https://www.cidrap.umn.edu/antimicr...-vaginal-estrogen-menopause-could-reduce-utis
‘Women don’t have to live in pain’: Vaginal estrogen in menopause could reduce UTIs, hospitalization
Meghan Holohan
Today at 11:19 a.m.
Antimicrobial Stewardship
It had been more than 30 years since she had a urinary tract infection (UTI), but Karen suspected that one was causing her frequent bathroom trips. She visited her gynecologist, but her urinary culture tested negative for infection. At the time, her doctor didn’t seem concerned by Karen’s discomfort.
“I was on my own,” Karen, 65, of Pittsburgh, told CIDRAP News. “Doing my own research, I upped my water intake and began taking a supplement called D-mannose. They kept my symptoms at bay.”
After Karen’s gynecologist retired, she visited a new one and described her symptoms. Following an exam, her doctor knew exactly what Karen was experiencing.
“She told me I had vaginal atrophy, but it was completely reversible with the usage of vaginal estrogen,” Karen said. “She assured me it would also alleviate the UTI symptoms, which it, in fact, did.”
Genitourinary syndrome of menopause
Karen’s experience is not unique. Declining estrogen levels during perimenopause and menopause make it more likely for women to experience a UTI. A feeling of urgency, UTIs, vaginal atrophy, pain with sex, and vaginal dryness fall under what’s called the genitourinary syndrome of menopause (GSM), which affects 13% to 87% of women, according to a 2024 editorial in the Annals of Internal Medicine.
She told me I had vaginal atrophy, but it was completely reversible with the usage of vaginal estrogen.
Karen
Unlike other symptoms of menopause that decline over time, GSM increases with age. And it can cause serious health complications such as kidney infections and sepsis. But there’s an underused way to prevent UTIs in women in menopause—vaginal estrogen.
“Vaginal estrogen helps by giving (back) the estrogen that is lacking, promoting the health of the tissue and the thickness of the tissue, maintaining the elasticity of the vagina,” Adi Katz, MD, director of Benign Gynecology at Lenox Hill Hospital in New York City, said. “(It) helps maintain a more healthy pH, which leads to maintaining the bio-flora of the vagina.”
Thinner, less-elastic tissues
Women’s hormonal changes in perimenopause affect many areas of the body, including the bladder and vagina.
“The pH rises, and that has to do with the way the estrogen stimulates the cells in both the vaginal area, but also in the urethra and in the base of the bladder,” Paul Tulikangas, MD, director of urogynecology at Hartford HealthCare and associate professor at the University of Connecticut, said. “When that happens, the normal bacteria that’s in the bladder … change.”
Healthy bacteria, lactobacilli, populate the vagina and the bladder of pre-menopausal women and play an important role in their health. “We’ve increasingly found that that bacteria is super helpful in preventing urinary tract infections,” Tulikangas said.
When the pH rises, it’s harder for lactobacillito survive, and its declinecontributes to an increased risk of UTIs. That loss of estrogen also changes the vagina, which can also contribute to UTIs.
“When you lose estrogen, tissues become thinner, less elastic, have less blood flow,” said Stephanie Faubion, MD, director of the Mayo Clinic Center for Women’s Health. “You have structural changes because the whole lower urinary tract becomes thinner, but you also have the change in the pH related to the microbiome change.” ‘
More and more suffering’
An occasional UTI makes life feel miserable for a week. But as women age, they often develop more frequent infections that can become dangerous.
Menopause management belongs in the hands of internal medicine, family medicine, because they’re the ones that take care of these women every day. They should be familiar with basic menopause care, and this is basic menopause care.
Stephanie Faubion, MD
“When you develop a urinary tract infection, you’re at increased risk of developing a recurrent urinary tract infection for the next few months, and that has to do with the inflammation in the tissue around the urethra and the bladder,” Tulikangas said. With recurrent UTIs women “go through more and more suffering.”
Women who have two UTIs within six months or three or more within a year are said to have recurrent UTIs, which “pose a significant healthcare burden with $6 billion spend on complicated UTIs in 2011,” according to a paper published in June in Urology. The high cost comes from the need to be hospitalized, because UTIs can lead to kidney infections and sepsis.
“The most serious complication you get from a urinary tract infection is that the infection would spread into your body,” Tulikangas said. ‘
This is basic menopause care’
As medical director of the Menopause Society, Faubion has long hoped that internal medicine and family practice physicians would start prescribing vaginal estrogen to their patients.
“I’ve been preaching this for years, as have many of my colleagues,” she said. “Menopause management belongs in the hands of internal medicine, family medicine, because they’re the ones that take care of these women every day. They should be familiar with basic menopause care, and this is basic menopause care.”
While gynecologists feel most comfortable prescribing menopause hormone therapy, Faubion said internal medicine and family practice doctors are “hopefully getting there.” Still, more work needs to be done.
“There’s a lack of awareness in general about the treatment options that are available for menopause, let alone treatment of genitourinary syndrome of menopause,” she added.
More widespread vaginal estrogen use could also bolster older women’s health. The study in Urology found that prescribing vaginal estrogen for women with recurrent UTIs lowered their rates of sepsis, hospitalization, and death for the next eight years.
“It’s been medically proven to decrease the risk of recurrent UTIs significantly from a relative risk of 6% down to a relative risk of less than 2%,” Katz said.
Until 2025, the Food and Drug Administration (FDA) had a black-box warning on vaginal estrogen, which cautioned of an increased risk of heart disease, breast cancer, and dementia. This frightened many women away from using it. But it’s prescribed at such a low dose that it contributes to fewer complications.
“There’s not an associated increased risk of breast cancer or heart disease,” Faubion said. “There may be a slight increased risk of blood clots associated with it. So there are some side effects.”
Lack of awareness
Vaginal estrogen is underused. A 2025 study in JAMA Network Open noted that only 9% of female Medicare recipients with GSM and a prescription for vaginal estrogen filled their prescription. But even women who fill their prescriptions struggle to use it.
“Not many women are continuing these medications at the end of a year,” Faubion said. “There seems to be barriers in terms of longer use.”
Unlike menopause hormone therapy, which is widely prescribed, vaginal estrogen suffers from public relations problem, with few women knowing what it is.
“Lack of awareness is a problem but also lack of awareness that there’s a separate product,” Faubion said. “Vaginal forms of estrogen are actually more effective in managing GSM symptoms than systemic estrogen is.”
As for Karen, she’s been using her vaginal estrogen consistently, applied internally and externally, twice weekly for five years. She often tells other women about it because it’s made such a huge difference for her.
“I tell anyone who will listen to me about its benefits,” she said. “It changed so much—UTIs, sex. Instead of feeling like, ‘Oh this is just a result of getting older,’ it made me realize that women don’t have to live in pain.”
‘Women don’t have to live in pain’: Vaginal estrogen in menopause could reduce UTIs, hospitalization
Meghan Holohan
Today at 11:19 a.m.
Antimicrobial Stewardship
In 2021, Karen, who asked that her last name not be used, was always running to the bathroom because of a burning sensation and the urge to urinate.It had been more than 30 years since she had a urinary tract infection (UTI), but Karen suspected that one was causing her frequent bathroom trips. She visited her gynecologist, but her urinary culture tested negative for infection. At the time, her doctor didn’t seem concerned by Karen’s discomfort.
“I was on my own,” Karen, 65, of Pittsburgh, told CIDRAP News. “Doing my own research, I upped my water intake and began taking a supplement called D-mannose. They kept my symptoms at bay.”
After Karen’s gynecologist retired, she visited a new one and described her symptoms. Following an exam, her doctor knew exactly what Karen was experiencing.
“She told me I had vaginal atrophy, but it was completely reversible with the usage of vaginal estrogen,” Karen said. “She assured me it would also alleviate the UTI symptoms, which it, in fact, did.”
Genitourinary syndrome of menopause
Karen’s experience is not unique. Declining estrogen levels during perimenopause and menopause make it more likely for women to experience a UTI. A feeling of urgency, UTIs, vaginal atrophy, pain with sex, and vaginal dryness fall under what’s called the genitourinary syndrome of menopause (GSM), which affects 13% to 87% of women, according to a 2024 editorial in the Annals of Internal Medicine.
She told me I had vaginal atrophy, but it was completely reversible with the usage of vaginal estrogen.
Karen
Unlike other symptoms of menopause that decline over time, GSM increases with age. And it can cause serious health complications such as kidney infections and sepsis. But there’s an underused way to prevent UTIs in women in menopause—vaginal estrogen.
“Vaginal estrogen helps by giving (back) the estrogen that is lacking, promoting the health of the tissue and the thickness of the tissue, maintaining the elasticity of the vagina,” Adi Katz, MD, director of Benign Gynecology at Lenox Hill Hospital in New York City, said. “(It) helps maintain a more healthy pH, which leads to maintaining the bio-flora of the vagina.”
Thinner, less-elastic tissues
Women’s hormonal changes in perimenopause affect many areas of the body, including the bladder and vagina.
“The pH rises, and that has to do with the way the estrogen stimulates the cells in both the vaginal area, but also in the urethra and in the base of the bladder,” Paul Tulikangas, MD, director of urogynecology at Hartford HealthCare and associate professor at the University of Connecticut, said. “When that happens, the normal bacteria that’s in the bladder … change.”
Healthy bacteria, lactobacilli, populate the vagina and the bladder of pre-menopausal women and play an important role in their health. “We’ve increasingly found that that bacteria is super helpful in preventing urinary tract infections,” Tulikangas said.
When the pH rises, it’s harder for lactobacillito survive, and its declinecontributes to an increased risk of UTIs. That loss of estrogen also changes the vagina, which can also contribute to UTIs.
“When you lose estrogen, tissues become thinner, less elastic, have less blood flow,” said Stephanie Faubion, MD, director of the Mayo Clinic Center for Women’s Health. “You have structural changes because the whole lower urinary tract becomes thinner, but you also have the change in the pH related to the microbiome change.” ‘
More and more suffering’
An occasional UTI makes life feel miserable for a week. But as women age, they often develop more frequent infections that can become dangerous.
Menopause management belongs in the hands of internal medicine, family medicine, because they’re the ones that take care of these women every day. They should be familiar with basic menopause care, and this is basic menopause care.
Stephanie Faubion, MD
“When you develop a urinary tract infection, you’re at increased risk of developing a recurrent urinary tract infection for the next few months, and that has to do with the inflammation in the tissue around the urethra and the bladder,” Tulikangas said. With recurrent UTIs women “go through more and more suffering.”
Women who have two UTIs within six months or three or more within a year are said to have recurrent UTIs, which “pose a significant healthcare burden with $6 billion spend on complicated UTIs in 2011,” according to a paper published in June in Urology. The high cost comes from the need to be hospitalized, because UTIs can lead to kidney infections and sepsis.
“The most serious complication you get from a urinary tract infection is that the infection would spread into your body,” Tulikangas said. ‘
This is basic menopause care’
As medical director of the Menopause Society, Faubion has long hoped that internal medicine and family practice physicians would start prescribing vaginal estrogen to their patients.
“I’ve been preaching this for years, as have many of my colleagues,” she said. “Menopause management belongs in the hands of internal medicine, family medicine, because they’re the ones that take care of these women every day. They should be familiar with basic menopause care, and this is basic menopause care.”
While gynecologists feel most comfortable prescribing menopause hormone therapy, Faubion said internal medicine and family practice doctors are “hopefully getting there.” Still, more work needs to be done.
“There’s a lack of awareness in general about the treatment options that are available for menopause, let alone treatment of genitourinary syndrome of menopause,” she added.
More widespread vaginal estrogen use could also bolster older women’s health. The study in Urology found that prescribing vaginal estrogen for women with recurrent UTIs lowered their rates of sepsis, hospitalization, and death for the next eight years.
“It’s been medically proven to decrease the risk of recurrent UTIs significantly from a relative risk of 6% down to a relative risk of less than 2%,” Katz said.
Until 2025, the Food and Drug Administration (FDA) had a black-box warning on vaginal estrogen, which cautioned of an increased risk of heart disease, breast cancer, and dementia. This frightened many women away from using it. But it’s prescribed at such a low dose that it contributes to fewer complications.
“There’s not an associated increased risk of breast cancer or heart disease,” Faubion said. “There may be a slight increased risk of blood clots associated with it. So there are some side effects.”
Lack of awareness
Vaginal estrogen is underused. A 2025 study in JAMA Network Open noted that only 9% of female Medicare recipients with GSM and a prescription for vaginal estrogen filled their prescription. But even women who fill their prescriptions struggle to use it.
“Not many women are continuing these medications at the end of a year,” Faubion said. “There seems to be barriers in terms of longer use.”
Unlike menopause hormone therapy, which is widely prescribed, vaginal estrogen suffers from public relations problem, with few women knowing what it is.
“Lack of awareness is a problem but also lack of awareness that there’s a separate product,” Faubion said. “Vaginal forms of estrogen are actually more effective in managing GSM symptoms than systemic estrogen is.”
As for Karen, she’s been using her vaginal estrogen consistently, applied internally and externally, twice weekly for five years. She often tells other women about it because it’s made such a huge difference for her.
“I tell anyone who will listen to me about its benefits,” she said. “It changed so much—UTIs, sex. Instead of feeling like, ‘Oh this is just a result of getting older,’ it made me realize that women don’t have to live in pain.”