How do you prescribe estrogen (hormone replacement therapy) to prevent urinary tract infections (UTI) in postmenopausal female patients?

From the Guidelines

For postmenopausal women with recurrent urinary tract infections (UTIs), vaginal estrogen therapy is recommended as an effective preventive measure. The preferred regimens include vaginal estradiol cream (Estrace) 0.5-1g applied nightly for two weeks, then twice weekly for maintenance; estradiol vaginal tablets (Vagifem) 10mcg inserted vaginally twice weekly; or an estradiol vaginal ring (Estring) inserted every 90 days 1.

Key Considerations

• Vaginal estrogen works by restoring the vaginal microbiome, increasing lactobacilli, normalizing vaginal pH, and strengthening urogenital tissues, which helps prevent bacterial colonization that leads to UTIs.
• Systemic absorption is minimal with vaginal preparations, making them safer than oral estrogen for elderly patients.
• Before initiating therapy, perform a baseline assessment including recent history of abnormal vaginal bleeding, breast cancer risk, and cardiovascular health.
• Patients should be informed that improvement typically occurs after 2-4 weeks of consistent use, and regular follow-up is recommended to assess efficacy and monitor for adverse effects.

Benefits and Risks

• Vaginal estrogen therapy has been shown to reduce the risk of future UTIs in peri- and post-menopausal women with rUTIs, with minimal systemic risks associated with its use 1.
• The benefits of vaginal estrogen therapy in reducing UTI risk should be weighed against its potential risks as part of shared decision-making.

Administration and Monitoring

• Treatment should continue long-term as benefits persist only while using the therapy.
• Regular follow-up is recommended to assess efficacy and monitor for adverse effects.
• Patients should be informed about the importance of consistent use and the potential for improvement after 2-4 weeks of therapy.

From the Research

Estrogen Therapy for Preventing UTIs in Female Geriatric Patients

• Estrogen therapy is a non-antimicrobial option for preventing UTIs in postmenopausal women 2
• The decreased estrogen levels in postmenopausal women can lead to changes in the urogenital epithelium and alterations in the urogenital microbiome, increasing the risk of UTIs 3
• Estrogen therapy may help to reduce the risk of UTIs in female geriatric patients by restoring the normal urogenital flora and preventing the adherence of uropathogenic bacteria to the urothelial cells 2

Dosage and Administration

• There is limited information available on the optimal dosage and administration of estrogen therapy for preventing UTIs in female geriatric patients 3
• Further studies are needed to investigate the proper dosing and routes for optimal management of UTIs in this population 3

Considerations for Prescribing Estrogen Therapy

• Estrogen therapy should be considered as part of a comprehensive management plan for preventing UTIs in female geriatric patients 3
• The decision to prescribe estrogen therapy should take into account the individual patient's risk factors, medical history, and current health status 4
• Healthcare professionals should follow local prescribing guidelines and consider the potential benefits and risks of estrogen therapy in each patient 4