Bacterial vaginosis after menopause: factors associated and women’s experiences: a cross-sectional study of Australian postmenopausal women
Linde L. Stewart![https://orcid.org/0000-0003-0642-2610](/media/client/orcid_16x16.png)
![https://orcid.org/0000-0003-3679-9195](/media/client/orcid_16x16.png)
![https://orcid.org/0000-0002-9520-5724](/media/client/orcid_16x16.png)
![https://orcid.org/0000-0001-9329-8501](/media/client/orcid_16x16.png)
A
B
C
Abstract
Bacterial vaginosis (BV) is the most common cause of vaginal discharge in reproductive age women; however, little is known about it after menopause. We aimed to learn more about BV in Australian postmenopausal women.
We conducted an online survey (July–September 2021). Participants were recruited via social media and professional networks and asked about demographic characteristics, sexual history and BV experiences. Outcomes of interest were the proportion who had heard of BV, had BV ever, or had BV after menopause. Factors associated with these outcomes were assessed using logistic regression.
Of 906 participants, 83% were included in the analysis. Overall, 37.9% had heard of BV, 11.0% reported having a BV diagnosis ever, 6.3% reported having a BV diagnosis after menopause and 4.4% reported having a BV diagnosis only after menopause. Multivariable analysis found that among all women the odds of having a BV diagnosis after menopause were increased for those who had BV before menopause, had douched in the past 12 months, or had a previous STI diagnosis. Among those in a sexual relationship, a BV diagnosis after menopause was associated with a BV diagnosis before menopause, or being in a sexual relationship of 5 years or less in duration. About half who reported BV after menopause described recurrences, distress, and a detrimental effect on sexual relationships.
BV in postmenopausal women is associated with sexual activity, and impacts negatively on their lives. Research into BV should not be limited to reproductive age women.
Keywords: Australian postmenopausal women, bacterial vaginosis, BV, factors associated, menopause, postmenopausal, postmenopausal women, vaginosis, women.
Introduction
Bacterial vaginosis (BV), the most common cause of abnormal vaginal discharge in women of reproductive age, is associated with significant morbidity including pregnancy complications (e.g. spontaneous abortion and premature labour), pelvic inflammatory disease, and a greater risk of acquiring a sexually transmissible infection (STI) including HIV.1–4 It has been estimated that between 23% and 29% of women will have BV at any point in time,5 with prevalence higher in women who have sex with women,6–9 women of African ethnicity,10–15 and women who engage in intravaginal practices.1,16 Although the aetiology is unclear, BV is characterised by a change in the composition of the vaginal microbiota. The predominant Lactobacillus species is replaced by a more diverse group of organisms including Gardnerella vaginalis, Fannyhessea vaginae (previously Atopobium vaginae), and genital mycoplasmas.17–22 Symptoms are common and can include a thin vaginal discharge and a fishy odour.1 Recurrence following first-line antimicrobial therapy is common and can be very distressing and have a significant impact on a woman’s self-esteem and intimate relations, affecting their quality of life.23,24
While BV is well recognised and readily diagnosed in women of reproductive age, little is known about it in postmenopausal women, perhaps because of the considerable obstetric and gynaecological complications associated with BV in younger women. Further, while much is known about the negative impact of BV on reproductive age women’s quality of life, there is little information about its impact in postmenopausal women. A recent systematic review found that few studies have reported on BV in postmenopausal women, with prevalence estimates ranging from 2% in women undergoing elective surgery to 57% in women presenting to a gynaecology clinic with vaginal symptoms.25
Given the paucity of data about BV in postmenopausal women, we conducted an online survey of Australian postmenopausal women that aimed to understand more about their experiences of BV and the factors associated with the condition after menopause.
Materials and methods
This was a cross-sectional study of Australian postmenopausal women conducted between 8 July and 8 September 2021. Participants were asked to complete an anonymous online survey.
Participants
Participants were recruited in a variety of ways: Facebook advertisements; promotion via Twitter; and emailing the recruitment flyer to professional networks, groups, and colleagues. No financial or other incentives were provided for participation in this survey. Interested women could click on a link that took them to an online Qualtrics survey. Participants were eligible to participate if they were female, over the age of 50 years and postmenopausal, and living in Australia.
Data collection
The online questionnaire sought information on demographic characteristics, sexual practices, sexual health, and experiences of BV. Sex was defined as intimate physical contact with another person for sexual pleasure, including activities such as intercourse, oral sex, or the use of sex toys. Participants were asked about any BV diagnoses either before or after menopause and were asked about any experiences of the condition. We had three key outcomes of interest: (1) the proportion who had heard of BV; (2) the proportion who self-reported having been diagnosed with BV by a doctor ever; and (3) the proportion who self-reported having been diagnosed with BV by a doctor after menopause (the latter group consisted of those diagnosed with BV both before and after menopause and those diagnosed with BV only after menopause).
Data analysis
As this was a convenience survey, we did not undertake any formal sample size calculations. However, we aimed to obtain responses from at least 800 postmenopausal women as this would allow us to detect 95% confidence intervals (CI) from 46% to 54% around a proportion of 50%.
Proportions were calculated for each outcome with binomial 95% confidence intervals. Among those women who reported a BV diagnosis after menopause, we also asked about any symptoms they had experienced and the impact of BV on their lives. Descriptive statistics were used to describe the sociodemographic and behavioural characteristics of participants. Categorical data are presented as percentages with frequency, and continuous data are presented as median and range. The demographic profile of our sample was compared with data from the Australian Bureau of Statistics to assess the representativeness of our sample. Among those women who reported a BV diagnosis after menopause, we also examined the frequency of self-reported episodes and the impact of BV on their lives using descriptive statistics. Univariable and multivariable logistic regression were used to investigate factors associated with our three outcomes of interest. For each outcome, our regression model was conducted for all participants. In addition, for the outcomes having been diagnosed with BV by a doctor ever, and having been diagnosed with BV by a doctor after menopause, we conducted an additional regression model limiting it to those participants who were currently in a sexual relationship to investigate the association of sexual practice data with the outcomes. As not everyone completed all questions, denominators are provided to put any missing data into context. Variables were included in multivariable models if the P-value was <0.1 on univariable analysis, however, age was included in each model as we believed there was a correlation with sexual activity. Odds ratios were reported with 95% confidence intervals and P-values; associations were considered significant at P < 0.05. All statistical analyses were performed using Stata ver. 17 (StataCorp, College Station, TX, USA).
Results
Participant characteristics
A total of 906 women commenced the survey, of whom 754 (83%) completed the first outcome question about having heard of BV and were included in the analysis (see Supplementary Fig. S1). Overall, 55.3% were aged under 60 years (median age = 59 years; range 51–90 years), 57.6% were born in Australia, 50.7% reported that they were tertiary educated and 91.5% indicated that they were heterosexual. Participants from every Australian state and territory were represented in the survey, with most respondents from New South Wales/Australian Capital Territory (35.2%) and Victoria (30.7%). In comparison with the 2021 Australian census data for women, those aged 51–59 years and tertiary educated women were over-represented (Table 1).
All women (N = 754) A | ||||
---|---|---|---|---|
Variable | n/N | % | ABS 2021 census data for same population % | |
Age (years) Median: 59 Range: 51–90 | ||||
51–59 | 417/754 | 55.3 | 31.6 | |
60–69 | 250/754 | 33.2 | 31.6 | |
70+ | 87/754 | 11.5 | 36.8 | |
State/territory | ||||
New South Wales/Australian Capital Territory | 263/748 | 35.2 | ||
Northern Territory | 1/748 | 0.1 | ||
Queensland | 121/748 | 16.2 | ||
South Australia | 51/748 | 6.8 | ||
Tasmania | 32/748 | 4.3 | ||
Victoria | 230/748 | 30.7 | ||
Western Australia | 50/748 | 6.7 | ||
Country of birth | ||||
Australia | 434/754 | 57.6 | 63.5 | |
NZ/US/UK/Europe | 111/754 | 14.7 | ||
Other (Asia, Sub-Saharan Africa, South America, Papua New Guinea, International Solar Alliance) | 24/754 | 3.2 | ||
Not stated | 185/754 | 24.5 | ||
Aboriginal and Torres Strait Islander identity | ||||
Identifies as Aboriginal or Torres Strait Islander peoples | 21/749 | 2.8 | ||
Highest level of education | ||||
Secondary school | 137/750 | 18.3 | 54.3 | |
TAFE certificate | 233/750 | 31.1 | 24.1 | |
University degree (undergraduate or postgraduate) | 380/750 | 50.7 | 19.6 | |
Smoker | ||||
Non | 662/752 | 88.0 | ||
Light <20 cigarettes per day | 74/752 | 9.8 | ||
Heavy ≥20 cigarettes per day | 16/752 | 2.1 | ||
Hormone replace therapy (HRT) use ever | ||||
Never | 630/751 | 83.9 | ||
Currently using HRT | 106/751 | 14.1 | ||
Only used HRT in the past | 15/751 | 2.0 | ||
Douching in past 12 months | ||||
No | 734/752 | 97.6 | ||
Yes | 18/752 | 2.4 | ||
STI diagnosis ever | ||||
No/not sure | 552/751 | 73.5 | ||
Yes | 199/751 | 26.5 | ||
Sexual identity | ||||
Heterosexual/straight | 688/752 | 91.5 | ||
Other (includes women who have sex with women/have female partners and women who are bisexual or asexual) | 64/752 | 8.5 | ||
Used sex toys alone in past 12 months | ||||
No | 474/747 | 63.5 | ||
Less than once a month | 130/747 | 17.4 | ||
At least once a month | 143/747 | 19.1 | ||
Current sexual relationship | ||||
No | 308/747 | 40.9 | ||
Yes | 446/747 | 59.2 |
Women currently in a sexual relationship (N = 446) B | |||
---|---|---|---|
Variable | n/N | % | |
Number of current sexual partners | |||
1 | 433/443 | 97.7 | |
≥2 | 10/443 | 2.25 | |
Length of time with current or primary partner | |||
>5 years | 351/444 | 79.1 | |
2–5 years | 40/444 | 9.0 | |
Less than 2 years | 53/444 | 11.9 | |
Vaginal or anal intercourse in past 12 months | |||
No | 56/440 | 12.7 | |
Less than once a month | 112/440 | 25.5 | |
At least once a month | 272/440 | 61.8 | |
Condom use during intercourse in past 12 months | |||
No intercourse in past 12 months | 56/442 | 12.7 | |
Intercourse without a condom | 364/442 | 82.4 | |
Intercourse with a condom | 22/442 | 5.0 | |
Used lubricant during intercourse in past 12 months | |||
No intercourse in past 12 months | 56/441 | 12.7 | |
Intercourse without lubricant | 151/441 | 34.2 | |
Intercourse with lubricant | 234/441 | 53.1 | |
Receptive oral sex in past 12 months | |||
Not at all | 200/441 | 45.4 | |
Less than once a month | 108/441 | 24.5 | |
At least once a month | 133/441 | 30.2 | |
Used sex toys with a partner in past 12 months | |||
No | 291/440 | 66.1 | |
Less than once a month | 79/440 | 18.0 | |
At least once a month | 70/440 | 15.9 |
Proportions
A total of 286 women had heard of BV (37.9%; 95% CI: 34.5, 41.5) and 82 women self-reported having been diagnosed with BV by a doctor ever (11.0%; 95% CI: 9.0, 13.4). Overall, 47 women self-reported having been diagnosed with BV by a doctor after menopause (6.3%; 95% CI: 4.8, 8.3), and of these, 33 women self-reported having been diagnosed with BV by a doctor only after menopause (4.4%; 95% CI: 3.2, 6.2).
Factors associated with having heard of BV
Among all women, regardless of whether or not they were in a sexual relationship, multivariable analysis found that the odds of having heard of BV were significantly increased for those currently using hormone replacement therapy (HRT) (AOR = 1.8, 95% CI: 1.2, 2.7; P = 0.007) compared to those not currently using hormone replacement therapy (HRT) or had a previous STI diagnosis (AOR = 1.8, 95% CI: 1.3, 2.5; P = 0.001) compared to those who did not have a previous STI diagnosis. The odds of having heard of BV were significantly decreased for those who were aged 60+ years (AOR = 0.6, 95% CI: 0.5, 0.9; P = 0.007) compared to those who were aged 51–59 years (Table 2).
All participants | ||||
---|---|---|---|---|
Variable | Have heard of BV n/N (%) | Unadjusted OR (95% CI; P-value) | Adjusted OR (95% CI; P-value) | |
Age | ||||
<60 years | 179/417 (42.9) | |||
60+ years | 107/337 (31.8) | 0.6 (0.5, 0.8; P = 0.002) | 0.6 (0.5, 0.9; P = 0.007) | |
Country of birth | ||||
Australia | 156/434 (35.9) | |||
Elsewhere | 65/147 (44.2) | 1.4 (1.0, 2.1; P = 0.075) | 1.5 (1.0, 2.2; P = 0.059) | |
Not stated | 65/173 (37.6) | 1.1 (0.7, 1.5; P = 0.707) | 1.1 (0.7, 1.5; P = 0.795) | |
Highest level of education | ||||
Secondary school | 46/137 (33.6) | |||
TAFE certificate | 88/233 (37.8) | 1.2 (0.8, 1.9; P = 0.418) | ||
University degree (undergraduate or postgraduate) | 151/380 (39.7) | 1.3 (0.9, 2.0; P = 0.204) | ||
Currently a smoker | ||||
No | 247/662 (37.3) | |||
Yes | 38/90 (42.2) | 1.2 (0.8, 1.9; P = 0.368) | ||
Current hormone replacement therapy (HRT) use | ||||
No | 231/645 (36.0) | |||
Yes | 55/108 (50.9) | 1.9 (1.2, 2.8; P = 0.003) | 1.8 (1.2, 2.7; P = 0.007) | |
Douching in past 12 months | ||||
No | 276/733 (37.6) | |||
Yes | 10/18 (55.6) | 2.1 (0.8, 5.3; P = 0.130) | ||
STI ever | ||||
No/not sure | 188/552 (34.1) | |||
Yes | 98/199 (49.3) | 1.9 (1.4, 2.6; P < 0.001) | 1.8 (1.3, 2.5; P = 0.001) | |
Sexual identity | ||||
Other (includes women who have sex with women/have female partners and women who are bisexual or asexual) | 258/688 (37.5) | |||
28/64 (43.8) | 1.3 (0.8, 2.2; P = 0.326) | |||
Sex toy use alone in past 12 months | ||||
No | 169/474 (35.7) | |||
Yes | 114/273 (41.8) | 1.3 (1.0, 1.8; P = 0.098) | 1.1 (0.8, 1.5; P = 0.459) | |
Current sexual relationship | ||||
No | 109/308 (35.4) | |||
Yes | 176/439 (40.1) | 1.2 (0.9, 1.7; P = 0.193) |
n, number who have had BV after menopause; N, total. Denominators vary due to missing data; TAFE, technical and further education.
Factors associated with having BV ever
Among all women, regardless of whether or not they were in a sexual relationship, multivariable analysis found that the odds of having a BV diagnosis ever were significantly increased for those currently using HRT (AOR = 2.2, 95% CI: 1.2, 3.8; P = 0.007) compared to those not currently using HRT, those who reported that they had douched in the past 12 months (AOR = 4.5, 95% CI: 1.6, 12.7; P = 0.005) compared to those who had not douched in the past 12 months or those who had a previous STI diagnosis (AOR = 2.0, 95% CI: 1.2, 3.2; P = 0.006) compared to those who did not have a previous STI diagnosis. Among only those women currently in a sexual relationship, the odds of having a BV diagnosis ever were increased for those currently using HRT (AOR = 2.4, 95% CI: 1.2, 5.0; P = 0.016) compared to those not currently using HRT (Table 3).
Variable | Had BV ever n/N (%) | Unadjusted OR (95% CI; P-value) | Adjusted OR (95% CI; P-value) | |
---|---|---|---|---|
A. All participants | ||||
Age | ||||
<60 years | 53/413 (12.8) | |||
60+ years | 29/333 (8.7) | 0.6 (0.4, 1.0; P = 0.075) | 0.7 (0.5, 1.2; P = 0.245) | |
Country of birth | ||||
Australia | 51/431 (11.8) | |||
Elsewhere | 12/145 (8.3) | 0.7 (0.3, 1.3; P = 0.238) | ||
Not stated | 19/170 (11.8) | 0.9 (0.5, 1.6; P = 0.821) | ||
Highest level of education | ||||
Secondary school | 18/136 (13.2) | |||
TAFE certificate | 27/230 (11.7) | 0.9 (0.5, 1.7; P = 0.674) | ||
University degree (undergraduate or postgraduate) | 36/376 (9.6) | 0.7 (0.4, 1.3; P = 0.236) | ||
Currently a smoker | ||||
No | 69/654 (10.6) | |||
Yes | 12/90 (13.3) | 1.3 (0.7, 2.5; P = 0.428) | ||
Current hormone replacement therapy (HRT) use | ||||
No | 62/638 (9.7) | |||
Yes | 20/107 (18.7) | 2.1 (1.2, 3.7; P = 0.007) | 2.2 (1.2, 3.8; P = 0.007) | |
Douching in past 12 months | ||||
No | 76/726 (10.5) | |||
Yes | 6/18 (33.3) | 4.3 (1.6, 11.7; P = 0.005) | 4.5 (1.6, 12.7; P = 0.005) | |
STI ever | ||||
No/not sure | 49/545 (9.0) | |||
Yes | 33/198 (16.7) | 2.0 (1.3, 3.3; P = 0.004) | 2.0 (1.2, 3.2; P = 0.006) | |
Sexual identity | ||||
Other (includes women who have sex with women/have female partners and women who are bisexual or asexual) | 74/680 (10.9) | |||
8/64 (12.5) | 1.2 (0.5, 2.5; P = 0.693) | |||
Sex toy use alone in past 12 months | ||||
No | 53/469 (11.3) | |||
Yes | 29/270 (10.7) | 0.9 (0.6, 1.5; P = 0.816) | ||
Current sexual relationship | ||||
No | 34/306 (11.1) | |||
Yes | 48/433 (11.1) | 3.0 (0.6, 1.6; P = 0.991) | ||
B. Participants currently in a sexual relationship | ||||
Age | ||||
<60 years | 30/263 (11.4) | |||
60+ years | 18/170 (10.6) | 0.9 (0.5, 1.7; P = 0.791) | 1.1 (0.6, 2.1; P = 0.780) | |
Country of birth | ||||
Australia | 29/251 (11.6) | |||
Elsewhere | 7/76 (9.2) | 0.8 (0.3, 1.9; P = 0.568) | ||
Not stated | 19/170 (11.2) | 1.0 (0.5, 1.8; P = 0.905) | ||
Highest level of education | ||||
Secondary school | 9/74 (12.2) | |||
TAFE certificate | 18/129 (14.0) | 1.2 (0.5, 2.8; P = 0.718) | ||
University degree (undergraduate or postgraduate) | 21/228 (9.2) | 0.7 (0.3, 1.7; P = 0.462) | ||
Currently a smoker | ||||
No | 43/391 (11.0) | |||
Yes | 5/41 (12.2) | 1.1 (0.4, 3.0; P = 0.817) | ||
Current HRT use | ||||
No | 35/367 (9.5) | |||
Yes | 13/66 (19.7) | 2.3 (1.2, 4.7; P = 0.018) | 2.4 (1.2, 5.0; P = 0.016) | |
Douching in past 12 months | ||||
No | 44/421 (10.5) | |||
Yes | 4/12 (33.3) | 4.3 (1.2, 14.8; P = 0.021) | 2.7 (0.7, 11.0; P = 0.148) | |
STI ever | ||||
No/not sure | 30/315 (9.5) | |||
Yes | 18/118 (15.3) | 1.7 (0.9, 3.2; P = 0.094) | 1.6 (0.8, 3.1; P = 0.159) | |
Sexual identity | ||||
Other (includes women who have sex with women/have female partners and women who are bisexual or asexual) | 45/404 (11.14) | |||
3/29 (10.3) | 0.9 (0.3, 3.2; P = 0.895) | |||
Sex toy use alone in past 12 months | ||||
No | 33/271 (12.2) | |||
Yes | 15/159 (9.4) | 0.75 (0.4, 1.4; P = 0.384) | ||
Number of current sexual partners | ||||
1 | 45/423 (10.6) | |||
≥2 | 3/10 (30.0) | 3.6 (0.9, 14.4; P = 0.070) | 2.1 (0.5, 9.4; P = 0.344) | |
Length of time with current/primary partner | ||||
>5 years | 31/340 (9.1) | |||
5 years or less | 17/93 (18.3) | 2.2 (1.2, 4.2; P = 0.014) | 1.5 (0.8, 3.2; P = 0.233) | |
Vaginal/anal intercourse in past 12 months | ||||
No/less than once a month | 11/165 (6.7) | |||
At least once a month | 37/264 (14.0) | 2.3 (1.1, 4.6; P = 0.022) | 2.1 (1.0, 4.3; P = 0.051) | |
Condom use during intercourse in past 12 months | ||||
No intercourse/intercourse with a condom | 7/77 (9.1) | |||
No | 41/354 (11.6) | 1.3 (0.6, 3.0; P = 0.530) | ||
Lubricant use during intercourse in past 12 months | ||||
No intercourse/intercourse without lubricant | 18/202 (8.9) | |||
Yes | 30/228 (13.2) | 1.5 (0.8, 2.9; P = 0.165) | ||
Receptive oral sex in past 12 months | ||||
No/less than once a month | 30/299 (10.0) | |||
At least once a month | 18/131 (13.7) | 1.4 (0.8, 2.7; P = 0.263) | ||
Sex toy use with a partner in past 2 months | ||||
No | 28/283 (9.9) | |||
Yes | 20/146 (13.7) | 1.4 (0.8, 2.7; P = 0.238) |
n, number who have had BV after menopause; N, total. Denominators vary due to missing data; TAFE, technical and further education.
Factors associated with having BV after menopause
Among all women, regardless of whether or not they were in a sexual relationship, multivariable analyses found that the odds of having a BV diagnosis after menopause were significantly increased for those who had had a BV diagnosis before menopause (AOR = 7.0, 95% CI: 3.4, 14.7; P < 0.001), compared to those who had not had a BV diagnosis before menopause, had douched in the past 12 months (AOR = 4.2, 95% CI: 1.2, 14.5; P = 0.026) compared to those who had not douched in the past12 months or had a previous STI diagnosis (AOR = 2.1, 95% CI: 1.1, 3.9; P = 0.025) compared to those who did not have a previous STI diagnosis. Among only those women currently in a sexual relationship, the odds of having a BV diagnosis after menopause were significantly increased for those who had had BV before menopause (AOR = 10.6, 95% CI: 3.7, 30.2; P < 0.001) compared to those who had not had BV before menopause) and those currently in a sexual relationship of 5 years or less in duration (AOR = 2.9, 95% CI: 1.2, 7.2; P = 0.019) compared to those not currently in a sexual relationship of 5 years or less in duration (Table 4).
Variable | Had BV after menopause n/N (%) | Unadjusted OR (95% CI; P-value) | Adjusted OR (95% CI; P-value) | |
---|---|---|---|---|
A. All participants | ||||
Had BV before menopause | ||||
No | 33/698 (4.7) | |||
Yes | 14/48 (29.2) | 8.3 (4.1, 16.9; P < 0.001) | 7.0 (3.4, 14.7; P < 0.001) | |
Age | ||||
<60 years | 29/413 (7.0) | |||
60+ years | 18/333 (5.4) | 0.8 (0.4, 1.4; P = 0.368) | 1.0 (0.5, 1.9; P = 0.950) | |
Country of birth | ||||
Australia | 31/431 (7.2) | |||
Elsewhere | 6/145 (4.1) | 0.6 (0.2, 1.4; P = 0.200) | ||
Not stated | 10/170 (5.9) | 0.8 (0.4, 1.7; P = 0.567) | ||
Highest level of education | ||||
Secondary school | 11/136 (8.1) | |||
TAFE certificate | 15/230 (6.5) | 0.8 (0.4, 1.8; P = 0.574) | ||
University degree-either undergraduate or postgraduate | 21/376 (5.6) | 0.7 (0.3, 1.4; P = 0.304) | ||
Currently a smoker | ||||
No | 41/654 (6.3) | |||
Yes | 6/90 (6.7) | 1.1 (0.4, 2.6; P = 0.884) | ||
Current horome replacement therapy (HRT) use | ||||
No | 36/638 (5.4) | |||
Yes | 11/107 (10.3) | 1.9 (0.9, 3.9; P = 0.072) | 1.6 (0.7, 3.4; P = 0.224) | |
Douching in past12 months | ||||
No | 43/725 (5.9) | |||
Yes | 4/18 (22.2) | 4.5 (1.4, 14.4; P = 0.010) | 4.2 (1.2, 14.5; P = 0.026) | |
STI ever | ||||
No/not sure | 27/545 (5.0) | |||
Yes | 20/198 (10.1) | 2.2 (1.2, 3.9; P = 0.013) | 2.1 (1.1, 3.9; P = 0.025) | |
Sexual identity | ||||
Other (includes women who have sex with women/have female partners and women who are bisexual or asexual) | 43/680 (6.3) | |||
4/64 (6.3) | 3.0 (0.3, 2.8; P = 0.982) | |||
Sex toy use alone in past 12 months | ||||
No | 32/469 (6.8) | |||
Yes | 15/270 (5.6) | 0.8 (0.4, 1.5; P = 0.497) | ||
Current sexual relationship | ||||
No | 17/306 (5.6) | |||
Yes | 30/433 (6.9) | 1.3 (0.7, 2.3; P = 0.452) | ||
B. Participants currently in a sexual relationship | ||||
Had BV before menopause | ||||
No | 22/687 (3.2) | |||
Yes | 8/25 (32.0) | 14.2 (5.5, 36.5; P < 0.001) | 10.6 (3.7, 30.2; P < 0.001) | |
Age | ||||
<60 years | 19/263 (7.2) | |||
60+ years | 11/170 (6.5) | 0.9 (0.4, 1.9; P = 0.763) | 1.4 (0.6, 3.2; P = 0.475) | |
Country of birth | ||||
Australia | 20/251 (8.0) | |||
Elsewhere | 3/76 (4.0) | 0.5 (0.1, 1.6; P = 0.240) | ||
Not stated | 10/170 (5.9) | 0.7 (0.3, 1.6; P = 0.416) | ||
Highest level of education | ||||
Secondary school | 6/74 (8.1) | |||
TAFE certificate | 11/129 (8.5) | 1.1 (0.4, 3.0; P = 0.917) | ||
University degree-either undergraduate or postgraduate | 13/228 (5.7) | 0.7 (0.3, 1.9; P = 0.461) | ||
Currently a smoker | ||||
No | 27/391 (6.9) | |||
Yes | 3/41 (7.3) | 1.1 (0.3, 3.7; P = 0.921) | ||
Current HRT use | ||||
No | 23/367 (6.3) | |||
Yes | 7/66 (10.6) | 1.8 (0.7, 4.3; P = 0.207) | ||
Douching in past 12 months | ||||
No | 26/421 (6.2) | |||
Yes | 4/12 (33.3) | 7.6 (2.1, 26.9; P = 0.002) | 3.9 (0.8, 18.7; P = 0.088) | |
STI ever | ||||
No/not sure | 19/315 (6.0) | |||
Yes | 11/118 (9.3) | 1.6 (0.7, 3.5; P = 0.233) | ||
Sexual identity | ||||
Other (includes women who have sex with women/have female partners and women who are bisexual or asexual) | 27/404 (6.7) | |||
3/29 (10.3) | 1.6 (0.5, 5.7; P = 0.457) | |||
Sex toy use alone in past 12 months | ||||
No | 20/271 (7.4) | |||
Yes | 10/159 (6.3) | 0.8 (0.4, 1.8; P = 0.699) | ||
Number of current sexual partners | ||||
1 | 27/423 (6.4) | |||
≥2 | 3/10 (30.0) | 6.3 (1.5, 25.7; P = 0.010) | 3.5 (0.7, 18.6; P = 0.145) | |
Length of time with current/primary partner | ||||
>5 years | 15/340 (4.4) | |||
5 years or less | 15/93 (16.1) | 4.2 (2.0, 8.9; P < 0.005) | 2.9 (1.2, 7.2; P = 0.019) | |
Vaginal/anal intercourse in past 12 months | ||||
No/less than once a month | 5/165 (3.0) | |||
At least once a month | 25/264 (9.5) | 3.3 (1.3, 8.9; P = 0.016) | 2.6 (0.8, 8.1; P = 0.107) | |
Condom use during intercourse in past 12 months | ||||
No intercourse/intercourse with a condom | 2/77 (2.6) | |||
No | 28/354 (7.9) | 3.2 (0.8, 13.8; P = 0.115) | ||
Lubricant use during intercourse in past 2 months | ||||
No intercourse/intercourse without lubricant | 8/202 (4.0) | |||
Yes | 22/228 (9.7) | 2.6 (1.1, 6.0; P = 0.025) | 2.1 (0.8, 5.2; P = 0.112) | |
Receptive oral sex in past 12 months | ||||
No/less than once a month | 16/229 (5.4) | |||
At least once a month | 14/131 (10.7) | 2.1 (1.0, 4.5; P = 0.05) | 0.9 (0.3, 2.2; P = 0.777) | |
Sex toy use with a partner in past 12 months | ||||
No | 18/283 (6.4) | |||
Yes | 12/146 (8.2) | 1.3 (0.6, 2.8; P = 0.476) |
n, number who have had BV after menopause; N, total. Denominators vary due to missing data; TAFE, technical and further education.
Impact of BV after menopause
Of 47 women who reported having a BV diagnosis after menopause, 26 (55%) said that their most recent episode was within the past 2 years and 12 (26%) within the past 12 months. Overall, 42 (89%) reported an abnormal vaginal odour and/or vaginal discharge that caused them distress, 22 (47%) women reported that BV made them feel self-conscious, 24 (51%) were worried that others may notice the fishy odour and 20 (43%) were worried that it would return. In addition, 23 (49%) said that it had affected a sexual relationship, with 8 (35%) saying that they try to avoid sex altogether and 12 (52%) saying they were unable to relax and enjoy sex. Furthermore, 21 (45%) had experienced recurrences and of those, 15 (71%) experienced a recurrence within 12 months and 19 (91%) experienced a recurrence within 2 years.
Discussion
To our knowledge, this is the first study to investigate knowledge and experiences of BV in postmenopausal women in Australia, finding that over a third had heard of BV and about 6% reported having a BV diagnosis after menopause. While a BV diagnosis before menopause was the strongest predictor of BV after menopause, it was also associated with having ever been diagnosed with an STI suggesting an association with sexual activity. Women diagnosed with BV after menopause reported being distressed with about half reporting that it had affected a sexual relationship.
We found that knowledge of BV among postmenopausal women was poor with only about one-third reporting that they had heard of BV. However, BV knowledge was associated with age, with younger women being much more likely to have heard of BV. This is not surprising given that the term ‘bacterial vaginosis’ only began to appear in the literature in the 1980s. The condition had previously been known as Haemophilus vaginalis vaginitis or non-specific vaginitis.26,27 Most published BV research is conducted in women of reproductive age with few BV prevalence estimates available for postmenopausal women, and while our study is not a prevalence survey, it does suggest that a considerable number of women continue to experience BV after menopause.
We found that a BV diagnosis after menopause was also associated with douching. The evidence of associations between douching and BV can be conflicting28–30 and the cross-sectional nature of our study design makes it difficult to determine causal associations and whether the douching or the BV came first. Our findings show that a BV diagnosis after menopause was associated with sexual activity. This is consistent with the substantial amount of evidence that suggests that BV is sexually transmissible1,4,31 and that women diagnosed with BV are more likely to have a comorbid diagnosis of an STI.3,32 Women in our study who were currently in a sexual relationship of 5 years or less in duration were more likely to report a BV diagnosis after menopause. This is consistent with evidence that suggests that people dating again later in life often lack knowledge of STIs and safer sexual practices, increasing their risk of acquiring BV and other STIs including HIV.33 A recent study found that STIs are increasing at a faster rate in older women than in younger women.34
Our survey found that, similar to reproductive age women,23 BV in postmenopausal women can negatively impact a woman’s quality of life, requiring support and management. Further, the strongest predictor of having a BV diagnosis after menopause was having had it before menopause, highlighting the importance of primary care physicians being informed about BV and understanding that it can affect a considerable proportion of older women at some stage, so that they can discuss it with their patients. However, research shows that primary care physicians are less likely to have conversations about sexual health with their female patients after menopause and older women are less likely to raise sexual health issues with their doctors,35,36 potentially placing them at risk of ongoing BV and its associated symptoms and complications.
The diagnosis of BV is commonly made by one of two gold standard diagnostic methods: (1) Nugent scoring; or (2) Amsel criteria. However, these methods have been developed in women of reproductive age and rely on the impact of premenopausal levels of oestrogen on key diagnostic criteria.37,38 Both of these methods become less suitable for diagnosing BV in women after menopause as endogenous oestrogen declines,39,40 and can hinder our ability to understand the prevalence and pathogenesis of BV in postmenopausal women. The development of a more appropriate diagnostic method suitable for BV in women after menopause is crucial.
A key strength of our study is that it is, to the best of our knowledge, one of the first studies to investigate the impact of BV on postmenopausal women’s health and wellbeing and provides data for women across a wide age range (51–90 years). However, our study has a number of limitations to be considered. This was a cross-sectional convenience sample, with women aged 51–59 years and tertiary educated women over-represented. Recall bias cannot be excluded as women were asked about BV diagnoses that may have happened many years earlier and older women were observed to have less knowledge of BV. The latter may be recall bias but may also reflect changes in terminology as BV had previously been known as non-specific vaginitis.26 Selection bias also cannot be excluded as women who have previously been diagnosed with BV may have been more likely to complete the survey. Furthermore, the questions regarding sexual practices referred to the past 12 months and diagnoses reported by some participants may have been many years earlier. Therefore, some associations will be difficult to interpret given the number of years that may have elapsed. However, over half of the women who had been diagnosed with BV after menopause reported that their most recent episode was within the past 2 years and nearly all reported that their most recent episode was within the past 5 years. However, it is also important to note that these data do not represent BV prevalence estimates. Finally, most questions gave the participants the option to skip therefore there is missing data, and, with the exception of country of birth, this is limited to less than 10%.
Conclusion
Although these are not prevalence data, our study provides evidence that BV occurs in postmenopausal women, is associated with sexual activity, and impacts negatively on their lives. About half the women in our study who reported having a BV diagnosis after menopause described recurrences, distress, and a detrimental effect on their sexual relationships. This highlights the need for research into BV that is not limited to women of reproductive age and includes the development of a diagnostic method that is suitable for use in women after menopause. This would further our understanding of BV in postmenopausal women and help to address this poorly understood but important area of public health.
Data availability
Ethics approval was not obtained to make the data publicly available. However, summary statistics are available on written request to the authors.
Conflicts of interest
Jane Hocking was a Joint Editor of Sexual Health at the time this was submitted but was blinded from the peer-review process for this paper. Jacqueline Coombe is an Associate Editor of Sexual Health but was blinded from the peer-review process for this paper. All other authors declare no conflicts of interest.
Declaration of funding
JSH was supported by a National Health and Medical Research Council (NHMRC) Senior Research Fellowship (1136117) and CSB is supported by a NHMRC Investigator Grant (1173361).
Author contributions
Designed the survey: all authors contributed. Responsible for administering the survey: LLS. Analysed the data: LLS and JSH. Wrote the paper: LLS and JSH. Contributed to drafting/review of final manuscript: all authors.
References
1 Koumans EH, Sternberg M, Bruce C, et al. The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis 2007; 34: 864-9.
| Google Scholar |
2 Gravett MG, Nelson HP, DeRouen T, Critchlow C, Eschenbach DA, Holmes KK. Independent associations of bacterial vaginosis and Chlamydia trachomatis infection with adverse pregnancy outcome. J AMA 1986; 256: 1899-903.
| Google Scholar |
3 Allsworth JE, Peipert JF. Severity of bacterial vaginosis and the risk of sexually transmitted infection. Am J Obstet Gynecol [205] 2011; 113e1-113e6.
| Google Scholar |
4 Allsworth JE, Peipert JF. Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data. Obstet Gynecol 2007; 109: 114-20.
| Google Scholar |
5 Peebles K, Velloza J, Balkus JE, McClelland RS, Barnabas RV. High global burden and costs of bacterial vaginosis: a systematic review and meta-analysis. Sex Transm Dis 2019; 46: 304-311.
| Crossref | Google Scholar | PubMed |
6 Vodstrcil LA, Walker SM, Hocking JS, et al. Incident bacterial vaginosis (BV) in women who have sex with women is associated with behaviors that suggest sexual transmission of BV. Clin Infect Dis 2015; 60: 1042-53.
| Google Scholar |
7 Evans AL, Scally AJ, Wellard SJ, Wilson JD. Prevalence of bacterial vaginosis in lesbians and heterosexual women in a community setting. Sex Transm Infect 2007; 83: 470-5.
| Google Scholar |
8 Bradshaw C, Bilardi J, Walker S, et al. Behavioural factors associated with bacterial vaginosis (bv) in women who have sex with women (WSW): The women on women’s (WOW) health study. Sex Transm Infect 2011; 87: A32-A3.
| Google Scholar |
9 Marrazzo JM, Koutsky LA, Eschenbach DA, Agnew K, Stine K, Hillier SL. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2002; 185: 1307-13.
| Google Scholar |
10 Kenyon C, Colebunders R, Crucitti T. The global epidemiology of bacterial vaginosis: a systematic review. Am J Obstet Gynecol 2013; 209: 505-23.
| Google Scholar |
11 Bukusi EA, Cohen CR, Meier AS, et al. Bacterial vaginosis: risk factors among Kenyan women and their male partners. Sex Transm Dis 2006; 33: 361-7.
| Google Scholar |
12 Chico RM, Mayaud P, Ariti C, Mabey D, Ronsmans C, Chandramohan D. Prevalence of malaria and sexually transmitted and reproductive tract infections in pregnancy in sub-Saharan Africa: a systematic review. Jama 2012; 307: 2079-86.
| Google Scholar |
13 Torrone EA, Morrison CS, Chen PL, et al. Prevalence of sexually transmitted infections and bacterial vaginosis among women in sub-Saharan Africa: An individual participant data meta-analysis of 18 HIV prevention studies. PLoS Med 2018; 15: e1002511.
| Google Scholar |
14 Cherpes TL, Hillier SL, Meyn LA, Busch JL, Krohn MA. A delicate balance: risk factors for acquisition of bacterial vaginosis include sexual activity, absence of hydrogen peroxide-producing lactobacilli, black race, and positive herpes simplex virus type 2 serology. Sex Transm Dis 2008; 35: 78-83.
| Crossref | Google Scholar | PubMed |
15 Ness RB, Hillier S, Richter HE, et al. Can known risk factors explain racial differences in the occurrence of bacterial vaginosis? J Natl Med Assoc 2003; 95: 201-12.
| Google Scholar | PubMed |
16 Brown JM, Hess KL, Brown S, Murphy C, Waldman AL, Hezareh M. Intravaginal practices and risk of bacterial vaginosis and candidiasis infection among a cohort of women in the United States. Obstet Gynecol 2013; 121: 773-80.
| Crossref | Google Scholar | PubMed |
17 Fredricks DN, Fiedler TL, Marrazzo JM. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med 2005; 353: 1899-911.
| Crossref | Google Scholar | PubMed |
18 Srinivasan S, Hoffman NG, Morgan MT, et al. Bacterial communities in women with bacterial vaginosis: high resolution phylogenetic analyses reveal relationships of microbiota to clinical criteria. PLoS ONE 2012; 7: e37818.
| Crossref | Google Scholar | PubMed |
19 Spiegel CA, Amsel R, Eschenbach D, Schoenknecht F, Holmes KK. Anaerobic bacteria in nonspecific vaginitis. N Engl J Med 1980; 303: 601-7.
| Crossref | Google Scholar | PubMed |
20 Ferris MJ, Masztal A, Aldridge KE, Fortenberry JD, Fidel PL, Jr, Martin DH. Association of Atopobium vaginae, a recently described metronidazole resistant anaerobe, with bacterial vaginosis. BMC Infect Dis 2004; 4: 5.
| Crossref | Google Scholar | PubMed |
21 Cox C, Watt AP, McKenna JP, Coyle PV. Mycoplasma hominis and Gardnerella vaginalis display a significant synergistic relationship in bacterial vaginosis. Eur J Clin Microbiol Infect Dis 2016; 35: 481-7.
| Crossref | Google Scholar | PubMed |
22 Plummer EL, Vodstrcil LA, Bodiyabadu K, et al. Are Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum associated with specific genital symptoms and clinical signs in nonpregnant women? Clin Infect Dis 2021; 73: 659-68.
| Crossref | Google Scholar | PubMed |
23 Bilardi JE, Walker S, Temple-Smith M, et al. The burden of bacterial vaginosis: women’s experience of the physical, emotional, sexual and social impact of living with recurrent bacterial vaginosis. PLoS ONE 2013; 8: e74378.
| Crossref | Google Scholar | PubMed |
24 Bradshaw CS, Morton AN, Hocking J, et al. High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. J Infect Dis 2006; 193: 1478-86.
| Crossref | Google Scholar | PubMed |
25 Stewart LL, Vodstrcil LA, Coombe J, Bradshaw CS, Hocking JS. Prevalence of bacterial vaginosis in postmenopausal women: a systematic review and meta-analysis. Sex Health 2022; 19: 17-26.
| Crossref | Google Scholar | PubMed |
26 Spiegel CA, Amsel R, Holmes KK. Diagnosis of bacterial vaginosis by direct gram stain of vaginal fluid. J Clin Microbiol 1983; 18: 170-7.
| Crossref | Google Scholar | PubMed |
27 Eschenbach DA, Hillier S, Critchlow C, Stevens C, DeRouen T, Holmes KK. Diagnosis and clinical manifestations of bacterial vaginosis. Am J Obstet Gynecol 1988; 158: 819-28.
| Crossref | Google Scholar | PubMed |
28 Klebanoff MA, Nansel TR, Brotman RM, et al. Personal hygienic behaviors and bacterial vaginosis. Sex Transm Dis 2010; 37: 94-9.
| Crossref | Google Scholar | PubMed |
29 Hutchinson KB, Kip KE, Ness RB. Vaginal douching and development of bacterial vaginosis among women with normal and abnormal vaginal microflora. Sex Transm Dis 2007; 34: 671-5.
| Crossref | Google Scholar | PubMed |
30 Amaral R, Giraldo PC, Gonçalves AK, et al. Evaluation of hygienic douching on the vaginal microflora of female sex workers. Int J STD AIDS 2007; 18: 770-3.
| Crossref | Google Scholar | PubMed |
31 Bradshaw CS, Morton AN, Garland SM, Morris MB, Moss LM, Fairley CK. Higher-risk behavioral practices associated with bacterial vaginosis compared with vaginal candidiasis. Obstet Gynecol 2005; 106: 105-14.
| Crossref | Google Scholar | PubMed |
32 Atashili J, Poole C, Ndumbe PM, Adimora AA, Smith JS. Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies. AIDS 2008; 22: 1493-501.
| Crossref | Google Scholar | PubMed |
33 Lyons A, Heywood W, Fileborn B, et al. Sexually active older Australian’s knowledge of sexually transmitted infections and safer sexual practices. Aust N Z J Public Health 2017; 41: 259-61.
| Crossref | Google Scholar | PubMed |
34 Bourchier L, Malta S, Temple-Smith M, Hocking J. Do we need to worry about sexually transmissible infections (STIs) in older women in Australia? An investigation of STI trends between 2000 and 2018. Sex Health 2020; 17: 517-24.
| Crossref | Google Scholar |
35 Malta S, Temple-Smith M, Bickerstaffe A, Bourchier L, Hocking J. ‘That might be a bit sexy for somebody your age’: older adult sexual health conversations in primary care. Australas J Ageing 2020; 39(Suppl 1): 40-8.
| Crossref | Google Scholar |
36 Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357: 762-74.
| Crossref | Google Scholar | PubMed |
37 Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983; 74: 14-22.
| Crossref | Google Scholar |
38 Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol 1991; 29: 297-301.
| Crossref | Google Scholar |
39 Cauci S, Driussi S, De Santo D, et al. Prevalence of bacterial vaginosis and vaginal flora changes in peri- and postmenopausal women. J Clin Microbiol 2002; 40: 2147-52.
| Crossref | Google Scholar | PubMed |
40 Hoffmann JN, You HM, Hedberg EC, Jordan JA, McClintock MK. Prevalence of bacterial vaginosis and Candida among postmenopausal women in the United States. J Gerontol B Psychol Sci Soc Sci 2014; 69(Suppl 2): S205-S214.
| Crossref | Google Scholar | PubMed |