From the Guidelines
Vaginal estrogen therapy is a safe and effective treatment for recurrent urinary tract infections (UTIs) in postmenopausal women and has not been associated with increased mortality. For women experiencing recurrent UTIs, I recommend using vaginal estrogen preparations such as estradiol vaginal cream (Estrace 0.01%, 0.5-1g applied nightly for two weeks, then twice weekly), estradiol vaginal tablets (Vagifem 10mcg inserted twice weekly), or an estradiol vaginal ring (Estring, replaced every 90 days) 1. These treatments help restore the vaginal microbiome and strengthen urogenital tissues, creating a less hospitable environment for pathogenic bacteria. Vaginal estrogen works by increasing vaginal epithelial thickness, lowering vaginal pH, and promoting the growth of protective Lactobacilli. Unlike systemic hormone therapy, vaginal estrogen has minimal systemic absorption, making it a safer option even for women with contraindications to oral estrogen.
The benefits of vaginal estrogen therapy in reducing UTI risk are well-supported by recent evidence, including a 2024 consensus statement that found topical estrogen to be effective in reducing recurrent UTIs in postmenopausal women 1. Additionally, the 2024 European Association of Urology guidelines strongly recommend the use of vaginal estrogen replacement in postmenopausal women to prevent recurrent UTIs 1. The treatment should be continued long-term for sustained protection against recurrent UTIs. Regular follow-up with your healthcare provider is recommended to monitor effectiveness and address any concerns. Most women notice improvement in UTI frequency within 1-3 months of consistent use.
Key points to consider when prescribing vaginal estrogen therapy include:
- The patient's menopausal status, as vaginal estrogen is most effective in postmenopausal women
- The presence of any contraindications to estrogen therapy, such as a history of estrogen-related malignant neoplasms
- The potential for vaginal irritation and poor adherence, which can be mitigated by proper dosing and follow-up
- The importance of continued long-term use for sustained protection against recurrent UTIs. As stated in the 2019 AUA/CUA/SUFU guideline, clinicians should recommend vaginal estrogen therapy to all peri- and post-menopausal women with recurrent UTIs to reduce the risk of future UTIs 1.
From the Research
Vaginal Estrogen and Recurrent UTI
- Vaginal estrogen has been shown to be effective in preventing recurrent urinary tract infections (UTIs) in postmenopausal women 2, 3, 4, 5, 6.
- A randomized clinical trial found that vaginal estrogen reduced the occurrence of UTIs at 6 months compared to placebo 2.
- A retrospective cohort study found that 67.7% of postmenopausal women with recurrent UTIs improved with vaginal estrogen cream alone, and that women with urinary incontinence were more likely to need additional therapy 3.
- A systematic review found that vaginal estrogen improved symptoms of genitourinary syndrome of menopause, including recurrent UTIs, and that the various estrogen preparations had similar efficacy and safety 4.
- A multicenter retrospective review found that vaginal estrogen prescription was associated with a 51.9% reduction in UTI frequency over the following year, and that predictors of postprescription UTI included age, baseline UTI frequency, urinary incontinence, and diabetes 5.
- A meta-analysis of randomized controlled trials found that vaginal estrogen resulted in a significant reduction in recurrent UTIs compared to placebo, and that oral estrogen did not show a significant difference in the number of recurrent UTIs compared to treatment with placebo 6.
Mortality
- There is no direct evidence in the provided studies on the relationship between vaginal estrogen and mortality in the context of recurrent UTIs.
- However, the studies suggest that vaginal estrogen can be an effective treatment for preventing recurrent UTIs, which can reduce the risk of complications and improve quality of life for postmenopausal women 2, 3, 4, 5, 6.