The vagina is a self-cleaning organ within the female reproductive system. It naturally secretes varying amounts of mucus throughout the menstrual cycle. Vaginal discharge is normal, and healthy discharge is typically clear, viscous, and odorless. At times, it can appear cloudy or white and may have a mild odor. However, certain changes in vaginal discharge are considered abnormal, such as those caused by an infection.(1)(2)
Bacterial vaginosis (BV) is an infection that causes discharge, odor, and itching, affecting approximately 30% of women of reproductive age in the United States.(3) Although cases of BV are mostly seen in women between the ages of 15 and 44, the infection doesn’t only affect women in their reproductive years.(4) Women going through the menopause transition, as well as those in postmenopause, are also vulnerable to BV.
Without treatment, women with BV may be at an increased risk for sexually transmitted infections (STIs) and other health problems.(4) Fortunately, prescription medications can help clear up the infection. This article will explore the unique relationship between menopause and BV and how women can lower their risk of developing the infection after menopause.
What is bacterial vaginosis?
The vagina hosts a diverse range of bacteria. In the event of bacterial overgrowth, infection can occur. BV develops under two conditions. The first is a decrease in dominant lactobacilli, a “good” type of bacteria that produces lactic acid and hydrogen peroxide in the vagina. The second condition is an increase in another type of bacteria known as anaerobic bacteria, which thrive in oxygen-free environments. Gardnerella is one type of anaerobic bacteria that has been linked to BV.(3)(5)(6)
Symptoms associated with BV usually involve changes in the appearance, texture, and odor of vaginal discharge, although some women do not experience any symptoms.
The exact cause of BV is unknown, but the condition more often affects individuals who engage in vaginal, anal, or oral sex.(7) Excessive bathing, douching, smoking, engaging in condomless sex, using sex toys without a condom, and increased stress levels are also risk factors.(3)(7) Research on BV prevalence rates among postmenopausal women is limited, but experts suggest that natural hormonal shifts during the menopause transition may contribute to BV infections that develop during midlife and older adulthood.
Can menopause cause bacterial vaginosis?
While experts do not know the cause of BV, hormonal changes that occur during the menopause transition may create conditions conducive to the development of BV.
During the menopause transition, levels of estrogen and progesterone in the body decline. As a result, the tissue lining the vagina starts to thin and break down. The vagina also experiences a decrease in lubrication, which increases the risk of microtears in the vaginal lining from sexual intercourse or masturbation. All of these changes combined can create a bacterial imbalance, increasing the likelihood of BV.(8)
When the levels of dominant lactobacilli bacteria and BV-associated anaerobic bacteria are balanced, bacterial overgrowth remains in check.(5)(8) This balance also allows the vagina to maintain a healthy pH level between 3.8 and 4.2.(9) However, hormonal fluctuations and changes to vaginal tissue that occur during the menopause transition reduce levels of vaginal lactobacilli and increase the vagina’s pH level.(5)(8) BV has been linked to a vaginal pH of 4.5 or higher, which is more common in postmenopausal women.
As women age, the body’s immune system becomes less effective at fighting off infections, which may further contribute to BV that develops during or after menopause.(8)
Although menopause cannot be considered a definitive cause of BV, the changing physiology of women during this time may create an environment for BV to develop.
Symptoms of Bacterial Vaginosis During Menopause
Approximately 50% of women affected by BV do not experience symptoms.(8) For those who do, symptoms may vary. Some of the most common symptoms of BV include the following:(3)(4)(5)
Vaginal discharge that has a “fishy” smell
Vaginal odor that worsens after sex
Gray or white vaginal discharge
Pain during urination
Pain during sexual intercourse
Vaginal Itching
Risks Associated With Bacterial Vaginosis in Postmenopause
If a person does not receive treatment for BV, they may be at risk for complications. Untreated BV in women of reproductive age can increase the risk of preterm birth and low birth weight. While postmenopausal women are not at risk for complications related to pregnancy or childbirth, untreated BV infections can pose other health risks:(5)
Pelvic Inflammatory Disease (PID): PID is characterized by inflammation of the uterus, ovaries, and/or fallopian tubes. The infection usually begins in the lower genital tract and is most often caused by an STI, primarily gonorrhea or chlamydia. Cases of PID are not always symptomatic, but some women may experience pelvic pain or soreness in the genital tract. Possible complications of PID include chronic pelvic pain, infertility, and ectopic pregnancy, in which the fetus grows outside the uterus.(10)
Post-Hysterectomy Infections: A hysterectomy is a gynecological procedure involving the surgical removal of the uterus. Potentially serious infections of the skin, muscles, tissue, organs, and more can occur following a hysterectomy procedure. This includes a common skin infection known as cellulitis. Patients may also develop deep or organ-space infections, which affect areas of the body beyond the surgical site. One study involving 13,822 women found that the occurrence rate of post-hysterectomy cellulitis was 1.6%, while the rate of deep and organ-space infections was 1.1%.(11)
Increased Risk of STIs: Women with BV may be more prone to herpes, chlamydia, gonorrhea, and a parasitic STI known as trichomoniasis. Because BV-associated bacteria can damage the vaginal lining, women with BV may also be more susceptible to human papillomavirus (HPV). Links have also been found between BV and the human immunodeficiency virus (HIV). Elevated vaginal pH levels, inflammation, and damage to the vaginal lining caused by BV infection may contribute to the relationship between BV and HIV.(3)(12)
Bacterial Vaginosis Treatments for Postmenopausal Women
Medication is the first-line treatment method for BV infections. However, a different approach may be recommended for women in postmenopause. Since BV has been linked to menopause-related hormone changes, a doctor may suggest addressing hormonal imbalances first to see if symptoms resolve before treating the infection.(5)Hormone replacement therapy (HRT) may be recommended to restore balance to declining levels of estrogen, progesterone, and other hormones during the menopause transition. HRT may be prescribed for symptomatic postmenopausal women for a trial period of several weeks. It’s available in various forms, including creams, oral tablets, and vaginal inserts.(5)Metronidazole, in oral tablet or gel form, and the cream form of clindamycin are the primary medications recommended for BV. These drugs have antimicrobial and antiparasitic properties. Alternatively, oral forms of clindamycin, secnidazole, or tinidazole may be prescribed. Depending on the medication, a course of treatment may require a one-time application or up to seven days of medication use.(5)
While research has been conducted on the effects of probiotics on vaginal bacterial imbalances in postmenopausal women, the U.S. Centers for Disease Control and Prevention (CDC) does not recommend the use of oral or vaginal probiotics to treat BV.(5)(13)
Although some cases of BV clear up on their own without treatment, it is common to experience recurrent infections. Additionally, because BV shares similar symptoms with other types of infections, physical and gynecological exams can help physicians make an accurate diagnosis.(3)
How to Reduce the Risk of Developing Bacterial Vaginosis After Menopause
More research is needed on BV infections after menopause, particularly regarding menopause-related changes to the vaginal microbiota and the potential influence of health status and medication use.(5)(8) While no established recommendations exist for the prevention and management of BV specific to postmenopausal women, there are strategies women of any age can implement to reduce the risk of BV during any stage of life:
Avoiding Douching: Nearly 1 in 5 women in the U.S. between the ages of 15 and 44 use water, soap, or cleansing products to wash the vagina.(1) This practice, known as douching, can disrupt bacterial balance and lead to potential health issues, including PID, yeast infections, ectopic pregnancy, and BV. The vagina is a self-cleaning organ, so the inside does not need to be washed.
Washing the Outside of the Vagina: Rinsing the external part of the vagina with warm water is sufficient to keep the area clean. Soaps and other harsh products can cause skin irritation, particularly those that contain chemical ingredients like fragrances. Wearing cotton underwear can also help keep the area clean, as cotton doesn’t trap moisture.(14)
Using Condoms: Condomless sex can increase the risk of BV. Using a fresh condom each time a person has vaginal, anal, or oral sex can help reduce the risk of infection. A new condom should also be applied to sex toys before each use.
Maintaining Regular Doctor Visits: For individuals assigned female at birth (AFAB), regular physical exams can help detect signs of potential health issues, including BV. While some experts recommend yearly visits, the American College of Obstetricians and Gynecologists (ACOG) notes that the frequency of physician visits may vary based on individual needs. During these appointments, patients can expect to receive a physical exam, pelvic exam, and any necessary screenings or immunizations. They can also discuss any questions or concerns during their visit.(15)(16)
The risk of BV is not isolated to a woman’s reproductive years. Postmenopausal women who receive HRT and engage in vaginal, anal, or oral sex may be at an increased risk. Individuals experiencing symptoms of BV should speak to a healthcare provider. Proper diagnosis and treatment can alleviate discomfort associated with BV after menopause.
