Have you noticed something smells “off” down there? Is it a bit fishy or accompanied by a strange discharge? Then you may be dealing with bacterial vaginosis (BV). During perimenopause or menopause, it becomes more common due to your changing hormonal landscape.
Bacterial vaginosis is essentially a case of imbalanced vaginal pH that allows the vaginal microbiome to, in turn, fall out of balance. When this happens, the bacteria that normally populate the vagina (primarly Lactobacillus) become sparse, and opportunistic microbes take over (like Gardnerella vaginalis).
Getting things back on track may not be easy, but it can be simple if you respond well to metronidazole or topical clindamycin (antibiotics). And I will say this: it is really important to make sure you visit your gynecologist for treatment if you suspect BV and get treatment, as it can make you more susceptible to infection.
Now, if you don’t respond to typical treatment or find yourself with BV that keeps coming back, let’s talk about why it happens more in depth and how to fight it with microbiome support, vulvar moisturizers, estrogen therapy, and a few lifestyle tips you may not have heard before.
What Is Bacterial Vaginosis?
Bacterial vaginosis, or BV, is the most common vaginal infection in women of reproductive age, and it is frequently misunderstood, including by the people experiencing it.
BV is not a sexually transmitted infection, though sexual activity can influence the vaginal microbiome. It is not a yeast infection, though the two are often confused. BV happens when the balance of bacteria in the vagina shifts. A healthy vaginal environment is dominated by Lactobacillus bacteria, which produce lactic acid and keep the vaginal pH low and protective.
When Lactobacillus populations decline, and other bacteria move in, the pH rises, and BV develops. (1)
Symptoms can include a thin, grayish/green/yellow discharge and a fishy odor, particularly after sex. But many women with BV have no symptoms at all, which is one reason it goes undiagnosed so often. Others get misdiagnosed with a yeast infection and treat the wrong thing entirely, which only adds to the frustration.
What makes BV particularly aggravating is that it is not caused by one single "bad" bacterium. It is a community-level imbalance, which is part of why it can be stubborn to treat and easy to recur.
Why Does BV Happen During Menopause and Perimenopause?
Is BV common during menopause? Yes, and the reason comes down to one word: estrogen.
Estrogen plays a critical role in vaginal health. It supports the thickness of vaginal tissue and, crucially, it helps Lactobacillus bacteria thrive. Lactobacillus feeds on glycogen, a sugar that estrogen encourages vaginal cells to produce. When estrogen levels begin to decline during perimenopause and drop further after menopause, glycogen production falls with it.
Less glycogen means less fuel for Lactobacillus. Less Lactobacillus means less lactic acid. Less lactic acid means a higher vaginal pH, and a higher pH is an open invitation for BV-associated bacteria to move in. (2,3,4)
Research has confirmed that postmenopausal women have significantly lower free glycogen concentrations than premenopausal women, and that premenopausal women have higher Lactobacillus levels and lower vaginal pH as a result. (5) One review published in Frontiers in Medicine summarized the cascade clearly: rising estrogen at puberty promotes glycogen accumulation in vaginal cells, which is metabolized into lactic acid by Lactobacillus, creating the acidic environment that keeps BV-associated bacteria at bay. Lactobacillus dominance then decreases as estrogen declines following menopause. (3)
This is why BV and perimenopause are increasingly talked about together. The transition years before your last period are marked by hormonal fluctuation, and those fluctuations directly affect your vaginal ecosystem. Many women who never dealt with BV in their 20s or 30s find themselves dealing with it regularly once they hit their mid-40s.
So yes, menopause can absolutely cause BV, or at least create the precise conditions that make BV far more likely. This is not a hygiene issue. It is not something you caused. It is a physiological consequence of a shifting hormonal landscape.
Chronic BV And Menopause: Why It Keeps Coming Back
One of the most demoralizing aspects of BV in midlife is recurrence. You take the antibiotics, things improve, and then a few weeks or months later, it's back. This pattern is especially common during and after menopause, and it actually makes sense once you understand the underlying biology.
Antibiotics like metronidazole or clindamycin kill off the offending bacteria, but they don't restore the Lactobacillus population, and they don't address the root cause: the low-estrogen environment that allowed the imbalance to develop in the first place. Research shows that after antibiotic treatment, the vaginal microbiota is often dominated by less protective Lactobacillus species rather than the more stable strains considered most beneficial, meaning the door is left open for BV to return. (6)
The antibiotic cleared the infection temporarily, but the door was left wide open.
The recurrence rates tell the full story. Approximately 80% of women may experience a BV recurrence within three months of completing treatment. (7) A review published in Frontiers in Reproductive Health puts the one-year recurrence figure even higher, noting that 50 to 80% of women experience a return of BV within a year of finishing antibiotics. (6)
Chronic BV and menopause are a particularly common pairing for this reason. Treating BV in menopausal women with antibiotics alone is a bit like mopping the floor without fixing the leaking pipe. It works short-term, but the problem keeps returning until you address what's actually causing it.
BV and HPV: Why the Connection Matters
Research over the past decade has increasingly pointed to a link between bacterial vaginosis and HPV, specifically the persistence of high-risk HPV strains and the risk of cervical changes.
A healthy, Lactobacillus-dominant vaginal microbiome appears to play a protective role against HPV taking hold and progressing. When the microbiome is disrupted, as it is with BV, that protection is reduced.
Studies have found that women with BV are more likely to test positive for high-risk HPV, and that BV-associated microbiome disruption may make it harder for the immune system to clear HPV naturally. For most people, HPV clears on its own. The concern is when it doesn't, and a disrupted vaginal environment may tip the balance in the wrong direction.
A 2025 review published in Medicina found that BV was significantly associated with HPV persistence, with studies reporting a 1.8 to 3.4-fold increased risk of persistent high-risk HPV infection in BV-positive women. (8) Researchers also found that a microbiome community state associated with BV was present at baseline in 43% of women whose HPV persisted after a year, compared to only 7.4% of women whose HPV cleared. (9)
The vaginal microbiome is now recognized, as one 2025 Frontiers in Cellular and Infection Microbiology review described it, "not merely as a bystander but as an active modulator of HPV persistence and cervical cancer risk." (10)
The mechanism matters too. BV-associated bacteria are thought to alter the vaginal environment, weaken the mucosal defense layer, and promote inflammation, collectively creating conditions where HPV is more likely to persist and progress. (8)
For menopausal and perimenopausal women, this connection carries particular weight. Cervical screening recommendations change after 65, and many women assume HPV is no longer a concern after a certain age. But HPV can reactivate in midlife, and a vaginal microbiome that has been compromised by hormonal changes and recurring BV may be less equipped to manage it.
None of this is meant to cause alarm. Having BV does not mean you have HPV, and having HPV does not mean you will develop cervical cancer. But it does mean that treating recurring BV proactively, rather than waiting until symptoms are unbearable, is about more than comfort. It may also be a meaningful part of supporting your long-term health. Stay current with your cervical screenings (pap smears) and talk to your provider about your full picture.
BV and the Copper IUD: What You Need to Know
Many perimenopausal women use the copper IUD as a non-hormonal form of contraception, and for good reason. It is highly effective and avoids adding hormones to an already hormonally complex time. However, there is a well-documented association between copper IUD use and an increased risk of bacterial vaginosis that is worth understanding.
The copper IUD works partly by creating an environment that is inhospitable to sperm. Unfortunately, some research suggests it may also shift the vaginal microbiome in ways that make BV more likely. The mechanism is not fully understood, but studies have shown higher rates of BV in copper IUD users compared to those using other contraceptive methods or no contraception.
A prospective cohort study following over 2,500 women for up to 33 months found that copper IUD users experienced a 28% elevated risk of BV compared to women using no contraception or an alternative non-hormonal method, and that this elevated risk persisted throughout use. (11) A separate study tracking women at 30, 90, and 180 days after copper IUD initiation found BV prevalence rising progressively from 27% at baseline to 49% at six months, while women using hormonal contraceptives showed no change. (12)
A 2023 randomized trial published in Nature Communications confirmed that copper IUD users showed elevated bacterial diversity, increased inflammatory markers, and decreased relative abundance of Lactobacillus after both one and six months of use. (13) Women using hormonal options did not show these shifts, suggesting the changes are specific to the copper device.
The suspected mechanism could relate to the heavier, longer menstrual bleeding that the copper IUD commonly causes. Increased menstrual blood flow is known to disrupt the vaginal microbiome, which might explain why the copper IUD has this effect while hormonal methods, which tend to reduce bleeding, do not. (11)
For perimenopausal women, who are already experiencing the microbiome changes that come with declining estrogen, using a copper IUD may compound the vulnerability. If you are using a copper IUD and experiencing recurring BV, this combination is worth raising explicitly with your gynecologist. It does not necessarily mean the IUD has to go, but it should be part of the conversation about why BV keeps happening and what can be done about it.
If you are also experiencing other symptoms of the genitourinary syndrome of menopause (GSM), such as vaginal dryness or discomfort, that context is relevant too. The full picture helps your provider make better recommendations.
What To Do About BV
The good news is that there is more in the toolkit for treating BV in menopause than antibiotics alone.
Conventional Treatment
Oral or topical metronidazole and topical clindamycin remain the standard first-line treatments and are effective for clearing active infections.
Boric acid vaginal suppositories also have a growing evidence base for treating recurrent BV and restoring vaginal pH. A retrospective review of 52 women with recurrent BV who had failed conventional antibiotics found that intravaginal boric acid normalized vaginal pH in 86.5% of participants, with 88.5% achieving improved Nugent scores (a test used to assess vaginal flora). (14)
The CDC currently recommends a protocol of antibiotics followed by boric acid suppositories for women with recurrent BV. (15) They are not appropriate during pregnancy, but for menopausal and perimenopausal women, they can be a genuinely useful tool.
Vaginal Probiotics
Lactobacillus-based vaginal probiotics are an emerging area with growing evidence. The goal is to reintroduce and support the protective bacteria that BV displaces.
One randomized trial published in the New England Journal of Medicine found that women who used a Lactobacillus crispatus preparation after antibiotic treatment had a significantly lower rate of BV recurrence at both 12 and 24 weeks compared to placebo. (16) While results across studies vary depending on the strains used, vaginal probiotics are increasingly viewed as a meaningful part of a long-term maintenance strategy, particularly following antibiotic treatment.
Vaginal Estrogen Therapy
This is one of the most underused tools for menopausal women with recurrent BV. Low-dose local vaginal estrogen, available as a cream, ring, or suppository, can help restore the vaginal environment by supporting tissue health and encouraging the conditions Lactobacillus needs to thrive.
Research published in Scientific Reports found that postmenopausal women treated with low-dose vaginal estrogen showed significant increases in Lactobacillus relative abundance alongside decreased vaginal pH. (17) Another study similarly found that vaginal estradiol increased Lactobacillus and Bifidobacterium abundance in postmenopausal women compared to moisturizer and placebo groups. (2)
Because it is local rather than systemic, vaginal estrogen is considered appropriate for most women, including many who cannot or prefer not to use systemic hormone therapy. Yet many women are never offered it, or are scared away from it by outdated information. Vaginal estrogen does not treat active BV, but it addresses the underlying hormonal vulnerability that keeps bringing it back. For women with chronic BV and menopause, it can be genuinely transformative.
Vulvar Moisturizers
This is another tool that does not get nearly enough attention. Vulvar and vaginal dryness is extremely common in perimenopause and menopause, and when the delicate skin of the vulva becomes dry, irritated, or compromised, it is easier for microbial imbalances to take hold and harder for the tissue to recover.
Keeping the vulvar area moisturized supports the skin barrier, reduces irritation, and can help maintain the overall environment in which your microbiome lives.
A vulvar moisturizer is different from a lubricant, which is designed for use during sex. A moisturizer is used regularly, regardless of sexual activity, to maintain tissue hydration and comfort over time.
Look for products that are fragrance-free, free from parabens and glycols, and formulated specifically for vulvar skin.
My Julva® vulvar moisturizer formula also includes DHEA, a building block hormone that gets converted to estrogen and testosterone by the body. It can also work in conjunction with other therapies quite nicely. Learn more about Julva here.
It is worth noting that the vulva and the vagina have different needs. You should not apply general body moisturizers inside the vaginal canal, but a good vulvar moisturizer used externally as part of a regular routine can make a meaningful difference in comfort and skin health, particularly when you are also working to restore vaginal microbiome balance from the inside.
Lifestyle and Hygiene Factors
Avoiding douching is essential. Scented soaps, washes, and sprays in and around the vagina can disrupt pH and microbiome balance and should be avoided. Breathable cotton underwear and avoiding prolonged exposure to tight, sweaty gym leggings can also help. These seem like small things, but for a microbiome that is already under hormonal stress, reducing additional disruption matters.
In a cruel twist of fate, semen can also throw off the vaginal pH. Always try to wash off as quickly as possible after sex if you’re struggling with BV.
Talking to Your Provider
Consider asking your provider directly about vaginal pH, about whether vaginal estrogen might be appropriate for you, about boric acid as a maintenance option, and about whether any contraceptive methods you are using may be contributing to the pattern.
If you feel dismissed, try to find a gynecologist who specializes in menopause. These providers do exist, and they approach vaginal health in midlife very differently than a general practitioner.
Bacterial Vaginosis + Menopause
I know BV can be frustrating. But give the ideas in this article a try and see if they get you closer to the pH balance you need to feel better.
And be sure to sign up here to get a special discount on my new probiotic formula when it releases.
Frequently Asked Questions
Is BV more common after menopause?
BV is common across all reproductive stages, but the hormonal changes of menopause create particularly favorable conditions for it. The drop in estrogen reduces the glycogen that Lactobacillus bacteria rely on, which raises vaginal pH and makes the environment more hospitable to BV-associated bacteria.
Women who rarely or never experienced BV in their younger years often find it becomes a recurring issue in their 50s and beyond, and this is entirely explained by the estrogen decline, not by anything they are doing wrong.
Can perimenopause cause BV?
Yes, perimenopause can absolutely contribute to BV. Estrogen levels during perimenopause are not simply declining in a straight line. They fluctuate unpredictably, and those fluctuations affect the vaginal microbiome.
When estrogen dips, even temporarily, the conditions that support Lactobacillus become less stable. This is why many women first notice recurring BV in their 40s, well before their last period. If you are in perimenopause and dealing with BV that did not used to be a pattern for you, the hormonal context is very likely playing a role.
Will BV go away on its own during menopause?
Occasionally, mild BV can resolve without treatment, but in menopausal and perimenopausal women, this is less likely than in younger women. Because the underlying hormonal environment that allows BV to develop is ongoing rather than temporary, the microbiome does not have the same capacity to self-correct. Untreated BV can also increase the risk of other infections and, as discussed in this article, is associated with reduced ability to clear HPV. If you suspect you have BV, it is worth getting it confirmed and treated rather than waiting it out.
Does BV get worse as you get older?
Not necessarily worse in terms of severity of any single episode, but it does tend to become more persistent and harder to resolve completely as estrogen continues to decline. The further into menopause you are, the more your vaginal ecosystem has shifted away from the Lactobacillus-dominant state that naturally keeps BV at bay. This is why treatment approaches that worked well in your 30s may feel less effective now, and why addressing the underlying hormonal environment, rather than just treating each episode with antibiotics, becomes increasingly important.
Can hormone therapy help with recurring BV?
Local vaginal estrogen therapy, which delivers low-dose estrogen directly to vaginal tissue without significant systemic absorption, can be genuinely helpful for women with recurring BV in menopause. Restoring some of the hormonal support that the vaginal environment has lost helps create conditions where Lactobacillus can re-establish and maintain dominance. It does not treat an active BV infection, but it can significantly reduce how often BV comes back.
Systemic hormone therapy may have a similar effect, though the evidence is more established for local vaginal estrogen specifically. This is a conversation worth having with a provider who understands both menopause and vaginal microbiome health.
This post is for informational purposes only and is not a substitute for personalized medical advice. Please consult your healthcare provider for diagnosis and treatment.
References
Centers for Disease Control and Prevention. Bacterial Vaginosis: STI Treatment Guidelines. https://www.cdc.gov/std/treatment-guidelines/bv.htm
Fred Hutchinson Cancer Center / Srinivasan et al. Can estrogen improve vaginal health for postmenopausal women? JAMA Network Open (secondary analysis). https://www.fredhutch.org/en/news/spotlight/2022/06/vidd-srinivasan-jamanetw.html
Pino A et al. The Vaginal Microenvironment: The Physiologic Role of Lactobacilli. Frontiers in Medicine, 2018. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2018.00181/full
Chen et al. Glycogen Levels in Undiluted Genital Fluid and Their Relationship to Vaginal pH, Estrogen, and Progesterone. PLOS One, 2016. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153553
