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What Should My Vaginal pH Be During Menopause?

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At a glance

  • Lactobacilli-dominated pH / average 3.5, range 2.8 to 4.2 [1]
  • Estrogen deficiency / raises vaginal pH [2]
  • Ospemifene trial entry / vaginal pH above 5.0 [3]
  • Estradiol vaginal tablets / lowered pH versus placebo over 12 weeks [4]
  • Vaginal DHEA / pH 0.66 unit lower than placebo at 12 weeks [5]
  • GSM prevalence / 27% to 84% of postmenopausal women [6]
  • Recurrent UTI / vaginal estrogen reduced UTIs in two small trials; oral estrogen did not [7]

Is there a normal vaginal pH after menopause?

In 56 women selected for a lactobacillus-dominated vaginal microbiota and no reproductive-tract symptoms, average vaginal pH was 3.5 (range 2.8 to 4.2) [1]. After menopause, estrogen deficiency raises vaginal pH [2]. In the phase 3 ospemifene trial for vulvovaginal atrophy, women had to have a vaginal pH above 5.0 to enroll [3]. Up to 40% of postmenopausal women have symptoms of atrophic vaginitis [2].

Why does pH rise?

Lactobacilli produce lactic acid, and lactic acid at acidic pH is microbicidal [1]. Estrogen deficiency increases vaginal pH, and the thinned tissue and higher pH predispose the vagina and urinary tract to infection and mechanical weakness [2]. The term for the resulting symptoms and signs is genitourinary syndrome of menopause, or GSM; it includes dryness, burning, lack of lubrication, pain with sex and recurrent urinary tract infections [8]. GSM affects about 27% to 84% of postmenopausal women [6].

What lowers pH in trials?

Low-dose vaginal estrogen: in a randomized trial of 230 postmenopausal women, estradiol vaginal tablets at 10 mcg and 25 mcg lowered pH more than placebo over 12 weeks [4].

Vaginal DHEA: in a phase 3 trial with 157 women on placebo and 325 on DHEA, 6.5 mg daily for 12 weeks lowered pH by 0.66 unit more than placebo [5].

Ospemifene: in a phase 3 trial of 826 women with vaginal pH above 5.0, ospemifene 60 mg was superior to placebo on pH and the other coprimary endpoints at 12 weeks [3].

NAMS recommends low-dose vaginal estrogen, vaginal DHEA or oral ospemifene for bothersome GSM not relieved by over-the-counter products [9]. Long-term endometrial safety data are lacking for vaginal estrogen, vaginal DHEA and ospemifene [6].

Does higher pH mean symptoms?

In 1,017 postmenopausal women, each 0.5-unit higher vaginal pH was associated with painful intercourse (OR 1.10, 95% CI 1.00 to 1.21) [10]. At baseline, about half reported problematic vaginal dryness and a third reported itching [10].

Recurrent UTI is part of GSM [8]. In a Cochrane review of 9 trials and 3,345 women, oral estrogens did not reduce UTI (RR 1.08, 95% CI 0.88 to 1.33); vaginal estrogens reduced UTI in two small studies (RR 0.25 and 0.64) [7].

What about moisturizers and douching?

NAMS lists vaginal lubricants and moisturizers among GSM options [6]. A small open-label study of 15 women per group found a nonhormonal vaginal moisturizer and vaginal estrogen cream both increased vaginal moisture, fluid volume and elasticity, with a return of the premenopausal pH state [11].

Douching alters vaginal flora and is associated with bacterial vaginosis [13].

Frequently asked questions

What is a normal vaginal pH after menopause?
In women with lactobacillus-dominated flora and no symptoms, average pH is about 3.5, range 2.8 to 4.2 [1]. Estrogen deficiency raises pH after menopause [2], and the ospemifene trial required pH above 5.0 [3].
Does vaginal estrogen lower pH?
In a trial of 230 postmenopausal women, 10 mcg and 25 mcg estradiol vaginal tablets lowered pH more than placebo over 12 weeks [4]. NAMS recommends low-dose vaginal estrogen for bothersome GSM not relieved by over-the-counter products [9].
How much does vaginal DHEA lower pH?
In a phase 3 trial of 482 women, 6.5 mg DHEA daily for 12 weeks lowered pH by 0.66 unit more than placebo [5].
Is higher vaginal pH linked to symptoms?
In 1,017 postmenopausal women, each 0.5-unit higher pH was associated with painful intercourse (OR 1.10, 95% CI 1.00 to 1.21) [10]. Recurrent UTI is part of GSM [8], and vaginal estrogen reduced UTI in two small trials while oral estrogen did not [7].

References

  1. O'Hanlon DE, Moench TR, Cone RA. Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota. PLoS One. 2013;8(11):e80074. Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota
  2. Bachmann GA, Nevadunsky NS. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician. 2000;61(10):3090-6. Diagnosis and treatment of atrophic vaginitis
  3. Bachmann GA, Komi JO, Ospemifene Study Group. Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study. Menopause. 2010;17(3):480-6. Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study
  4. Bachmann G, Lobo RA, Gut R, Nachtigall L, Notelovitz M. Efficacy of low-dose estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Obstet Gynecol. 2008;111(1):67-76. Efficacy of low-dose estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial
  5. Labrie F, Archer DF, Koltun W, Vachon A, Young D, Frenette L, et al. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2016;23(3):243-56. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause
  6. The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society
  7. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev. 2008;2008(2):CD005131. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women
  8. Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):1063-8. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society
  9. “The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. The 2022 hormone therapy position statement of The North American Menopause Society
  10. Huang AJ, Moore EE, Boyko EJ, Scholes D, Lin F, Vittinghoff E, et al. Vaginal symptoms in postmenopausal women: self-reported severity, natural history, and risk factors. Menopause. 2010;17(1):121-6. Vaginal symptoms in postmenopausal women: self-reported severity, natural history, and risk factors
  11. Nachtigall LE. Comparative study: Replens versus local estrogen in menopausal women. Fertil Steril. 1994;61(1):178-80. Comparative study: Replens versus local estrogen in menopausal women
  12. Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev. 2015;2015(12):CD008772. Probiotics for preventing urinary tract infections in adults and children
  13. Cottrell BH. An updated review of of evidence to discourage douching. MCN Am J Matern Child Nurs. 2010;35(2):102-7; quiz 108-9. An updated review of of evidence to discourage douching
Evidence overview for What Should My Vaginal pH Be During Menopause?