From the Guidelines
Local estrogen therapy is a highly effective treatment for managing recurrent urinary tract infections (UTIs) in postmenopausal women and should be considered a first-line treatment option. The most recent and highest quality study, published in 2024 in the Journal of the American Medical Association (JAMA) Network Open 1, supports the use of topical estrogen to prevent UTIs in postmenopausal women. This study found that topical estrogen is effective at reducing recurrent UTIs in postmenopausal women, with minimal systemic absorption and no concerning safety signals.
The European Association of Urology guidelines, published in 2024, also recommend the use of vaginal estrogen replacement in postmenopausal women to prevent recurrent UTIs, with a strong strength rating 1. The guidelines suggest that vaginal estrogen therapy can help restore the vaginal microbiome, reduce vaginal atrophy, and decrease the frequency of UTIs.
The American Urological Association (AUA) guidelines, published in 2019, also recommend vaginal estrogen therapy for peri- and post-menopausal women with recurrent UTIs, with a moderate recommendation and evidence level of Grade B 1. The guidelines suggest that vaginal estrogen therapy can reduce the risk of future UTIs, with minimal systemic risks associated with its use.
Some key points to consider when prescribing local estrogen therapy for recurrent UTIs in postmenopausal women include:
- The most commonly prescribed formulations include vaginal estradiol tablets, estradiol vaginal rings, or estrogen creams
- Treatment typically begins with a loading dose period followed by a maintenance regimen
- Local estrogen works by restoring the vaginal epithelium, normalizing vaginal pH, reducing colonization by uropathogens, and strengthening the urogenital tissues
- Unlike systemic hormone therapy, local estrogen has minimal systemic absorption, making it safer for most women
- Patients with a history of estrogen-sensitive cancers should consult their oncologist before starting treatment
- Treatment is typically continued long-term, as UTI prevention benefits diminish when therapy is discontinued
Overall, the evidence suggests that local estrogen therapy is a safe and effective treatment for managing recurrent UTIs in postmenopausal women, and should be considered a first-line treatment option.
From the Research
Role of Local Estrogen Therapy in Managing Recurrent UTIs
- Local estrogen therapy has been studied as a potential management option for recurrent Urinary Tract Infections (UTIs) in postmenopausal women 2, 3, 4.
- The decrease in estrogen levels in postmenopausal women can lead to changes in the urogenital epithelium, making them more susceptible to UTIs 5.
- Vaginal estrogen therapy has been shown to reduce the number of recurrent UTIs and lower the vaginal pH in postmenopausal women 3.
Efficacy of Local Estrogen Therapy
- A meta-analysis of randomized controlled trials found that vaginal estrogen therapy resulted in a significant reduction in recurrent UTIs (relative risk, 0.42; 95% CI, 0.30-0.59) 3.
- However, oral estrogen therapy did not decrease UTI recurrence and resulted in local and systemic side effects in up to nearly 30% of the patients 4.
- Local estrogen therapy may be a useful option for postmenopausal women with recurrent UTIs, especially those who cannot tolerate or do not respond to antibiotic prophylaxis 2, 4.
Comparison with Other Management Options
- Antibiotic prophylaxis is often used to manage recurrent UTIs, but it can increase the risk of antibiotic resistance and adverse effects 2, 6.
- Local estrogen therapy may be a safer alternative to antibiotic prophylaxis, especially for postmenopausal women with recurrent UTIs 3, 4.
- Other management options, such as cranberry products and oral lactobacillus, may also be effective in reducing recurrent UTIs, but more research is needed to determine their efficacy 2, 4.