menopause and bacterial vaginosis (BV)

There is a smell. You noticed it a week ago and told yourself you were imagining it, and now you are washing more, which is making it worse, and you have not said anything to anyone.

Bacterial vaginosis is extremely common, it is nobody's fault, and there are a couple of popular home remedies for it that can genuinely hurt you. So we are going to be straight about what works.

Start here: this needs a diagnosis, not a guess

Bacterial vaginosis is an infection. It is diagnosed with a simple swab and treated with a short course of antibiotics, usually metronidazole or clindamycin, and they work well.

The reason to get it confirmed rather than self-treat is that BV, thrush, trichomoniasis, other sexually transmitted infections, and the vaginal changes of menopause itself all produce overlapping symptoms. Treating the wrong one wastes weeks and leaves the real thing untreated.

Untreated BV is not harmless either. It raises susceptibility to sexually transmitted infections and to pelvic inflammatory disease. This page used to say the condition could often be resolved without medical intervention. That was wrong, and we have taken it off.

See a doctor promptly for any of these: a discharge with a fever, a discharge that is different from any you have had before, pelvic pain, or any vaginal bleeding after menopause, which always needs evaluation on its own account.

What is bacterial vaginosis?

Your vagina is supposed to have bacteria in it. A healthy vaginal environment is dominated by lactobacilli, which produce lactic acid and keep the pH low and acidic, which in turn keeps other organisms from taking over.

BV is what happens when lactobacilli levels drop and other bacteria multiply in their place. The pH rises, the balance tips, and the result is inflammation.

The symptoms, when there are any, are a thin gray, white or greenish discharge, a distinctive fishy odor that is often stronger after sex, itching, and sometimes burning when you pee. Plenty of women have BV with no symptoms at all.

Recognized risk factors include a new sexual partner or multiple partners, douching, a natural lack of lactobacilli which some women simply have, and scented soaps or tampons.

Why does it become more common after menopause?

Because lactobacilli depend on estrogen, indirectly but completely.

Estrogen drives glycogen production in the cells lining the vagina. Lactobacilli feed on that glycogen and convert it to lactic acid, which keeps the pH low. Falling estrogen means less glycogen, which means fewer lactobacilli, which means a higher pH.

A study in the Journal of Menopausal Medicine notes that with extremely low estrogen after menopause and reduced lactobacilli, "their intravaginal microflora can be colonized by harmful microorganisms that can cause BV."

That is the whole mechanism, and it explains why this becomes a recurring problem for some women rather than a one-off. It is not that you are washing wrong. The environment changed. More on how the microbiome works generally.

Is it BV, or is it menopause?

An important distinction, because they need different treatment and they can look similar.

Falling estrogen produces its own set of vaginal changes, thinning, dryness, irritation, discomfort and a change in discharge, which sit under genitourinary syndrome of menopause. That is not an infection and antibiotics will not touch it. See menopause and vaginal dryness.

The odor is the most useful distinguishing feature. A distinctly fishy smell, particularly after sex, points at BV. Dryness, tightness and discomfort without that smell points at GSM.

They also frequently coexist, and this is the part worth taking to an appointment. If you keep getting BV after menopause, treating the episodes one at a time with antibiotics addresses the symptom and not the reason. Local vaginal estrogen restores the tissue and the glycogen supply that lactobacilli need, which is why it is used to reduce recurrent infections in postmenopausal women. If you are on your third or fourth round of antibiotics, that is the conversation to have.

Two things this page used to recommend that you should not do

We rewrote this page and removed both of these. Given how long they have been up, we would rather explain than quietly delete.

Do not irrigate your vagina with hydrogen peroxide. This page previously suggested an ounce daily for a week. Hydrogen peroxide is an irritant to vaginal mucosa, particularly the thinner, more fragile tissue after menopause, and irrigating is douching, which is itself one of the recognized risk factors for BV. The old page said not to douche a few paragraphs after recommending it. Do not do this.

Do not insert a tea tree oil soaked tampon. This was suggested here for an hour at a time. Tea tree oil is a well-documented cause of contact dermatitis and chemical burns, and internal use on inflamed mucous membranes is exactly the wrong place for it. A patch test on your arm does not make it safe internally.

The general rule this leaves: the vagina is self-cleaning and it does not want anything acidic, antiseptic or essential-oil based put inside it. That includes vinegar, that includes garlic cloves, and it includes anything else you find recommended in a forum.

What about probiotics?

This is the one complementary approach with genuine research behind it, though it is supportive rather than curative.

The reasoning is sound, since BV is a loss of lactobacilli and probiotics supply lactobacilli. Meta-analyses have found a positive effect for probiotic supplements in BV, and they are studied most often alongside antibiotics rather than instead of them, particularly for reducing recurrence.

Two practical points. Strain matters: the strains studied for vaginal health are specific ones, generally Lactobacillus rhamnosus and Lactobacillus reuteri, and a general digestive probiotic is not the same product. And vaginal preparations exist as well as oral ones.

Fermented foods with live cultures, yogurt, kefir and real sauerkraut, are good for you and are not a treatment for an infection. Mayo Clinic's page on BV is a reliable overview, and there is background on how probiotics work.

On garlic: it has real antibacterial properties in a laboratory and there is some research on oral garlic tablets in BV. Eat it, enjoy it, read about its other benefits, and do not put it anywhere other than your mouth.

What actually reduces your risk?

Prevention is where you have real influence, and most of it is about leaving things alone.

• Stop douching, permanently. It strips lactobacilli and raises pH. It is one of the clearest risk factors there is.
• Water only on the vulva, nothing inside. No scented soap, no intimate wash, no wipes, no bubble bath. If you want something, a plain unscented emollient.
• Unscented products. Scented tampons, pads and liners all irritate.
• Front to back, always. Contamination from the bowel is a recognized risk factor.
• Condoms with new or multiple partners, which reduce BV risk as well as everything else.
• Wash sex toys properly with hot water and soap after every use.
• Change tampons and pads several times a day if you are still menstruating.
• Cotton underwear, and nothing overnight if you can manage it.
• Treat the underlying dryness if you are postmenopausal and this keeps coming back. That is the root cause.

When should you see a doctor?

For a discharge with fever, or a discharge that is unlike any you have had before. If you have treated it and it has come back. If home measures have not worked, which they generally will not, because this is an infection. And because several sexually transmitted infections present similarly, an examination is worthwhile rather than an assumption.

Any bleeding after menopause needs evaluation on its own account, regardless of anything else going on.

One practical tip: if you are still menstruating, book the appointment for when you are not bleeding, since a better sample can be taken.

The short version

Bacterial vaginosis is an infection, diagnosed with a swab and treated with antibiotics, and it should not be self-treated because thrush, sexually transmitted infections and the vaginal changes of menopause all look similar. It becomes more common after menopause because falling estrogen means less glycogen, which means fewer lactobacilli and a higher pH. If it keeps recurring, local vaginal estrogen addresses the cause rather than the episode, and that is the conversation worth having. Do not irrigate with hydrogen peroxide and do not insert tea tree oil, both of which this page used to suggest and both of which can hurt you. Probiotics with the right strains have real supporting evidence alongside antibiotics.

Related perimenopause and menopause symptoms

• Menopause and vaginal dryness
• Menopause and urinary tract infections
• Menopause and frequent urination
• Menopause and itching

Frequently Asked Questions

What causes bacterial vaginosis after menopause?

Estrogen drives glycogen production in the cells lining the vagina, and lactobacilli feed on that glycogen to produce the lactic acid that keeps vaginal pH low. Falling estrogen means less glycogen, fewer lactobacilli and a higher pH, which allows other bacteria to take over. It is an environmental change rather than a hygiene failure.

Can bacterial vaginosis be treated at home?

No. BV is an infection diagnosed with a swab and treated with a short course of antibiotics, usually metronidazole or clindamycin. Self-treating risks missing thrush, a sexually transmitted infection, or the vaginal changes of menopause, all of which produce overlapping symptoms. Untreated BV also raises susceptibility to sexually transmitted infections and pelvic inflammatory disease.

Is hydrogen peroxide safe for bacterial vaginosis?

No, and this page previously recommended it, which was wrong. Hydrogen peroxide irritates vaginal mucosa, especially the thinner tissue after menopause, and irrigating the vagina is douching, which is itself a recognized risk factor for BV.

How do I tell bacterial vaginosis from menopausal dryness?

The odor is the most useful clue. A distinctly fishy smell, often stronger after sex, along with a thin gray or greenish discharge, points at BV. Dryness, tightness and irritation without that smell points at genitourinary syndrome of menopause, which is not an infection and does not respond to antibiotics. They frequently coexist.

Why does my bacterial vaginosis keep coming back after menopause?

Because antibiotics treat the episode without restoring the environment that prevents it. Local vaginal estrogen rebuilds the tissue and the glycogen supply that lactobacilli depend on, which is why it is used to reduce recurrent infections in postmenopausal women. If you are on repeated courses of antibiotics, that is worth raising specifically.

Do probiotics help with bacterial vaginosis?

They have genuine supporting evidence, mostly alongside antibiotics rather than instead of them, and particularly for reducing recurrence. Strain matters: the strains studied for vaginal health are specific, generally Lactobacillus rhamnosus and Lactobacillus reuteri, and a general digestive probiotic is not the same product.