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UTI risk increases with menopause. Here's what you can do about it

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Many women find themselves getting more UTIs as they get older. UTIs are not only painful, they can even lead to sepsis and delirium. It’s an easily preventable problem, yet many women in perimenopause or menopause end up with recurring infections, hospitalization, or life-threatening infections.

Vaginal estrogen cream is among the highly effective treatments that can be prescribed by a medical practitioner like a board-certified doctor here at Interlude. And if you’re curious about antibiotics or other strategies for preventing UTIs, we’ll cover those as well!

Skip to what you need to know:

UTI infection in older women | UTI menopause symptoms | Medications for UTIs | Vaginal estrogen cream for UTI prevention | How to apply vaginal estrogen cream | Antibiotics for UTI prevention | Other options for UTI prevention | Getting the help you need

What causes UTI infection in older women?

If you find yourself getting more UTIs as you get older, then you’re probably not doing anything to cause the UTI. After menopause, it’s rarely sexual activity or poor hygiene that leads to UTIs. Instead, the risk of UTIs is probably due to the drop in estrogen levels that happens around the time of menopause.

What does menopause have to do with UTI risk?

Women are already more prone to UTIs than men, since the urethra is closer to the anus. But when estrogen levels decline around the time of menopause, UTIs are even more likely to occur. The lack of estrogen in the vaginal environment alters the vaginal microbiome which increases UTI risk.

Before menopause, your body produces estrogen which helps the cells in the vagina produce glycogen, which in turn feeds lactobacillus, a beneficial bacteria that acts as a defense against infections. When estrogen levels drop, this defense mechanism weakens, making women more susceptible to UTIs through menopause and well beyond.

What are menopause UTI symptoms?

Menopause UTI symptoms include all the classic signs of a UTI. For example, UTI symptoms in menopause can include the sudden need to urinate, plus pain and burning during urination.

And it’s not just urinary issues like UTIs that arise during menopause. As estrogen levels decline, significant changes to the vagina, bladder, urethra, and vulva can occur. And many of these symptoms can seem like UTIs. The skin in and around the vagina loses moisture and elasticity and this can lead to problems like pain during intimacy, diminished orgasms, loss of libido, and everyday discomfort. Many women can also experience increased urinary urgency or urinary frequency. You may also notice an unusual vaginal odor or an increased vaginal pH.

Medications for UTIs

A UTI infection can be cured with medications like antibiotics. But the pain of ongoing UTIs can wreak havoc on your health and well-being. UTIs are chronic or recurrent if you have three or more UTIs in one year. If your symptoms are recurrent, a medical practitioner, such as a board-certified doctor at Interlude can help you determine if prevention strategies like vaginal estrogen may be appropriate.

Vaginal estrogen cream for UTI prevention

One of the benefits of vaginal estrogen cream is that it restores your body's natural defense against UTIs by bringing vaginal microbiome and vaginal pH back to healthy levels.(1, 2) And if you’re experiencing vaginal dryness, incontinence, or pain with sex, vaginal estrogen therapy will help with that too!

The American Urological Society recommends that clinicians offer vaginal estrogen to all perimenopausal and postmenopausal women with recurrent UTIs.(3) And the Menopause Society supports vaginal estrogen as a safe and effective treatment for menopause-related vaginal and urinary symptoms, including UTIs.(4)

Numerous studies support the use of vaginal estrogen for UTI prevention. For example, in one study published in the American Journal of Obstetrics and Gynecology in 2023, researchers reported that women with an average age of 70 reduced their rate of UTIs by more than half after a year of using vaginal estrogen.(5)

Despite the proven benefits of vaginal estrogen therapy, there remains a gap in awareness and accessibility. Many women are understandably concerned about the link between estrogen and health risks like cancer and heart disease. This hesitancy is increased by the fact that vaginal estrogen products carry warnings about risks that are relevant only to oral estrogens.

However, vaginal estrogen therapy does not have the same risks as oral estrogens. The medication is applied to the vagina in very small doses and is released only into the nearby areas. This targeted approach directly addresses the changes in the vaginal microbiome without significantly affecting the rest of the body.

If you have recurrent UTIs and are already taking systemic estrogen in the form of a pill or patch, you can and should still be offered vaginal estrogen therapy. There is no increase in health risks. However, systemic estrogen therapy alone is not recommended to treat recurrent UTIs.

Most women can safely take vaginal estrogen therapy. There is no age limit. And it can be used for as long as you wish to prevent symptoms. If you’re curious to know more, we’ve created a complete guide to the side effects, risks, and benefits of vaginal estrogen.

How to apply estrogen cream for UTIs

The standard dose of vaginal estrogen cream is 2-4 grams daily for about two weeks, followed by 1 gram one to three times a week for as long as you wish to prevent symptoms.(6)

Vaginal estrogen cream comes with a tampon-like applicator that’s inserted about one inch into the vaginal opening and helps push the medication into the vaginal area.

Sometimes, specific placement of the cream around the affected areas can be more helpful. With a fingertip, vaginal cream can be spread around the opening of the vagina, around the urethra, and immediately inside the opening of the vagina.

The most important thing is to be consistent. It may take about 2-3 months to experience the benefits of vaginal estrogen for UTI prevention. With consistent use of vaginal estrogen, you can significantly reduce your risk of UTIs.

Low-dose antibiotics for UTI prevention

It’s not uncommon for women with recurrent UTIs to be offered a long-term course of low-dose antibiotics to prevent UTIs.

However, long-term use of antibiotics will probably cause unwanted problems in the future. Antibiotics can destroy any protective bacteria that may exist in the vaginal microbiome and can also create antibiotic resistance.

If you experience frequent UTIs in perimenopause or menopause, then antibiotics will usually help clear an infection. But if you want to prevent UTIs long-term, then vaginal estrogen therapy is probably the way to go.

Other ways you can prevent UTIs

Vaginal estrogen is available as a cream, suppository, or ring. In a scientific review of the clinical data, there was no evidence to show that the cream was more effective than the suppository or ring at preventing UTIs.(7) At Interlude, we find that most patients choose vaginal estrogen cream because it costs less than the suppositories or rings and is easy to use.

For women who don’t feel comfortable taking vaginal estrogen, other treatments such as vaginal DHEA are available. Vaginal DHEA is available by prescription, and it’s used to treat menopause-related vaginal and urinary symptoms including UTIs.

Whether you’re considering vaginal estrogen or not, lifestyle changes might help. There isn’t a lot of research on effectiveness for postmenopausal women, but staying hydrated, drinking cranberry juice, and considering the use of UTI-specific probiotics may also support your urinary health.

Next steps

Menopause is inevitable. But suffering from recurrent UTIs is avoidable. At Interlude, we can help you avoid UTIs and other uncomfortable vaginal and urinary symptoms that come with menopause.

If you want to give vaginal estrogen therapy a try, then it’s worth speaking to a medical professional, and a board-certified doctor here at Interlude can help. If you’re not sure where to start, browse our treatment options, take our quiz, and learn about how to get connected with a doctor, including NAMS-certified practitioners, here at Interlude.

Disclaimer: This information isn't a substitute for professional medical advice, diagnosis, or treatment. You should never rely upon this article for specific medical advice. If you have any questions or concerns, please talk to your doctor.
References
1. Galhardo CL, Soares JM, Simoes RS, Haidar MA, Rodrigues de Lima G, Baracat EC. 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.
2. Heineman C, Reid G. Vaginal microbial diversity among postmenopausal women with and without hormone replacement therapy. Can J Microbiol 2005;51:777-781.
3. American Urological Association. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. American Urological Association. 2022. Available at: https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti.
4. The North American Menopause Society. Genitourinary Syndrome of Menopause (GSM) Position Statement. The North American Menopause Society. 2020. Available at: https://www.menopause.org/docs/default-source/default-document-library/2020-gsm-ps.pdf.
5. Tan-Kim J, Shah NM, Menefee SA. Efficacy of vaginal estrogen for recurrent urinary tract infection prevention in hypoestrogenic women. American Journal of Obstetrics & Gynecology. 2023;229(2):143.E1-143.E9.
6. Estrace package insert.
7. Rahn D, Carberry C, Sanses TV et al: Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol 2014;124;1147.
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