Hidden "gifts" of menopause

Photo source: pexels.com Voitkevich

Bacterial vaginosis (BV) the most common vaginal infection worldwide. This vaginal infection is caused by an imbalance in the vaginal microbiome, typically characterized by a reduction in protective Lactobacillus species and an overgrowth of anaerobic bacteria such as Gardnerella vaginalis and Prevotella bivia. While BV is well-studied in premenopausal women, it also affects postmenopausal women, though with some distinct features and challenges in diagnosis and management.

Knowing in advance you will be prepared and could ask doctor for targeted questions.

Scientific Background on BV and Menopause

During menopause, endogenous estrogen levels decline significantly, leading to physiological changes in the vaginal environment. Estrogen deficiency results in thinning of the vaginal epithelium, decreased glycogen content, and reduced Lactobacillus colonization. This leads to an increase in vaginal pH (making it less acidic), which weakens the natural defense mechanisms against pathogenic bacteria, thereby increasing susceptibility to BV and other vaginal infections 2,5.

Research shows that the vaginal microbiota composition differs between premenopausal and postmenopausal women. Postmenopausal women tend to have lower levels of Lactobacillus and higher prevalence of anaerobic bacteria associated with BV. Studies using 16S rRNA gene sequencing have identified distinct community state types (CSTs) in postmenopausal women, with a shift toward bacterial communities less dominated by Lactobacillus and more by anaerobes like Fannyhessea spp. This shift correlates with symptoms of vaginal atrophy and increased BV risk 2.

The prevalence of BV in postmenopausal women varies widely in studies, ranging from 2% to 57%, partly due to diagnostic challenges. Traditional diagnostic criteria such as Amsel's and Nugent's scores were developed for premenopausal women and may not be as reliable in postmenopausal women, especially those not on estrogen therapy 2,3. Molecular diagnostic methods (e.g., nucleic acid amplification tests) are emerging as potentially more accurate tools in this population but require further validation 2,3.

What Doctors Say

Clinicians recognize the diagnostic overlap between BV and the genitourinary syndrome of menopause (GSM), which includes symptoms like vaginal dryness, irritation, and elevated pH.

Acc. John Hopkins University researchers survey of clinician’s treatment options showed wide variation in how BV in menopausal women is assessed and managed. Most (89%) treat BV‐like symptoms with antibiotics; about 28% add vaginal estrogen; 12% use estrogen alone. Only ~35% apply full Amsel criteria; many rely on wet mounts or molecular swabs. 10

Acc. Harward University researchers – unfortunately, standard-of-care metronidazole therapy for BV typically results in dominance of bacteria - Lactobacillus iners, which likely contributes to post-treatment relapse. 9

Experts emphasize treating estrogen deficiency first in symptomatic postmenopausal women before diagnosing and treating BV, as restoring estrogen can help re-establish a protective Lactobacillus-dominant vaginal environment and reduce BV recurrence 2,3. The use of vaginal estrogen has been shown to promote healthier vaginal mucosa and microbiota, potentially lowering BV incidence in postmenopausal women 2. Yet, it comes with higher risk to get Candidiasis, as it is directly associated with estrogen. 1, 10

What Women Say

Women undergoing menopause often notice changes in vaginal health, including increased susceptibility to infections like BV. Many women report symptoms such as unusual vaginal discharge, odor, irritation, and discomfort during intercourse. Some women may mistakenly believe that menopause ends the risk of vaginal infections, but in reality, hormonal changes increase vulnerability to BV 5,6.

Women also express concerns about recurrent infections and the impact of symptoms on quality of life. There is growing interest among women in non-antibiotic approaches, such as probiotics and vaginal estrogen, to maintain vaginal health and prevent BV recurrence during and after menopause 5,7.

In summary, bacterial vaginosis remains a relevant concern during and after menopause due to hormonal changes that alter the vaginal environment. Diagnosis and management in postmenopausal women require careful consideration of overlapping symptoms with GSM and may benefit from combining estrogen therapy with targeted antimicrobial treatment. Ongoing research is needed to refine diagnostic criteria and optimize treatment strategies for this population.

References:

• Hormonal changes in menopause raise vaginal pH and reduce acid resistance, increasing BV risk 2.

• BV prevalence in postmenopausal women ranges 2%-57%; diagnosis is complicated by menopausal changes; vaginal estrogen promotes Lactobacillus dominance and reduces BV incidence 2.

• Clinician surveys show varied approaches; antibiotics plus vaginal estrogen often recommended; molecular diagnostics emerging 3.

• Women report increased BV risk and symptoms during menopause; interest in probiotics and estrogen therapy for prevention 5,6,7.

  
  

  1. G J Dennerstein et al. Oestrogen, glycogen and vaginal candidiasis. Aust N Z J Obstet Gynaecol . 2001 Aug;41(3):326-8. doi: 10.1111/j.1479-828x.2001.tb01238.x. https://pubmed.ncbi.nlm.nih.gov/11592551/

  2. Van Gerwen OT, Smith SE, Muzny CA. 2023. Bacterial Vaginosis in Postmenopausal Women. Current Infectious Disease Reports 25(1):7–15. doi:10.1007/s11908-022-00794-1 hellobonafide.com+15pubmed.ncbi.nlm.nih.gov+15pmc.ncbi.nlm.nih.gov+15

  3. Mark KS, Tenorio B, Stennett CA, et al. 2020. Bacterial vaginosis diagnosis and treatment in postmenopausal women: a survey of clinician practices. Menopause 27(6):679–683. doi:10.1097/GME.0000000000001515 pubmed.ncbi.nlm.nih.gov+1magonlinelibrary.com+1

  4. Stewart LL, Vodstrcil LA, Coombe J, Bradshaw CS, Hocking JS. 2024. Bacterial vaginosis after menopause: factors associated and women’s experiences: a cross-sectional study of Australian postmenopausal women. Sexual Health 21: SH23094. doi:10.1071/SH23094 publish.csiro.au+1researchgate.net+1

  5.  (Web article) byWinona. What is Bacterial Vaginosis? byWinona.com journal. [Accessed 2025].

  6. Kim JM, Park YJ. 2017. Probiotics in the Prevention and Treatment of Postmenopausal Vaginal Infections: Review Article. Journal of Menopausal Medicine 23(3):139–145. doi:10.6118/jmm.2017.23.3.139 (Repeated reference to #4)

  7. Mayo Clinic Staff. Bacterial Vaginosis: Diagnosis & Treatment. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/bacterial-vaginosis/diagnosis-treatment/drc-20352285

  8. Seth M Bloom et all. Cysteine dependence of Lactobacillus iners is a potential therapeutic target for vaginal microbiota modulation. Nat Microbiol. Author manuscript; available in PMC: 2023 Sep 1.Published in final edited form as: Nat Microbiol. 2022 Mar 3;7(3):434–450. doi: 10.1038/s41564-022-01070-7 https://pmc.ncbi.nlm.nih.gov/articles/PMC10473153/

  9. Johns Hopkins University / Authors not specified. Bacterial Vaginosis Diagnosis and Treatment in Postmenopausal Women. Johns Hopkins Pure repository. https://pure.johnshopkins.edu/en/publications/bacterial-vaginosis-diagnosis-and-treatment-in-postmenopausal-wom

  10. Mohammad Tahseen AL Bataineh et al. Exploring the effect of estrogen on Candida albicans hyphal cell wall glycans and ergosterol synthesis. Front Cell Infect Microbiol . 2022 Sep 21;12:977157. doi: 10.3389/fcimb.2022.977157. https://pmc.ncbi.nlm.nih.gov/articles/PMC9578540/