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.

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. 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, with 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 and bladder neck, which is why 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. 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 tablets that act on the infection and its return.⁷ The evidence for the oestrogen option: in a 1993 randomised trial of 93 post-menopausal women with recurrent UTIs, vaginal oestriol cream brought lactobacilli back in 61% and cut infections from 5.9 to 0.5 per woman per year.⁴ A UK trial of 240 women found methenamine hippurate, a non-antibiotic prescription tablet, no worse than daily antibiotics, and NICE lists it as an alternative to antibiotic prophylaxis.⁸ 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: everything you need to know covers cranberry, D-mannose and the rest.

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

Atrophy itches, burns and stings when urine passes, which is exactly what 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 to atrophy until proved otherwise.⁹ The signs: dryness that is there every day rather than in episodes, pain or small splits during sex, light bleeding after sex, a thin yellowish discharge rather than a thick white one, and no response to antifungals. Is it thrush, BV or something else? puts atrophy, lichen sclerosus and the infections in one table. Can a 60-year-old woman still get wet? Yes: arousal lubrication slows and lessens with lower oestrogen but does not stop, and it takes longer; a water-based lubricant during sex and a vaginal moisturiser between times are the NHS's first suggestions, and vaginal oestrogen improves the symptoms themselves.^{3, 10}

Smell and BV-like symptoms after the menopause

A "musty" or "stale" smell after the menopause is usually not BV. With fewer lactobacilli the vagina is less acidic, the discharge changes, and small amounts of urine leakage, more common as the pelvic floor and urethra weaken, add their own smell. BV does occur after the menopause, with its fishy, thin, grey discharge, and the treatment is the same antibiotic; how BV is treated in the UK covers it. The difference matters because vaginal oestrogen, which brings lactobacilli back, may reduce a musty smell, while antibiotics act only on BV.

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 a body-wide dose for hot flushes and the rest; 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, and symptoms tend to return if it is stopped because the cause has not gone. 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 consultation in which the pharmacist works through a checklist.¹² Women with a history of breast cancer discuss it with their specialist.

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 for the hour; moisturisers hold water in the tissue for days and are used two or three times a week whether or not you have sex. Neither has been shown to restore the lining; both help alongside the medical options.

Pelvic floor training

Leaks, urgency and the "never feel clean" feeling have a muscular side. The NHS programme is at least eight pelvic floor contractions, three times a day, for at least three months, ideally taught by a specialist physiotherapist through an NHS continence service.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 One small trial, but it costs nothing.

Live cultures after the menopause: one small study, no symptom trial

The question women ask is whether taking live cultures brings the lactobacilli back. The evidence is one 14-day study: 72 post-menopausal women with intermediate vaginal flora took an oral capsule of two specific lactobacillus strains or placebo, and the Gram-stain score of the vaginal flora improved by two or more grades in 60% against 16%.¹⁵ Symptoms were not measured, nothing was followed beyond two weeks, and no trial has tested live cultures against dryness, smell or UTIs in post-menopausal women; for UTIs in women generally, the 2015 Cochrane review found no significant effect.¹⁶ Which menopause supplements have evidence? grades the rest of the shelf.

When to see a GP

Bleeding after the menopause, including after sex, is always a GP visit, promptly; it is usually atrophy, and it must be 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. Thrush symptoms over 60 go to a GP, not a pharmacist.⁹

Frequently asked questions

Is vaginal oestrogen safe?

The dose is small and local, with little reaching the bloodstream, which is why the MHRA allowed one form to be sold from pharmacies to women over 50 after a pharmacist consultation. Anyone with a history of breast cancer discusses it with their specialist.^{3, 12}

What are the benefits of vaginal oestrogen?

In the trials: less dryness, burning and pain during sex, a lower pH, lactobacilli returning in 61%, and fewer urinary infections (5.9 down to 0.5 a year in the 1993 trial).^{3, 4}

How long does vaginal oestrogen take to work?

The Cochrane trials ran at least 12 weeks; women often report change within a few weeks, and it is used long term because the cause continues.³

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

Thinner urethral tissue, fewer lactobacilli near the urethra 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. 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. 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. PubMed 8350884.
5. Brotman RM, et al. Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy. Menopause, 2014. PubMed 24080849.
6. NHS. Menopause: symptoms. nhs.uk/conditions/menopause/symptoms.
7. NHS. Urinary tract infections (UTIs). 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. PubMed 35264408.
9. NHS. Thrush in men and women. nhs.uk/conditions/thrush-in-men-and-women.
10. NHS. Vaginal dryness. nhs.uk/conditions/vaginal-dryness.
11. NHS. Menopause: treatment. nhs.uk/conditions/menopause/treatment.
12. MHRA. Easier access to locally-applied HRT to treat postmenopausal vaginal symptoms in landmark MHRA reclassification, 20 July 2022. gov.uk.
13. NHS. Urinary incontinence: treatment. 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. 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. 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. PubMed 26695595.

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