Highlights
- •Vaginal lactobacilli are strongly associated with vaginal health in menopause.
- •Disruption in the vaginal microbiome correlates with vaginal symptoms of menopause.
- •Lactobacilli decrease along with menopause-related hormonal and epithelial changes.
- •Hormone replacement therapy can restore vaginal lactobacilli following menopause.
- •Probiotic therapies show promise in reinstating vaginal homeostasis in menopause.
Abstract
For over a century it has been well documented that bacteria in the vagina maintain
vaginal homeostasis, and that an imbalance or dysbiosis may be associated with poor
reproductive and gynecologic health outcomes. Vaginal microbiota are of particular
significance to postmenopausal women and may have a profound effect on vulvovaginal
atrophy, vaginal dryness, sexual health and overall quality of life. As molecular-based
techniques have evolved, our understanding of the diversity and complexity of this
bacterial community has expanded. The objective of this review is to compare the changes
that have been identified in the vaginal microbiota of menopausal women, outline alterations
in the microbiome associated with specific menopausal symptoms, and define how hormone
replacement therapy impacts the vaginal microbiome and menopausal symptoms; it concludes
by considering the potential of probiotics to reinstate vaginal homeostasis following
menopause. This review details the studies that support the role of Lactobacillus species in maintaining vaginal homeostasis and how the vaginal microbiome structure
in postmenopausal women changes with decreasing levels of circulating estrogen. In
addition, the associated transformations in the microanatomical features of the vaginal
epithelium that can lead to vaginal symptoms associated with menopause are described.
Furthermore, hormone replacement therapy directly influences the dominance of Lactobacillus in the microbiota and can resolve vaginal symptoms. Oral and vaginal probiotics hold
great promise and initial studies complement the findings of previous research efforts
concerning menopause and the vaginal microbiome; however, additional trials are required
to determine the efficacy of bacterial therapeutics to modulate or restore vaginal
homeostasis.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to MaturitasAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The microbiota of the vagina and its influence on women's health and disease.Am. J. Med. Sci. 2012; 343: 2-9
- Emerging role of lactobacilli in the control and maintenance of the vaginal bacterial microflora.Rev. Infect. Dis. 1990; 12: 856-872
- Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota.PLoS One. 2013; 8: e80074
- A persistent(ly) enigmatic ecological mystery: bacterial vaginosis.J. Infect. Dis. 2006; 193: 1475-1477
- Vaginal microbiome: rethinking health and disease.Annu. Rev. Microbiol. 2012; 66: 371-389
- Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. The vaginal infections and prematurity study group.N. Engl. J. Med. 1995; 333: 1737-1742
- A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections.N. Engl. J. Med. 1993; 329: 753-756
- Sexually transmitted infections in the older woman.Menopause Int. 2008; 14: 134-135
- Vaginal lactobacilli, microbial flora, and risk of human immunodeficiency virus type 1 and sexually transmitted disease acquisition.J. Infect. Dis. 1999; 180: 1863-1868
- Lifetime changes in the vulva and vagina.Arch. Gynecol. Obstet. 2006; 273: 195-202
- Vaginal microflora in postmenopausal women who have not received estrogen replacement therapy.Clin. Infect. Dis. 1997; 25: S123-6
- Prevalence of bacterial vaginosis and vaginal flora changes in peri- and postmenopausal women.J. Clin. Microbiol. 2002; 40: 2147-2152
- Prevalence and determinants of vaginal flora alterations in postmenopausal women.J. Infect. Dis. 2003; 188: 1054-1058
- Evaluation of the bacterial vaginal flora of 20 postmenopausal women by direct (Nugent score) and molecular (polymerase chain reaction and denaturing gradient gel electrophoresis) techniques.J. Infect. Dis. 2002; 186: 1770-1780
- Vaginal microbiome of reproductive-age women.Proc. Natl. Acad. Sci. U. S. A. 2011; 108: 4680-4687
- Understanding vaginal microbiome complexity from an ecological perspective.Transl. Res. 2012; 160: 267-282
- Temporal dynamics of the human vaginal microbiota.Sci. Transl. Med. 2012; 4: 132ra52
- Temporal variability of human vaginal bacteria and relationship with bacterial vaginosis.PLoS One. 2010; 5: e10197
- Quantitative bacteriology of the vaginal flora.J. Infect. Dis. 1977; 136: 271-277
- Influence of the normal menstrual cycle on vaginal tissue, discharge, and microflora.Clin. Infect. Dis. 2000; 30: 901-907
- Free glycogen in vaginal fluids is associated with Lactobacillus colonization and low vaginal pH.PLoS One. 2014; 9: e102467
- Diagnosis and clinical manifestations of bacterial vaginosis.Am. J. Obstet. Gynecol. 1988; 158: 819-828
- Vaginal flora and pelvic inflammatory disease.Am. J. Obstet. Gynecol. 1993; 169: 470-474
- Clinical diagnosis of bacterial vaginosis.Int. J. Gynaecol. Obstet. 2006; 94: 28-32
- Comparison of methods for diagnosing bacterial vaginosis among pregnant women.J. Clin. Microbiol. 1989; 27: 1266-1271
- The Lactobacillus flora in vagina and rectum of fertile and postmenopausal healthy Swedish women.BMC Womens Health. 2011; 11: 17
- Randomized, double-blind, placebo-controlled study of oral lactobacilli to improve the vaginal flora of postmenopausal women.Eur. J. Obstet. Gynecol. Reprod. Biol. 2008; 141: 54-57
- Qualitative and semiquantitative analysis of Lactobacillus species in the vaginas of healthy fertile and postmenopausal Chinese women.J. Med. Microbiol. 2012; 61: 729-739
- Differences in the vaginal lactobacilli of postmenopausal women and influence of rectal lactobacilli.Climacteric. 2013; 16: 356-361
- The recent review of the genitourinary syndrome of menopause.J. Menopausal Med. 2015; 21: 65-71
- Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women.Menopause. 2008; 15: 661-666
- Vaginal symptoms in postmenopausal women: self-reported severity, natural history, and risk factors.Menopause. 2010; 17: 121-126
- Detection of Atopobium vaginae in postmenopausal women by cultivation-independent methods warrants further investigation.J. Clin. Microbiol. 2004; 42: 1829-1831
- Bacterial vaginosis in climacteric and menopausal women.Int. J. STD AIDS. 2002; 13: 449-452
- Vaginal microbiome and epithelial gene array in post-menopausal women with moderate to severe dryness.PLoS One. 2011; 6: e26602
- Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy.Menopause. 2014; 21: 450-458
- Commonly used types of postmenopausal estrogen for treatment of hot flashes: scientific review.JAMA. 2004; 291: 1610-1620
- Novel insight into the vaginal microflora in postmenopausal women under hormone replacement therapy as analyzed by PCR-denaturing gradient gel electrophoresis.Eur. J. Obstet. Gynecol. Reprod. Biol. 2004; 117: 76-81
- Effect of bacterial vaginosis, Lactobacillus and Premarin estrogen replacement therapy on vaginal gene expression changes.Microbes Infect. 2008; 10: 620-627
- Vaginal flora in postmenopausal women: the effect of estrogen replacement.Infect. Dis. Obstet. Gynecol. 1993; 1: 94-97
- Vaginal microbial diversity among postmenopausal women with and without hormone replacement therapy.Can. J. Microbiol. 2005; 51: 777-781
- Estrogen effects on the vaginal pH, flora and cytology in late postmenopause after a long period without hormone therapy.Clin. Exp. Obstet. Gynecol. 2006; 33: 85-89
- Vaginal estrogen use and effects on quality of life and urogenital morbidity in postmenopausal women after publication of the Women's Health Initiative in New York City.Menopause. 2016; 23: 7-10
- Breast cancer survivorship: a comprehensive review of long-term medical issues and lifestyle recommendations.Perm. J. 2015; 19: 48-79
- Association of breast cancer and its therapy with menopause- related symptoms.Menopause. 2004; 11: 519-530
- Ultra-low-dose estriol and Lactobacillus acidophilus vaginal tablets (Gynoflor((R))) for vaginal atrophy in postmenopausal breast cancer patients on aromatase inhibitors: pharmacokinetic, safety, and efficacy phase I clinical study.Breast Cancer Res. Treat. 2014; 145: 371-379
- Vaginal estriol-lactobacilli combination and quality of life in endocrine-treated breast cancer.Climacteric. 2015; 18: 252-259
- Short term oral estriol treatment restores normal premenopausal vaginal flora to elderly women.Maturitas. 2001; 39: 253-257
- The use of two estrogen preparations (a combined contraceptive pill versus conjugated estrogen cream) intravaginally to treat urogenital symptoms in postmenopausal Thai women: a comparative study.Clin. Pharmacol. Ther. 1998; 64: 204-210
- Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and postmenopausal women.J. Sex Med. 2005; 2: 154-165
- Probiotics for the treatment of bacterial vaginosis.Cochrane Database Syst. Rev. 2009; 4: CD006289
- Bacteria in the vaginal microbiome alter the innate immune response and barrier properties of the human vaginal epithelia in a species-specific manner.J. Infect. Dis. 2014; 209: 1989-1999
- The vaginal and gastrointestinal microbiomes in gynecologic cancers: a review of applications in etiology, symptoms and treatment.Gynecol. Oncol. 2015; 138: 190-200
- Antimicrobial peptides in the female reproductive tract: a critical component of the mucosal immune barrier with physiological and clinical implications.Hum. Reprod. Update. 2015; 21: 353-377
- Improved understanding of the bacterial vaginal microbiota of women before and after probiotic instillation.Appl. Environ. Microbiol. 2003; 69: 97-101
- Ultra-low-dose estriol and lactobacilli in the local treatment of postmenopausal vaginal atrophy.Climacteric. 2013; 16: 347-355
Article info
Publication history
Published online: June 01, 2016
Accepted:
May 31,
2016
Received in revised form:
May 27,
2016
Received:
April 15,
2016
Identification
Copyright
© 2016 Elsevier Ireland Ltd. All rights reserved.
