gram-variable bacteria, such as \u003cem\u003ePseudomonas\u003c/em\u003e spp., \u003cem\u003eEscherichia coli\u003c/em\u003e, \u003cem\u003ePrevotella\u003c/em\u003e spp., and \u003cem\u003eDialister microaerophilus\u003c/em\u003e, produce polyamines like agmatine, cadaverine, putrescine, and spermine that have musty, rotting flesh, putrid, or semen-like odors, respectively (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The fungi \u003cem\u003eCandida albicans\u003c/em\u003e can also cause vaginal malodor through the production of carbon dioxide, creating a scent akin to brewing beer (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe TF neovagina supports distinct microbiota than the rCF vagina, with differing potential capacities to produce odorous metabolites (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Bacterial metabolism is responsible for many body odors: isovaleric and acetic acid from the skin commensal \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e cause foot odor (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), sweat odour is the result of sulfanyl compounds produced by \u003cem\u003eCorynebacterium\u003c/em\u003e, \u003cem\u003ePropionibacterium\u003c/em\u003e, yeasts, and \u003cem\u003eMicrococcaceae\u003c/em\u003e (\u003cspan additionalcitationids=\"CR36 CR37 CR38\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e); and oral malodor is caused by a complex interplay of many bacteria (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Understanding the sources of neovaginal malodor is necessary for effective treatment. For example, metronidazole effectively reduces fishy odor from gram-negative anaerobes in the cF vagina by targeting of \u003cem\u003eT. vaginalis\u003c/em\u003e and trimethylamine-producers, but is not effective against aerobic skin commensals responsible for foot malodor.\u003c/p\u003e\u003cp\u003eThough the impact, causes of, and treatments for vaginal malodor are well characterized in cF, there is a paucity of information on neovaginal malodor in TF. We use thematic analysis to gain insight into the experiences of transfeminine people with neovaginal malodor.\u003c/p\u003e\u003cp\u003eGenital odor reporting is highly variable \u0026ndash; individuals do not perceive odor in the same way, leading to a lack of consensus on what constitutes \u0026ldquo;normal\u0026rdquo; genital odor (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Here, we employ a scent test, which normalizes malodor reporting by providing scent vials and prompting participants to report vial resemblance their own neovaginal odor, regardless of whether participants consider the odor bothersome. This provides a more consistent and standard system for odor reporting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipant cohort\u003c/h2\u003e\u003cp\u003eParticipants were recruited from the \u003cem\u003eTransBiota\u003c/em\u003e study (2021\u0026ndash;2022), which included n\u0026thinsp;=\u0026thinsp;56 adult TF from across Canada who had received vaginoplasty at least one year prior (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). \u003cem\u003eTransBiota\u003c/em\u003e participants who indicated previously experiencing neovaginal malodor, and who had consented to be recontacted for future research, were offered participation by email. Consenting individuals (n\u0026thinsp;=\u0026thinsp;23) were mailed a scent test to their homes and asked to provide feedback through a secure online questionnaire in REDCap (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Of those 23 participants, 20 completed study activities.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eScent Test Kit\u003c/h3\u003e\n\u003cp\u003eMalodorous chemicals putrescine, cadaverine, spermine, isovaleric acid, acetic acid, and trimethylamine were purchased from Sigma-Aldrich. Each sample was diluted to a concentration commonly found in the environment (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR43 CR44 CR45\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). 1 mL/chemical was absorbed onto a small cotton ball and placed in a 10 mL glass vial (ThermoFisher) and labelled with a number to blind participants to the chemical contents.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMalodorous chemical concentrations and volumes in mailed scent test kit\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChemical\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConcentration (in H\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmount Added\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePutrescine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.16%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e200 \u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCadaverine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e500 \u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpermine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e273 \u0026micro;g/mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e500 \u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrimethylamine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.8 \u0026micro;g/ mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e500 \u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIsovaleric Acid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 \u0026micro;g/mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e500 \u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcetic Acid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e500 \u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eScent test kits comprised of one vial of each chemical (six per kit), two pairs of nitrile gloves, and a booklet providing instructions for conducting the scent test (\u003cb\u003eAdditional File 1\u003c/b\u003e). Vials were wrapped in bubble wrap and placed into individual plastic bags with absorbent sheets. Scent test kits were mailed to consenting participants by Canada Post and arrived in 2\u0026ndash;5 business days.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eStudy participants were provided a link to a two-part questionnaire (\u003cb\u003eAdditional File 2\u003c/b\u003e) in REDCap (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The first part of the questionnaire prompted participants to describe their malodor, its duration and impact, exacerbating factors, and attempted reduction methods. Questions were framed in Likert scales with descriptors, text boxes, or \u0026ldquo;other\u0026rdquo; options for participants to write in responses. Participants were asked to report additional symptoms experienced during their most recent occurrence of malodor.\u003c/p\u003e\u003cp\u003eThe second part of the questionnaire collected data from the scent test kit. Participants were instructed to remove the lid of the first scent test vial, waft air from the vial towards themselves, and rate the proximity of the scent to their own odor on a Likert scale from zero to four. Participants were also provided the option to indicate if they did not detect a scent from the vial. To capture the potential diversity of odors, participants were able to report multiple previously experienced malodours: after completing the scent test, participants were then asked to indicate if they had ever experienced a second odor that was distinct from the first. If they indicated yes, they were asked to repeat the scent test, describing this second odor. Participants were asked to complete this to a maximum of three unique odors.\u003c/p\u003e\u003cp\u003e After completing the scent test, participants were sent an email with a second questionnaire link and asked to repeat the scent test if malodor returned.\u003c/p\u003e\n\u003ch3\u003eThematic Analysis\u003c/h3\u003e\n\u003cp\u003eThematic analysis was applied to the open-ended questions about neovaginal symptoms, odor-exacerbating factors, and general experiences surrounding neovaginal malodor. Thematic analysis is flexible and can be tailored to the dataset, allowing production of a specific and robust account of qualitative data; this method has been successfully used in the analysis of vaginal malodor described by cF (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThematic analysis was conducted in alignment with the six stages proposed by Braun and Clarke (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). In stage 1, participant comments were reviewed to promote familiarity with the content. In stage 2, codes and subcodes were assigned to participant comments to the granularity of a sentence clause. Codes were reviewed and re-assigned by a second team member to reduce bias and then reviewed and refined by all research team members to better reflect participant comments. A code tree was synthesized assigning definitions to each code. In stage 3, codes were categorized into themes intended to describe the experiences of TF with neovaginal malodor. Themes were reviewed, synthesized, and modified by all members of the research team to accurately reflect participant comments. In stage 5, data were reviewed and analyzed to create specific definitions and names for themes. In stage 6, participant comments were reviewed, and specific representative examples were chosen to represent each theme and aid in theme communication.\u003c/p\u003e\n\u003ch3\u003eQuantitative Analysis\u003c/h3\u003e\n\u003cp\u003eA two-sided Fisher\u0026rsquo;s exact test was performed to evaluate potential associations between discharge color and texture (GraphPad Prism version 8 for Windows, GraphPad Software, Boston, Massachusetts, USA, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.graphpad.com\" target=\"_blank\"\u003ewww.graphpad.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.graphpad.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Participants\u0026rsquo; scent test ratings were binned into three groups: no resemblance (Likert scale 0), low resemblance (Likert scale 1\u0026ndash;2), and high resemblance (Likert scale 3\u0026ndash;4). A Shapiro-Wilk test of normality was performed. Spearman\u0026rsquo;s correlation test was performed on all scent study response reports to examine for correlation between each reported scent (GraphPad Prism version 8 for Windows, GraphPad Software, Boston, Massachusetts, USA, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.graphpad.com\" target=\"_blank\"\u003ewww.graphpad.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.graphpad.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData storage\u003c/h2\u003e\u003cp\u003eData were deidentified prior to data analysis. All data were encrypted, password-protected, and stored on secure institutional servers.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eMalodor experiences and related concerns\u003c/h2\u003e\u003cp\u003e Sixteen participants responded to semi-structured interview questions. Half (50.0%) of participants were experiencing neovaginal malodor at the time of participation. Approximately half reported experiencing additional symptoms when they have malodour (45.0%), which included abnormal discharge (100.0%), neovaginal pain (33%), itching/burning (22%), and pelvic pain (11%). Reported discharge colours included white (66.7%), clear (22.2%) and yellow (11.1%), while two participants (22.2%) were unsure. Discharge consistency included runny (55.6%), thick (33.3%), clumpy (22.2%) and cottage cheese-like (11.1%). Discharge texture and color were not significantly associated (p\u0026thinsp;=\u0026thinsp;0.85). Malodour duration varied: 60.0% reported\u0026thinsp;\u0026lt;\u0026thinsp;1 week, 25.0% reported that malodour typically lasts for weeks, and 11.1% reported less than a day (\u003cem\u003ee.g.\u003c/em\u003e, minutes). Participant experiences with malodor are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTransfeminine participant malodor self-reports (n\u0026thinsp;=\u0026thinsp;20 unless otherwise stated)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-reports (n, %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrently experiencing bothersome malodor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhen you experience malodor, how much are you bothered by it?\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot at all (I do not think about it)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA little bit (It is easy to put it out of my mind)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA moderate amount (I occasionally think about it)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA lot (I think about it frequently)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAn extreme amount (It prevents me from participating in activities)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhen you experienced malodor, did you experience any other symptoms?\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (45.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (55.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther symptom reports with malodor\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbnormal discharge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (100.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItching/burning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (22.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePelvic pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeovaginal pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbnormal discharge color\u003c/b\u003e\u003csup\u003e\u003cb\u003ea,b\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (66.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYellow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (11.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnsure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (22.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbnormal discharge texture\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClumpy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (22.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThick\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCottage cheese-like\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRunny\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (55.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTypical length of time of malodor\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (11.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDays\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Data reported for most recent malodor instance only\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Multiple descriptions may be selected\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eParticipant Self-Reports Reveal Three Distinct Malodor Typologies\u003c/h2\u003e\u003cp\u003eTwenty-nine unique odor reports were submitted, and one report out of three provided by a single participant was excluded as they reported the scent test odours were undetectable. Three participants repeated the scent test when their malodor returned, and three participants reported multiple odor types.\u003c/p\u003e\u003cp\u003e Scent tests revealed that neovaginal malodors are diverse: of the six sample scents provided, all except acetic acid were identified as having high resemblance by at least 3 participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e Given that an individual instance of malodor may be the result of a mixture of multiple volatile compounds, participants were able to select multiple scents and a similarity rating for each (Likert). For each instance of malodor, a correlation matrix was generated to assess the frequency with which different scents were observed together (n\u0026thinsp;=\u0026thinsp;28 instances reported by the 20 participants). Results reveal three distinct malodor typologies characterized by (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) isovaleric acid, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) trimethylamine, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) multiple scents (polyamines cadaverine, putrescine, and spermine, alongside acetic acid) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMalodor Management Strategies\u003c/h2\u003e\u003cp\u003eMost participants (75.0%) reported attempting malodor reduction methods. The most common reduction method was exterior washing (neovulva, 60%), followed by douching (50.0%), yeast infection treatments (30.0%), hygienic wipes (25.0%), and prescription medication (15.0%). One participant (5.0%) used Vagisil, two (10.0%) reported probiotic use (oral \u0026ldquo;Renew Life Ultimate Flora VS 50 billion\u0026rdquo; and vaginal \u0026ldquo;Probaclac\u0026rdquo;), and one used soap inside the neovaginal canal. Of those who reported douching, douching substances included water (81.8%), soapy water (27.3%), saline (18.2%), vinegar solution (18.2%), and betadine 9.0%). Malodour reduction methods are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNeovaginal malodor reduction methods (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalodor Reduction Method Characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-reports (n, %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEver attempted malodor reduction method\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (75.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOdor reduction method attempted\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;20\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDouching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (55.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWashed exterior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrescription medication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOver-the-counter medication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHygienic wipes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYeast infection treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeodorant product\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDouching substance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;11\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWater\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (81.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBetadine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (9.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSaline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (18.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiluted vinegar solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (18.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSoapy water\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (27.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOver-the-counter medication\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVagisil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYeast infection treatment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCanesten\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonistat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther malodor reduction method\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProbiotic use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEfficacy, defined as participant-reported lasting reduction or elimination of malodour, varied. Equal numbers of participants reported exterior washing with soap was effective and ineffective (n\u0026thinsp;=\u0026thinsp;5 and n\u0026thinsp;=\u0026thinsp;5 respectively, 42.0%). Douching was effective for 60.0%, while 40.0% reported no or an inconsistent/transient benefit. Vagisil and Betadine were each used by one participant and reported to be effective. Of those that used prescription medications (n\u0026thinsp;=\u0026thinsp;2 metronidazole; n\u0026thinsp;=\u0026thinsp;1 could not recall), two (66.7%) found them effective, and one (33.3%) reported that it was sometimes or briefly effective. Equal numbers of participants reported that over-the-counter yeast infection treatments were and were not effective (n\u0026thinsp;=\u0026thinsp;3 each, 50.0%). Efficacies are reported in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSelf-reported neovaginal malodor reduction method efficacy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalodor Reduction Method\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEfficacy self-reports\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDouching, n(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot effective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBriefly/sometimes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWashing exterior\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;12\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (42.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot effective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (42.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBriefly/sometimes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (17.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrescription medication\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (66.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot effective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBriefly/sometimes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (33.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVagisil\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (100.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYeast infection treatment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot Effective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProbiotic use\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDid Not Report\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBoric Acid\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBetadine\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (100.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ea\u003c/sup\u003e Participants reported all strategies previously used, multiple strategies could be reported\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003eb\u003c/sup\u003e Interventions were considered effective if they reduced or eliminated malodor\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eParticipant descriptions of neovaginal malodor\u003c/h2\u003e\u003cp\u003e Sixteen participants responded to open-ended questions about neovaginal symptoms, odor-exacerbating factors, and general experiences surrounding neovaginal malodor (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Comments were reviewed and organized into codes (\u003cb\u003eAdditional File 3\u003c/b\u003e), which were then organized into themes describing participant experiences with neovaginal malodour.\u003c/p\u003e\u003cp\u003eThe most common theme was exacerbating factors, accounting for 34.4% (22/64) of the total comments. Among these, intravaginal exposures (dilating, penetration with toys or flesh genitals, lubricant use) and neovaginal physiology (internal hair growth, urine stream diversion resulting in urine entering the neovagina) were most frequently discussed (7/22 and 4/22, respectively). Participants provided the fewest comments on unsuccessful management, intermittence, and delayed onset (2/64). Under intermittence, participants reported that reduction methods are sometimes effective. Two participants reported instances in which a diagnosed yeast infection was initially unsuccessfully managed by over-the-counter treatment, requiring three rounds of over-the-counter treatment for resolution, and that odor could not be controlled by washing externally. One participant reported that hygienic practices provided temporary relief.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eThematic Analysis of Participant Comments\u003c/h2\u003e\u003cp\u003eThematic analysis revealed three key themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) preventative hygienic practices, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) lifestyle and physiological factors, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) odor diversity (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePreventative hygienic practices\u003c/h2\u003e\u003cp\u003eParticipants described routine use of preventative hygienic practices as critical for malodor management (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Four of the 16 participants who commented (25.0%) reported that regular hygienic practices resulted in successful malodor management. Hygienic practices varied considerably; three participants (18.8%) reported douching, one participant (6.3%) reported using hygienic wipes, and two (12.5%) reported washing the neovulva as effective management strategies. Participants often mentioned that malodor would return in the absence of these practices.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRepresentative participant comments relating to each identified theme\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipant comment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreventative hygienic practices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; \u0026ldquo;This odor returns unless I am douching daily\u0026rdquo; [P6]\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;I have been using boric acid for vaginal use and it has been working amazingly, even better than canesten [sic]\u0026rdquo; [P9]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLifestyle and physiological factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; \u0026ldquo;\u0026hellip;only noticeable after dilation or penetration\u0026rdquo; [P16]\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;Internal hair growth most significant factor\u0026rdquo; [P5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOdor diversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; \u0026ldquo;\u0026hellip;there are different \"smells\" depending on time/area of the neovagina\u0026rdquo; [P16]\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;The second smell is not something I would describe as malodors/unpleasant\u0026rdquo; [P23]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLifestyle and physiological practices\u003c/h2\u003e\u003cp\u003eMany participants reported that lifestyle and sexual practices \u0026ndash; including dilation, penetrative intercourse, exercise, stress, clothing, hygiene, and rest \u0026ndash; exacerbated their observed malodor (expanded in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Intravaginal exposures were the most common exacerbating factors discussed (insertive sex, dilation, lubricant use, masturbation), mentioned in 10.9% (7/64) of comments and reported by 37.5% (6/16) of participants. Some participants reported noticing the malodor on the inserted item (e.g. dilators). Neovaginal physiology (internal hair growth, bleeding, urinary stream direction resulting in urine entering the neovagina) was the second most common, accounting for 6.3% (4/64) of comments and reported by 18.9% of participants (3/16). Stress and rest were mentioned by one participant. Three participants (18.9%) cited exercise, two participants (12.5%) cited form-fitted clothing including underwear and workout tights, and two participants (12.5%) cited specific hygiene practices (e.g. soap, douching) as exacerbating factors. Some participants reported that the exacerbating factors did not initiate the malodor, but rather intensified it.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eOdor diversity\u003c/h2\u003e\u003cp\u003e Many participants described experiencing multiple distinct odors. Five participants (31.3%) reported a non-bothersome odor, with one participant expressing \u0026ldquo;I wish I knew how to encourage it!\u0026rdquo; [P18] (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Many participants reported a second or third odor that they described as abnormal, and that a few participants specifically described as unpleasant. Diverse descriptors, including \u0026ldquo;musk\u0026rdquo;, \u0026ldquo;salty\u0026rdquo;, \u0026ldquo;acidic\u0026rdquo;, \u0026ldquo;decay\u0026rdquo;, \u0026ldquo;bad breath\u0026rdquo;, \u0026ldquo;fishy\u0026rdquo;, and \u0026ldquo;pre-cum\u0026rdquo;, were used to describe malodors. Participants reported that these bothersome odors could not be easily managed through hygienic practices, with some participants stating that these practices were intermittently effective, and others describing multiple courses of treatment prior to resolution. Three participants reported malodor as being persistent (18.8%), and three reported it as recurrent (18.8%). One participant attributed their malodor to a persistent yeast infection (6.3%), and two others described malodor as being connected to other symptoms, including pain and itching (12.5%). One participant reported diversity of both malodor type and location within the neovagina (6.3%).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003ePrinciple Results\u003c/h2\u003e\u003cp\u003eTF experiences of neovaginal malodor were classified into three key themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) preventative hygienic practices, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) lifestyle and physiological factors, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) odor diversity. Three distinct neovaginal malodor typologies were identified, defined by resemblance to isovaleric acid, trimethylamine, and a combinatorial odor resembling multiple polyamines (cadaverine, putrescine, and spermine) and acetic acid.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003ePreventative Hygienic Practices\u003c/h2\u003e\u003cp\u003eTF reported using varied hygienic practices and self-reported effectiveness of hygienic practices varied substantially. Post-vaginoplasty care guidelines differ significantly between institutions, which may explain the diversity in reported practices (\u003cspan additionalcitationids=\"CR49 CR50\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). For example, Women\u0026rsquo;s College Hospital recommends daily or as-needed douching to treat symptoms (e.g. discharge and odor), providing multiple solution options including betadine, saline, vinegar solution, and soap and water, but strongly advises against douching in the first three months after surgery (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). In contrast, Vancouver Coastal Health recommends douching with betadine solution for the first two weeks post-vaginoplasty, saline following six weeks, and warm water starting two months postoperatively (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Variability in participant experiences and provider guidance provide strong rationale for appropriately powered clinical trials to evaluated the role of hygienic practices in reducing symptoms like neovaginal malodor (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eProvider recommendations for douching contradict guidelines for CF, for whom douching and hygienic wipe use are associated with increased risk of malodor and decreased \u003cem\u003eLactobacillus\u003c/em\u003e (\u003cspan additionalcitationids=\"CR53 CR54 CR55 CR56\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). However, penile inversion vaginoplasty uses keratinized and soft-cornified penile skin, and preliminary evidence suggests that \u003cem\u003eLactobacillus\u003c/em\u003e dominance is rare in the neovagina (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This finding aligns with a previously published case study of one TF patient experiencing bacterial vaginosis (BV)-like symptoms and malodor, where douching, rather than administration of metronidazole or doxycycline, was effective in long-term malodor elimination (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eLifestyle and Physiological Factors\u003c/h2\u003e\u003cp\u003eMost participants reported that lifestyle or physiological factors including sexual exposures, exercise, clothing, internal hair growth, and diverted urinary stream impacted and/or exacerbated neovaginal malodor. Depending on the availability of penile skin and desired neovaginal depth, varying amounts of scrotal skin is used in the back of the canal. Scrotal skin contains hair follicles and previous studies of post-vaginoplasty complications have described internal hair growth as associated with malodor (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Both scrotal and penile skin contain apocrine (sweat) glands, which produce secretions that are metabolized by skin-colonizing bacteria into malodorous compounds (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Participants reported that exercise and the use of specific tight-fitting clothing exacerbated malodor, which may be due to increased sweating. Though underwear type is associated with \u003cem\u003eCandida\u003c/em\u003e infection in the natal vagina, it is not associated with bacterial vaginosis in cF (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Some participants reported odor associated with sex (insertion of a natal penis, lubricants, ejaculation into the neovagina, or neovaginal secretions during sex). Roughly 30% of TF report secretions with orgasm (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) and the bulbourethral gland, seminal vesicle, and prostate are not removed in vaginoplasty. Prostate secretions contains high concentrations of putrescine, spermine, and spermidine (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e), and may contribute to neovaginal malodor in some study participants.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eOdor Diversity\u003c/h2\u003e\u003cp\u003eSurprisingly, many participants described experiencing multiple distinct malodor types that varied across time and region of the neovagina. Specifically, one participant reported a unique malodor type that they observed only towards the apex of the neovaginal canal, and that this decay-like malodor could be observed on inserted objects. This may reflex a gradient in oxygen availability \u0026ndash; and anaerobe density \u0026ndash; in the neovaginal canal. \u003cem\u003ePrevotella\u003c/em\u003e are strict anaerobes that produce metabolites with a decay-like odour (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), and are common in the neovagina and uncircumcised penis. The diversity of reported malodor types and differential efficacy of attempted treatment methods suggest that there are multiple bacterial and chemical sources of malodor.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eMalodor State Types\u003c/h2\u003e\u003cp\u003eScent test results revealed three distinct malodour typologies: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) isovaleric acid, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) trimethylamine, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) polyamines with some acetic acid. Isovaleric acid is responsible for foot malodor (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and results from the incomplete bacterial degradation of skin lipids by species belonging to \u003cem\u003eStaphylococcus\u003c/em\u003e, and \u003cem\u003eBacillus\u003c/em\u003e, and \u003cem\u003eCorynebacterium\u003c/em\u003e (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), all common in the penile-skin lined neovagina (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Trimethylamine is a volatile small molecule, in part responsible for the fishy odor associated with BV and trichomoniasis in rCF (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In rCF, trimethylamine can be produced by \u003cem\u003ePrevotella\u003c/em\u003e or \u003cem\u003eM. curtisii\u003c/em\u003e, which are also prevalent in TF (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The third odour typology included high resemblance to polyamines \u0026ndash; putrescine, cadaverine, and spermine \u0026ndash; and moderate resemblance to acetic acid. Putrescine and cadaverine are responsible for decay-like malodors associated with bacterial metabolism of organic material, and contribute to wound, skin fold, and rCF vaginal malodor (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Spermine occurs in high concentrations in seminal fluid, and spermine carries a similar odor profile to spermidine, another related polyamine expressed by all cell types (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Participants specifically described malodor as smelling like \u0026ldquo;pre-cum\u0026rdquo; and \u0026ldquo;decay\u0026rdquo;, further supporting the role of these polyamines in the etiology of neovaginal malodor.\u003c/p\u003e\u003cp\u003eThe multiple, distinct odor types identified suggest multiple chemical sources, which aligns with the diversity of self-reported exacerbating factors and discrepancies in efficacy of prevention/treatment methods. These findings provide rationale for larger studies, powered to stratify by malodour type.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThis is the first study to examine potential neovaginal malodor sources using a standardized scent test. Use of scent test vials eliminates the need for participants to be familiar with scent descriptions (e.g., rotting flesh vs. garbage) and reduces subjectivity introduced by asking participants to describing odours as normal, unpleasant, etc. Allowing participants to augment the structured questionnaire with write-ins provided a more comprehensive understanding of participant experiences. However, specific prompts (such as on malodor exacerbating factors) may have led to overrepresentation of specific codes. Additionally, self-enrolment may have biased participation to those experiencing particularly challenging cases of neovaginal malodor.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe presence of multiple, different malodor types caused by different bacterial communities may explain the differential success of treatments and hygienic interventions in reducing neovaginal malodor. The prevalence of scents associated with non-vaginal malodour underscore the need to assess the efficacy of treatments intended for the natal vagina. The diversity of malodor reduction methods reported, including douching substances, reflects the lack of care guidelines for neovaginal malodor and highlights the need for further research aimed to develop evidence-based treatments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTransfeminine\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCisgender female\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003erCF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ereproductive-aged cisgender female\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the research ethics board at Western University (REB #121787). Informed consent was obtained for all participants. This study adhered to the Declaration of Helsinki. Research was conducted in accordance with all applicable guidelines and regulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the sensitive nature of this research and potential for compromising individual privacy, data is not available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a Collaborative Research Seed Grant (0000055231) from the Schulich School of Medicine and Dentistry (Western University). JLP received salary support from the Canada Research Chairs Program (Canadian Institutes of Health Research, CRC-2020-00175). ACS was supported by a Canadian Graduate Scholarship from the Canadian Institutes of Health Research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eACS and JLP conceived of the study. ACS created and distributed study materials with support from HW and AG. ACS and RP analysed survey data. ACS analysed scent test data with support from JRV. EP, DP, and JR assisted in developing study materials, and directing data analysis strategies. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge Jason Hallarn for providing guidance on the ethics approval process and design of REDCap questionnaire. We also wish to acknowledge the participants of this cohort for their time, energy, and effort.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEllis SA, Dalke L. Midwifery Care for Transfeminine Individuals. J Midwifery Women\u0026rsquo;s Health. 2019;64(3):298\u0026ndash;311.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnger CA. Hormone Therapy for Transgender Patients. Transl Androl Urol. 2016;5(6):877\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eColeman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. 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Appl Environ Microbiol. 2002;68(2):608\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using Thematic Analysis in Psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWomen\u0026rsquo;s College Hospital [Internet]. 2022 [cited 2024 May 29]. Post Transition Related Surgery Resources. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.womenscollegehospital.ca/care-programs/surgery/post-transition-related-surgery-resources/\u003c/span\u003e\u003cspan address=\"https://www.womenscollegehospital.ca/care-programs/surgery/post-transition-related-surgery-resources/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVancouver Coastal Health [Internet]. [cited 2024 May 29]. Dilation After Vaginoplasty. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://vch.eduhealth.ca/en/viewer?file=%2fmedia%2fVCH%2fGN%2fGN.1140.D55.pdf#phrase=false\u0026amp;pagemode=bookmarks\u003c/span\u003e\u003cspan address=\"https://vch.eduhealth.ca/en/viewer?file=%2fmedia%2fVCH%2fGN%2fGN.1140.D55.pdf#phrase=false\u0026amp;pagemode=bookmarks\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVaginal Rinsing. (Gender Surgery Program BC) [Internet]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://vch.eduhealth.ca/en/permalink/phem4362\u003c/span\u003e\u003cspan address=\"https://vch.eduhealth.ca/en/permalink/phem4362\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrS Montr\u0026eacute;al [Internet]. [cited 2024 May 29]. GrS Montreal | Male to Female: Vaginoplasty. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.grsmontreal.com/en/surgeries/male-to-female/1-vaginoplasty.html\u003c/span\u003e\u003cspan address=\"https://www.grsmontreal.com/en/surgeries/male-to-female/1-vaginoplasty.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYıldırım R, Vural G, Ko\u0026ccedil;oğlu E. Effect of Vaginal Douching on Vaginal Flora and Genital Infection. J Turk Ger Gynecol Assoc. 2020;21(1):29\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrotman RM, Klebanoff MA, Nansel TR, Andrews WW, Schwebke JR, Zhang J, et al. A Longitudinal Study of Vaginal Douching and Bacterial Vaginosis\u0026mdash;A Marginal Structural Modeling Analysis. 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Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Nov 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK482278/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK482278/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHamlin AA, Sheeder J, Muffly TM. Brief versus Thong Hygiene in Obstetrics and Gynecology (B-THONG): A survey study. J Obstet Gynaecol Res. 2019;45(6):1190\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKloer C, Parker A, Blasdel G, Kaplan S, Zhao L, Bluebond-Langner R. Sexual Health after Vaginoplasty: A systematic review. Andrology. 2021;9(6):1744\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRomijn JC. Polyamines and Transglutaminase Actions. Andrologia. 1990;22(Suppl 1):83\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePotter AJ, Paton JC. Spermidine Biosynthesis and Transport Modulate Pneumococcal Autolysis. J Bacteriol. 2014;196(20):3556\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMichael AJ. Polyamine Function in Archaea and Bacteria. J Biol Chem. 2018;293(48):18693\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bacterial vaginosis, vaginoplasty, post-operative care, transgender, transfeminine","lastPublishedDoi":"10.21203/rs.3.rs-7348971/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7348971/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePenile inversion vaginoplasty, which uses penile and scrotal skin to surgically create a neovagina, is a medically necessary gender-affirming surgery for some transfeminine individuals. Much like cisgender women, roughly a third of transfeminine individuals who have undergone vaginoplasty report having experienced bothersome neovaginal malodor in the past 30 days. However, sources of neovaginal malodor remain unclear. This study sought to collect data on odour quality and characterize the experiences of transfeminine individuals with neovaginal malodor.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;20) completed a cross-sectional questionnaire answering semi-structured interview questions on malodor experiences, exacerbating factors, and attempted reduction methods. Participants were mailed scent test kits containing samples of known malodorous compounds, and rated sample resemblance to their own malodor on a Likert scale. Results were evaluated by Spearman\u0026rsquo;s correlation. Participant comments were analysed using a thematic analysis and organized into key themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e Twenty-nine different scents were reported by 20 participants. Sixteen participants completed semi-structured interview questions, providing sixty-four total comments. Three key themes were identified: (i) odor and malodor diversity, ii) lifestyle and physiological factors, and iii) preventative hygienic practices. Participants often described both nonbothersome, desirable neovaginal odor, as well as unpleasant and undesirable neovaginal malodors. Scent test results revealed three malodor typologies, characterized by i) trimethylamine, ii) isovaleric acid, and iii) a diverse combination of the polyamines spermine, cadaverine, putrescine, as well as acetic acid. Participants engaged in diverse malodor management strategies, which were differentially effective.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe identification of three unique malodour typologies and varying success of treatments and hygienic practices in reducing neovaginal malodour suggests that different microbial communities may underlie each odour type. Further, the diversity of malodor reduction methods and douching substances reported highlight the lack of standard care guidelines for neovaginal malodor, demonstrating the need for further research aimed to develop evidence-based treatments.\u003c/p\u003e","manuscriptTitle":"Experiences and evidence of transfeminine people’s challenges with chronic, recurrent neovaginal malodor: a cross-sectional qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-26 06:25:07","doi":"10.21203/rs.3.rs-7348971/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-26T12:50:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208662671277210232450404112540267768855","date":"2026-04-15T06:38:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245338755901928324493696866570555609579","date":"2026-04-10T06:37:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301488735380879464320055589092649545386","date":"2026-03-24T14:50:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T20:29:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211351401975774660590499787468519512720","date":"2025-09-23T13:29:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197451290227017869545384222357037179673","date":"2025-09-22T13:19:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104567353889099655005605713152819194211","date":"2025-09-18T10:18:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56324846656675339405391745580015276049","date":"2025-09-16T14:41:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-16T09:43:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-10T07:24:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-20T09:26:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-19T13:58:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-08-19T13:53:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6bca43cf-2303-4e04-b4f5-a954afc83736","owner":[],"postedDate":"September 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-26T06:25:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-26 06:25:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7348971","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7348971","identity":"rs-7348971","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}