Bacterial Vaginosis Diagnosis and Treatment in Postmenopausal Women

A Survey of Clinician Practices

Katrina S. Mark, MD; Beatriz Tenorio, MD; Christina A. Stennett, MPH; Khalil G. Ghanem, MD, PhD; Rebecca M. Brotman, PhD, MPH


Menopause. 2020;27(6):679-683. 

In This Article

Abstract and Introduction


Objective: Some diagnostic features of the genitourinary syndrome of menopause (GSM) and bacterial vaginosis (BV) overlap, such as low levels of vaginal Lactobacillus and pH > 5. We sought to determine clinicians' diagnostic and treatment practices for postmenopausal women presenting with BV and GSM scenarios and how commercial molecular screening tests are utilized.

Methods: Anonymous surveys were sent to practicing women's health clinicians to evaluate assessment and treatment strategies for postmenopausal women presenting with BV and GSM scenarios.

Results: When given a scenario of a postmenopausal woman with symptoms overtly positive for BV, a majority of providers (73%) would conduct a wet mount, though only 35% would evaluate full Amsel's criteria. A majority (89%) recommended treatment with antibiotics, 28.2% recommended vaginal estrogen in addition to antibiotics, and 11.8% recommended vaginal estrogen alone. Of providers who would use a molecular swab, 30% would wait for results before treating the patient's symptoms. When given a scenario of a postmenopausal woman presenting with GSM, a majority (80%) recommended vaginal estrogen, and only 4.6% recommended antibiotics. Few (16%) responders would evaluate with a molecular swab, half of whom would wait for results before prescribing treatment. Clinicians in practice for less than 10 years were more likely to rely on molecular swabs than those who had been practicing longer (P < 0.0003).

Conclusions: Methods used to evaluate postmenopausal women with vaginal symptoms vary. Future studies of postmenopausal women that differentiate diagnostic criteria between BV and GSM, and validate commercial molecular testing for BV in women over age 50 are needed.


Bacterial vaginosis (BV) is characterized, in part, by low relative abundance of key Lactobacillus spp. and high levels of anaerobic and facultative bacteria.[1] The common presenting symptoms of BV are abnormal vaginal discharge and fishy odor, although half of women with BV are asymptomatic.[2] Among reproductive-age women, BV has a US prevalence of 29% and is a common cause of abnormal vaginal discharge.[3,4] Reports of BV prevalence in postmenopausal women vary more widely (5.4%-38%), likely because the standard criteria for diagnosis are more relevant for premenopausal women.[4–9]

Several modalities are available for diagnosis of BV. Although rarely used in the clinical setting, Nugent's method of Gram stain scoring is a standardized classification system for identifying BV samples based on morphology.[8] Amsel's clinical criteria, which can be performed as point-of-care testing, is more commonly used by clinicians due to its ease and immediacy of results that can aid in management decisions. Amsel's criteria has moderate reproducibility compared with Nugent scoring, with sensitivity ranging from 37% to 70% and specificity ranging from 94% to 99%.[10] Where Amsel's criteria relies on symptoms, clinical evaluation, in-office microscopy, and pH testing for determination of BV, Gram-stain scoring requires a sample to be sent to a laboratory for microscopy. Nugent scoring is typically only used in research settings and provides only morphological information, which provides limited insight into the composition of the vaginal microbiota.

Nucleic acid amplification tests (NAAT) for vaginitis (vulvovaginal candidiasis and BV) have emerged and are becoming increasingly used in clinical applications. As an infectious correlate has not been identified in BV, these nucleic acid tests quantify loads for a panel of various bacteria, including Gardnerella vaginalis, Atopobium vaginae, BV-associated bacteria (BVAB), and others such as Megaspharea phylotype 1 and 2. The tests may also distinguish multiple types of Lactobacillus spp. including Lactobacillus crispatus, Lactobacillus gasseri, and Lactobacillus jensennii.[10] The tests report either binary positive/negative or a risk category of low/moderate/high risk for BV with certain Lactobacillus species being protective against BV diagnosis and the other bacteria as more indicative of BV.

The diagnosis and treatment of BV in postmenopausal women is not standardized. The vaginal microbiota in postmenopausal women is known to have a different makeup compared with reproductive-aged women. In general, postmenopausal women have lower levels of estrogen and glycogen in the vaginal mucosa, and also thinner vaginal epithelium, lower levels of Lactobacillus, and higher microbial diversity and higher vaginal pH.[11–15] However, 20% to 50% of postmenopausal women do retain Lactobacillus spp.[16,17] Given that the natural physiology of aging can mimic some of the same changes seen in BV, the validity of the standard diagnostic criteria in postmenopausal women is unclear. The original studies that developed both the Nugent scoring and Amsel's criteria—the two most commonly accepted forms of diagnosis for research and clinical purposes—excluded menopausal women. As one of these two methods are used as the standard diagnostic criteria against which all subsequently developed diagnostic tools are compared and validated, the optimal method for diagnosing BV in postmenopausal women is unknown. The utility of the Nugent scoring system in postmenopausal women has recently been called into question, given that many women will have an abnormal score with no pathology or symptoms detectable.[4,6] In benchmarking of NAAT studies for BV, postmenopausal women were either explicitly excluded or represented a small proportion and were not analyzed separately.[18–23] Consequently, it is unclear how molecular diagnostics tests for BV are utilized in postmenopausal women.

We sought to survey healthcare practitioners who treat menopausal women to determine their practice patterns regarding diagnostic approaches, and specifically, use of molecular assays for detection of BV in postmenopausal women.