UTIs and menopause: what’s the link?

From self-help measures to vaginal oestrogen, how to manage UTIs during the menopause

• More than half of women will experience a UTI at some point in their lifetime
• But what are UTIs, and why can they occur during the menopause?
• How vaginal oestrogen can help

Have an urge to wee more than usual, or experiencing pain or a burning sensation when going to the toilet?

Then you may have a urinary tract infection (UTI). UTIs affect more than half of women at some point in their lives, and new data shows UTIs have led to more than 800,000 hospital admissions in England over the past five years alone.

But what are UTIs, and how can they be connected to the menopause – and crucially, what can you do about them?

UTIs explained

UTI is an umbrella term for infections affecting your urinary tract, including your bladder (an infection known as cystitis), your urethra, (an infection known as urethritis), or your kidneys (an infection known as pyelonephritis).

Common symptoms include:

• Discomfort, pain or a stinging/burning sensation when you pass urine
• Needing to pass urine more frequently
• Feeling like you need to go to the toilet, even when your bladder is almost empty
• An ache in your lower tummy
• Cloudy, dark and/or strong-smelling urine, which may contain blood
• A high or unusually low temperature
• Confusion or heightened brain fog
• Fever, nausea and vomiting – if this happens it’s important to see a doctor

RELATED: More than ‘a little vaginal dryness’: how vaginal hormones can transform lives

What causes UTIs?

UTIs are usually caused by bacteria entering your urinary tract via your urethra, the tube which carries urine out of your body. Women have a shorter urethra than men, which means bacteria are more likely to reach your bladder or kidneys and cause an infection.

Things that increase the risk of bacteria getting into the bladder include pregnancy, sex, conditions blocking the urinary tract such as kidney stones, conditions that make it difficult to empty your bladder, urinary catheters (a tube in your bladder used to drain urine), having a weakened immune system, not drinking enough fluids and not keeping your genital area clean and dry.

What’s the link between UTIs and the menopause?

Your urinary tract is lined with cells that have receptors for oestrogen, progesterone, and testosterone on them, which use these hormones to keep your tissues strong and supple. Oestrogen has been shown to stimulate secretion of antimicrobial substances in your bladder and vaginal cells, which then improve immunity and reduce the risk of infections [3]. When these hormone levels fall during the perimenopause and menopause, your urinary tract lining can thin and your body’s ability to fight off bacteria is reduced, which can increase the risk of urinary-related symptoms and recurrent UTIs [4].

You may also experience thinning and soreness of the tissues around your vulva and vagina, and you change your wiping habits after using the toilet because it causes discomfort, which can also increase the chance of infection.

It can be common to experience symptoms of a UTI during the perimenopause and menopause even if you have no actual infection, due to the lack of hormones in your bladder and surrounding tissues.

I have a UTI. What should I do?

There are a few self-help measures that can help ease the symptoms of a UTI and reduce the risk of recurrence, including drinking plenty of water and avoiding caffeine, fizzy drinks or fruit juice, as these can make symptoms worse. Over the counter painkillers such as paracetamol or ibuprofen can help with any pain or high temperature.

When to see a doctor

If your symptoms persist, or you begin to feel unwell with fever, nausea or vomiting, you should contact your GP, as you may need to take antibiotics.

RELATED: Urinary incontinence in menopause: are you ignoring the symptoms?

How to prevent UTIs from occurring

• Aim to drink two litres of water each day and limit alcohol and sugary food and drink
• Wipe from front to back after using the toilet
• Keep your genital area clean and dry
• Try to go to the toilet after sex to flush away any bacteria
• Avoid perfumed products that can cause irritation
• Avoid tight-fitting synthetic underwear
• Avoid using condoms or diaphragms with spermicidal lube, use non-spermicidal lube instead.

What about hormones?

HRT replaces hormones throughout your body when levels fluctuate and fall during the perimenopause and menopause, and should bring relief to any urinary symptoms you are experiencing. There are also vaginal hormonal preparations available which just work locally in your vulva, vagina, bladder, and surrounding tissues. You should speak to your healthcare professional for an individualised conversation about what HRT would be best for your symptoms, medical history and personal preferences.

Vaginal hormones

Vulval, vaginal and urinary symptoms associated with the perimenopause and menopause, including UTIs and vaginal dryness, are collectively known as genitourinary syndrome of menopause (GSM). GSM symptoms can be particularly distressing; they often worsen with time and usually persist post-menopause. Despite GSM being very common and often having a very negative effect on women’s quality of life, it is still underdiagnosed and often treated too late, or not at all [5].

Often, women will respond very well to HRT, but symptoms associated with vaginal dryness and urinary symptoms like UTIs can still be an issue.

A very effective solution is to put oestrogen directly on the affected area [6,7]. This is known as ‘vaginal’, ‘topical’ or ‘local’ oestrogen, and is not the same as the oestrogen you take as part of your HRT; vaginal oestrogen treatments can be taken safely for a long time with no associated risks [8].

How do I use vaginal oestrogen?

There are two types of oestrogen used – oestradiol and oestriol – and three main ways to absorb it directly from your vagina and surrounding area.

The most common choice of vaginal oestrogen is a pessary, which is a small tablet you insert into your vagina, using an applicator. Brands include:

• Gina
• Imvaggis
• Vagifem
• Vagirux

Another option is inserting a cream or gel oestrogen into your vagina. Brands include:

• Blissel
• Estriol  
• Ovestin

A third way to use vaginal oestrogen is via an oestrogen ring, which is a soft silicon ring you insert inside your vagina. The ring’s centre releases a slow and steady dose of oestradiol over 90 days. You can find more about the Estring vaginal ring here.

What about other vaginal hormonal preparations?

Intrarosa (prasterone) is a daily pessary which contains a hormone called DHEA, which your body produces naturally. Once inserted into your vagina, this hormone is released and converted to both oestrogen and testosterone. It often works really well to improve symptoms and reduce the likelihood of UTIs occurring.

RELATED: What is Intrarosa and how do I use it?

Where can I find more information about UTIs during the menopause?

Newson Health’s Confidence in the Menopause Course includes a module based on a case study of a patient called Cathy, who is experiencing GSM symptoms. You can sign up for the course here.

We have also worked with the British Society for Sexual Medicine on a position statement for the treatment of GSM during the menopause, to help healthcare professionals in diagnosing and managing the condition. You can read the position statement here.

References

1. The Urology Foundation, ‘Urinary tract infections (UTIs)’
2. NHS Digital (2023) ‘Hospital admissions relating to urinary tract infections’
3. Beerepoot, M. A. et al. (2013), ‘Non – antibiotic prophylaxis for recurrent UTI; a systematic review and meta – analysis of RCTs, Journal of Urology, 190 (6), pp. 1981–9. doi:10.1016/j.juro.2013.04.142
4. Luthje, P., Browner, H., Ramos, N. L. et al. (2013), ‘Estrogen supports urothelial defense mechanisms’, Science Translational Medicine, 5 (190); 190ra80 doi:10.1126/scitranslmed.3005574
5. Kingsberg, S. A., Krychman, M., Graham, S., Bernick, B., Mirkin, S. (2017), ‘The women’s EMPOWER survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment’, Journal of Sexual Medicine, 4(3), pp. 413–24. doi:10.1016/j.jsxm.2017.01.010
6. Anger J. et al (2019),‘Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol. 2019 Aug;202(2):282-289. doi:10.1097/JU.0000000000000296
7. Palacios S., Combalia J., Emsellem C., Gaslain Y., Khorsandi D. (2020), ‘Therapies for the management of genitourinary syndrome of menopause’, Post Reproductive Health; 26 (1):32-42. doi:10.1177/2053369119866341
8. The NAMS 2020 GSM Position Statement Editorial Panel (2020), ‘The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society’, Menopause, 27 (9) pp. 976–92. doi:10.1097/GME.0000000000001609