Vaginal Health After the Menopause: UTIs, Dryness and Smell

After the menopause, falling oestrogen thins the lining of the vagina and the urethra, the lactobacilli that keep the vagina acidic fall away and the pH rises. In a two-year study of 750 women, low-lactobacillus communities were found at 21% of check-ups before the menopause and 50% after it.¹ The results are dryness and soreness, pain during sex, a "musty" smell, urgency, repeated urinary infections, and "thrush" that every swab says is not thrush: together, the genitourinary syndrome of menopause.² The treatment with the strongest evidence is vaginal oestrogen, a low-dose local medicine distinct from HRT: in the Cochrane review of 30 trials and 6,235 women every form improved symptoms, and in a 1993 trial it cut urinary infections from 5.9 to 0.5 a year.^{3, 4} It sits beside the Wellgard guide to what causes BV, because much of what feels like BV after 50 is not.

Sources checked on 29 October 2026.

Why does vaginal health change after the menopause?

Oestrogen keeps the vaginal lining thick and stocked with glycogen, which lactobacilli ferment into the lactic acid that holds the pH near 4. When oestrogen falls, the lining thins, the glycogen goes and the pH rises above 5.⁴ In an 87-woman study, the 19 women with signs of atrophy had far higher odds of a low-lactobacillus community than of one dominated by Lactobacillus crispatus (a very wide uncertainty range), and in the 750-woman cohort L. crispatus dominance after the menopause cut the odds of atrophy by three-quarters.^{1, 5} The same thinning affects the urethra, so bladder symptoms arrive with the vaginal ones; the NHS lists dryness, burning, irritation, painful sex, more frequent UTIs and needing to pee more often among menopause symptoms.⁶

Why do older women get so many UTIs?

Three reasons, all downstream of oestrogen: the urethral lining thins, the lactobacilli that used to crowd out E. coli near the urethra are gone, and the bladder empties less completely.⁴ The NHS defines recurrent UTI as two in six months or three in a year, and says a GP may offer a low-dose antibiotic for up to six months, an oestrogen-containing vaginal product in or after the menopause, or a non-antibiotic tablet.⁷ The evidence for the oestrogen option: in a 1993 randomised trial of 93 post-menopausal women, vaginal oestriol cream brought lactobacilli back in 61% and cut infections from 5.9 to 0.5 a year.⁴ A UK trial of 240 women found methenamine hippurate, a non-antibiotic prescription tablet, no worse than daily antibiotics; NICE lists it as an option.^{8, 19} Red flags: fever, shivering, back or side pain, blood in the urine, being sick, new confusion, or no improvement after 48 hours mean a GP or 111 the same day, and 999 for signs of sepsis.⁷ Cystitis, self-care for a UTI and recurrent UTIs under 50 cover the rest.

Dryness, soreness and "thrush" that isn't thrush

Atrophy itches, burns and stings when urine passes, exactly as thrush does. The NHS tells women over 60 with thrush symptoms to see a GP rather than a pharmacist, and a negative swab in a woman past the menopause points towards atrophy.^{2, 9} The signs: dryness every day rather than in episodes, pain or small splits during sex, light bleeding after sex, and no response to antifungals.² Is it thrush, BV or something else? puts atrophy, lichen sclerosus and the infections in one table; itching and soreness at any age and discharge changes at any age cover the years before. Can a 60-year-old woman still get wet? Yes: less lubrication is a symptom of the syndrome, not an end to arousal, and vaginal oestrogen improves the symptoms themselves.^{2, 3}

Smell and BV-like symptoms after the menopause

A "musty" or "stale" smell after the menopause is not necessarily BV. With fewer lactobacilli the vagina is less acidic and the discharge changes,¹ and small amounts of urine leakage, which the NHS lists among menopause symptoms, add their own smell.⁶ BV does occur after the menopause, fishy, thin and grey, and the treatment is the same antibiotic (how BV is treated in the UK).

Vaginal oestrogen: what it is, how it differs from HRT, and why it is a GP or pharmacist conversation

Vaginal (local) oestrogen is a small dose of oestrogen placed in the vagina as a cream, pessary, tablet or ring, absorbed into the tissue with very little reaching the bloodstream. HRT is the body-wide dose; the NHS notes that oestrogen is also used as a cream or pessary for vaginal dryness, soreness and urinary symptoms after the menopause.¹¹ In the 2016 Cochrane review of 30 randomised trials with 6,235 women, cream, pessary, tablet and ring all improved atrophy symptoms with no clear difference between them; against placebo, the odds of reporting improvement were about 13 times higher in one trial of 67 women.³ The trials ran at least 12 weeks, so allow that long; NICE says symptoms often return when it is stopped, and it can be restarted.^{3, 20} Since 2022 a low-dose oestradiol vaginal tablet has been available from UK pharmacies without a prescription for women aged 50 and over who have not had a period for at least a year, supplied after a pharmacist consultation.¹² Women with a history of breast cancer discuss it with their specialist.²⁰

Moisturisers and lubricants

The NHS self-help list: a water-based lubricant before sex, a vaginal moisturiser used regularly inside the vagina, unperfumed soap or none on the vulva, and no perfumed washes, douches or creams meant for elsewhere.¹⁰ Lubricants act during sex; moisturisers hold water in the tissue for days and are used regularly, with or without sex.¹⁰ Vaginal dryness at any age covers the other causes.

Pelvic floor training

The NHS programme is at least eight pelvic floor contractions, three times a day, for at least three months, taught by a specialist.¹³ In a 2026 randomised trial of 58 post-menopausal women with genitourinary symptoms, eight weeks of supervised pelvic floor training added to education reduced vulvovaginal and urinary symptoms and the impact of incontinence more than education alone.¹⁴

Live cultures after the menopause: one flora study, one UTI trial

The flora evidence is one 14-day study: 72 post-menopausal women with intermediate vaginal flora took two specific lactobacillus strains by mouth or placebo, and the Gram-stain score of the vaginal flora improved by two or more grades in 60% against 16%.¹⁵ For recurrent UTIs, a year-long trial in 252 post-menopausal women found live cultures short of a daily antibiotic (3.3 against 2.9 infections) but without its rise in resistance; the 2015 Cochrane review found no significant effect against placebo.^{16, 17} Which menopause supplements have evidence? covers the rest.

When to see a GP

Bleeding after the menopause, including after sex, always means a GP visit: usually atrophy, always checked.¹⁰ Also: dryness or soreness that self-help has not eased in a few weeks, any new discharge, UTI symptoms with the red flags above or two infections in six months, an itch with white patches or skin changes, pain during sex, and any lump or ulcer on the vulva.

What we don't know

Whether live cultures change any symptom after the menopause: the one flora study lasted 14 days and scored a Gram stain, not dryness or smell.¹⁵ Whether pelvic floor training keeps helping genitourinary symptoms beyond eight weeks: one trial of 58 women, no longer follow-up.¹⁴ Whether the low-dose pharmacy tablet cuts urinary infections as the 1993 oestriol cream did: no trial has tested it.^{4, 12}

Frequently asked questions

Is vaginal oestrogen safe?

The dose is small and local, with little reaching the bloodstream, which is why the MHRA allows one form to be sold from pharmacies after a pharmacist consultation.^{12, 20}

Why does a UTI cause confusion in an older woman, and is it permanent?

The NHS lists sudden confusion (delirium) as a possible UTI symptom in frail older people with memory problems such as dementia, and in four studies antibiotics did not improve it without infection signs.^{7, 18} Delirium is acute, not permanent; new confusion is a same-day GP or 111 call.

Why does a 60-year-old woman get UTIs after sex?

Thinner urethral tissue, fewer lactobacilli and less complete emptying; passing urine after sex, a lubricant, and the GP conversation about vaginal oestrogen are the measured responses.^{4, 7}

Sources

1. Shardell M, et al. Association of vaginal microbiota with signs and symptoms of the genitourinary syndrome of menopause across reproductive stages. Journals of Gerontology Series A, 2021. Two-year cohort, 750 women. PubMed 33903897.
2. Portman DJ, Gass MLS. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy. Menopause, 2014. PubMed 25160739.
3. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews, 2016. 30 trials, 6,235 women. PubMed 27577677.
4. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. New England Journal of Medicine, 1993. Randomised placebo-controlled trial, 93 women. PubMed 8350884.
5. Brotman RM, et al. Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy. Menopause, 2014. Cross-sectional study, 87 women. PubMed 24080849.
6. NHS. Menopause: symptoms. Reviewed 19 May 2026. nhs.uk/conditions/menopause/symptoms.
7. NHS. Urinary tract infections (UTIs). Reviewed 11 July 2025. nhs.uk/conditions/urinary-tract-infections-utis.
8. Harding C, et al. Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: the ALTAR randomised trial. BMJ, 2022. Randomised non-inferiority trial, 240 women, NIHR-funded. PubMed 35264408.
9. NHS. Thrush in men and women. Reviewed 28 July 2023. nhs.uk/conditions/thrush-in-men-and-women.
10. NHS. Vaginal dryness. Reviewed 24 July 2025. nhs.uk/conditions/vaginal-dryness.
11. NHS. Menopause: treatment. Reviewed 19 May 2026. nhs.uk/conditions/menopause/treatment.
12. MHRA. Reclassification of a low-dose vaginal oestradiol tablet to pharmacy supply, 20 July 2022. gov.uk.
13. NHS. Urinary incontinence: treatment. Reviewed 15 June 2023. nhs.uk/conditions/urinary-incontinence/treatment.
14. Taşkıran G, Taşkıran AT, Özgül S. Effects of pelvic floor muscle training combined with patient education in genitourinary syndrome of menopause: a randomized controlled trial. Menopause, 2026. Randomised trial, 58 women, eight weeks. PubMed 42808780.
15. Petricevic L, et al. Randomized, double-blind, placebo-controlled study of oral lactobacilli to improve the vaginal flora of postmenopausal women. European Journal of Obstetrics, Gynecology and Reproductive Biology, 2008. Placebo-controlled trial, 72 women, 14 days. PubMed 18701205.
16. Schwenger EM, Tejani AM, Loewen PS. Probiotics for urinary tract infections in adults and children (Cochrane review). Cochrane Database of Systematic Reviews, 2015. Nine trials, 735 people. PubMed 26695595.
17. Beerepoot MA, et al. Lactobacilli against daily antibiotics for recurrent UTIs: non-inferiority trial, 252 postmenopausal women. Archives of Internal Medicine, 2012. PubMed 22782199.
18. Stall NM, et al. Antibiotics for delirium in older adults with pyuria or bacteriuria: a systematic review. Journal of the American Geriatrics Society, 2024. Four studies, 652 adults. PubMed 38895992.
19. NICE NG112. Urinary tract infection (recurrent): antimicrobial prescribing, 1.2.8. Updated 12 December 2024. nice.org.uk.
20. NICE NG23. Menopause: identification and management, 1.5.5 to 1.5.15. Updated 15 April 2026. nice.org.uk.

This article is general information, not medical advice; nothing here recommends a medicine. Bleeding after the menopause is always checked by a GP.

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