Synonyms
Vaginal estrogen therapy
Topical estrogen
Hormone replacement therapy (HRT)
Subdivisions
General Discussion
Recurrent urinary tract infections (rUTIs) are a significant concern for many women,
particularly after menopause. The decline in estrogen levels associated with menopause can
lead to changes in the urogenital tract, making it more susceptible to infections. Vaginal
estrogen therapy has been recognized as an effective non-antibiotic treatment option for
reducing the incidence and recurrence of UTIs in postmenopausal women.
How Vaginal Estrogen Prevents UTIs:
1. Restoring the Normal Vaginal Flora:
● Before menopause, the vagina naturally has a healthy balance of bacteria,
known as vaginal flora. One of the key players in this balance is a type of
bacteria called Lactobacillus. These bacteria help keep the vaginal
environment slightly acidic, which prevents harmful bacteria from growing.
● After menopause, the body produces less estrogen, which can disrupt this
balance. With lower estrogen levels, Lactobacillus bacteria decrease, and the
vaginal environment becomes less acidic. This makes it easier for harmful
bacteria to thrive and potentially travel up into the urinary tract, leading to
infections.
● Vaginal estrogen therapy helps by restoring estrogen levels in the vaginal
tissue, encouraging the growth of Lactobacillus. This restores the acidic
environment that helps protect against harmful bacteria, reducing the
likelihood of a UTI.
2. Increasing Glycogen Production:
● Estrogen also helps the vaginal cells produce glycogen, a type of sugar that
Lactobacillus bacteria feed on. When there is more glycogen, Lactobacillus
can grow and thrive, which in turn keeps harmful bacteria in check. 2
● By boosting glycogen production through vaginal estrogen therapy, the
vaginal environment becomes more supportive of healthy bacteria, which
helps protect against UTIs.
3. Maintaining the Thickness of the Vaginal Epithelium:
● The vaginal epithelium is the outer layer of cells lining the vagina. Estrogen
plays a crucial role in keeping this layer thick and healthy. A thicker epithelium is better at providing a physical barrier that prevents harmful bacteria from
entering the urinary tract.
● After menopause, without enough estrogen, the vaginal epithelium becomes
thinner and more fragile, making it easier for bacteria to penetrate and cause
infections.
● Vaginal estrogen therapy helps to maintain and even rebuild the thickness of
this protective layer, which reduces the risk of harmful bacteria entering the
urinary tract and causing a UTI.
Signs & Symptoms
Common symptoms of rUTIs include dysuria, urinary frequency, urgency, and suprapubic
pain. Postmenopausal women experiencing these symptoms, particularly those with vaginal
dryness or atrophy, may benefit from vaginal estrogen therapy. This treatment not only
alleviates the symptoms associated with vaginal atrophy but also decreases the frequency of
UTIs.
Causes
Affected Populations
Recurrent UTIs are particularly prevalent in postmenopausal women due to the reduction in
estrogen levels that occurs during this stage of life. Vaginal estrogen therapy offers a
targeted solution for these women by directly addressing the changes in the urogenital tract
that contribute to recurrent infections.
Diagnosis
Recurrent UTIs are typically diagnosed based on the occurrence of at least two symptomatic
episodes within six months or three episodes within a year. For postmenopausal women,
vaginal estrogen therapy is a recommended preventive measure, especially when other risk
factors such as vaginal atrophy are present.
Standard Therapies
The standard treatment for preventing rUTIs in postmenopausal women involves the use of
vaginal estrogen creams, tablets, or rings. These therapies deliver low doses of estrogen
directly to the vaginal tissues, promoting the regrowth of healthy epithelium and supporting
the maintenance of a protective vaginal microbiome. The effectiveness of vaginal estrogen in
reducing rUTIs has been well-documented, with significant reductions in UTI recurrence
observed in treated women.
Investigational Therapies
Support Available
References
1. Gupta K, et al. Nonantibiotic prevention and management of recurrent urinary tract
infection. Nature Reviews Urology. 2018.
2. Dielubanza EJ, et al. The Etiology and Management of Recurrent Urinary Tract
Infections in Postmenopausal Women. Journal of Urology. 2019.
3. Anger J, et al. Guideline of guidelines: management of recurrent urinary tract
infections in women. BJUI. 2022.
