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How to Balance Vaginal pH in Perimenopause and Menopause

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A healthy vaginal pH is 3.5 to 4.5, but as you progress through menopause and well beyond, your vaginal pH can become elevated. You may also notice changes and discomfort in the vulva, vaginal environment, urinary tract, and bladder. The medical term for this is vaginal atrophy, or the genitourinary syndrome of menopause.

If your vaginal pH is off, you may find yourself trying to treat what seems like a yeast infection, bacterial vaginosis, or UTI symptoms. Medications like antibiotics or antifungals could be appropriate for your symptoms, but they may not address the underlying problem. So what can you do to balance your vaginal pH?

1. Determine if you are in perimenopause or menopause

Menopause triggers more than hot flashes and night sweats. When it comes to menopause symptoms, there are whole-body menopause symptoms, and there are vaginal menopause symptoms.

Interestingly, vaginal menopause symptoms are chronic and progressive. This means that common concerns like vaginal dryness, itching, burning, painful sex, frequent UTIs, and urgency won’t magically get better with time. Instead, they’ll probably get worse.

Perimenopausal woman with vaginal pH.
Up to 84% of postmenopausal women experience the genitourinary syndrome of menopause (1). And symptoms can start earlier in the perimenopause years.

Menopause is defined as the absence of your periods for one year. However, symptoms can start in perimenopause - a period of fluctuating hormones that can last for years before the stop of your periods. In either case, declining estrogen levels can lead to uncomfortable vaginal symptoms, including an elevated vaginal pH.

2. Understand your vaginal microbiome

Hormonal shifts throughout a woman’s life will affect the vaginal microbiome (2). So it’s key to understand how the vaginal microbiome changes as you move through the dramatic hormonal shifts of menopause.

Vaginal pH depends on the presence of protective bacteria in the vaginal bacterial community (or vaginal microbiome). In a healthy vaginal microbiome, Lactobacillus is the dominant protective bacteria.

After menopause, the vaginal microbiome changes because of decreased estrogen. Women are less likely to have a protective vaginal bacterial community and less likely to have a healthy vaginal pH (3, 4).

An illustration of protective bacteria and vaginal pH.
When estrogen is absent in menopause, protective bacteria are less abundant and the vaginal pH changes.

Interestingly, the vaginal microbiome of a postmenopausal woman has many similarities with the microbiome of a reproductive-aged woman with BV or bacterial vaginosis (5). There’s a higher vaginal pH and a higher diversity of bacteria. Symptoms can include:

  • Burning when peeing
  • Unusual discharge
  • Vaginal odor
  • Itchiness
  • Soreness

However, for postmenopausal women, abnormalities in the vaginal microbiome reflect a decline in protective bacteria rather than an increase in harmful bacteria (6, 7).

So what does this mean for your vaginal health? Well, if you’re treating your symptoms with antibiotics (as if you have bacteria vaginosis or a UTI) then you may be eliminating what little protective bacteria you have. This might lead to repeat infections.

Woman understanding vaginal pH.
Medications that treat BV, UTIs, or yeast infections will temporarily relieve symptoms. But they won’t address the root cause, which is estrogen deficiency.

3. Consider vaginal estrogen

For vaginal menopause symptoms, vaginal estrogen can be a safe and effective treatment option.

According to the research, treatment with vaginal estrogen is associated with an increase in protective bacteria (8, 9). This suggests that the best treatment for vaginal menopause symptoms is vaginal estrogen, rather than antibiotics (5).

There is no treatment that can restore vaginal pH overnight. But with consistent use, vaginal estrogen will work to improve the condition of the overall vaginal environment and restore vaginal pH to healthy levels. You may notice results within a couple of weeks, with continued improvements over the subsequent weeks and months.

Remember, vaginal menopause symptoms get worse with time and without treatment. Vaginal estrogen can help reverse symptoms, improving your overall health and quality of life.

Vaginal estrogen is available in several FDA-approved formulations, including a cream, suppository, and ring.

4. Other options to balance vaginal pH

Besides vaginal estrogen, other prescription medications have been shown to help balance vaginal pH:

  • DHEA (prasterone) vaginal inserts. These vaginal suppositories are inserted daily. Studies have shown that 6.5mg of DHEA can improve condition of the vaginal skin, balance vaginal pH, and reduce painful sex. Although the body converts DHEA into estrogen, have shown that 6.5mg of DHEA inserted daily will not significantly raise estrogen levels throughout the body.
  • Systemic menopause hormone therapy (HRT). This estrogen-based pill or patch delivers a higher dose of estrogen than vaginal estrogen. And, unlike vaginal estrogen, systemic HRT is absorbed throughout the body. Systemic hormone therapy (HRT) isn't for everyone, but it is shown to restore vaginal pH to healthy levels. It can also help with other menopause-related symptoms like hot flashes and night sweats.

Certain lifestyle changes can also be helpful:

  • Choose a good lubricant
  • Avoid harsh chemicals or washes in the vaginal area
  • Avoid vaginal products that contain petroleum jelly

5. Next steps

Whether you’re 40 years old or 90 years old, declining estrogen levels can throw off your vaginal pH. If you’re experiencing vaginal infections or discomfort, remember, the usual antibiotics or antifungals may not address the root cause.

Take a step back and determine if you are in perimenopause or menopause. And remember, genitourinary symptoms such as elevated vaginal pH, vaginal discomfort, or vaginal infections are not only common - they’re highly treatable and preventable with vaginal estrogen.

At Interlude, our medical team is here to support you on your journey to optimal vaginal health through menopause and beyond. Take our quiz, explore our treatment options, and learn how this all works.