Burning issue: addressing the risk of UTIs in midlife

The risk of developing a urinary tract infection increases as women’s hormone levels change in midlife. Health campaigners say antibiotics alone are not enough and want doctors to prescribe vaginal oestrogen to address the underlying cause

Pic: iStock

Most women know the symptoms of a urinary tract infection (UTI). We feel a sudden urge to pee and rush to the toilet, only to experience a burning sensation as we relieve ourselves. Moments later, the process begins again and continues on repeat until we take antibiotics.

Experts in women’s health now say vaginal oestrogen could dramatically reduce the infection rate among women from mid-life onwards.

Females are uniquely susceptible to UTIs which is why they account for nearly 25% of all infections and why 60% will get one in their lifetimes. The corresponding figure for men is 20%.

Los Angeles-based urologist Dr Ashley Winter, who has a high profile on social media, explains that this discrepancy is down to biology. “The female urethra is much shorter,” she says. “This means it’s easier for bacteria, particularly faecal bacteria on the skin, to enter from the surrounding environment.”

There are other contributing factors, according to Dr Lisa Smyth, a consultant urology surgeon at Tallaght University Hospital and St James’s Hospital in Dublin. “Sexual intercourse can trigger infection as can poor hygiene,” she says. “As women age, the efficiency of their bladder emptying can decrease, leaving stagnant urine behind. The opening of their bladder can also descend lower. Both predispose the female body even more to infection.”

Infection rates in women over 65 are double those of the female population overall and the main reason is plummeting oestrogen levels. “Because of their anatomy, women need additional defences against infection, which are provided by the natural healthy bacteria in the vaginal microbiome,” says Winter. “Premenopausal oestrogen levels help the cells that line the vagina produce a sugar called glycogen, which feeds lactobacillus, a beneficial bacteria that acts as a barrier to infection.”

These defences can start to fail during perimenopause, typically starting around the mid-40s. “Oestrogen drops which reduces the production of glycogen and lactobacillus,” says Winter. “That’s why 15% or so of older women suffer from recurrent UTIs, which is defined as three or more infections in any 12 months.”

Deirdre Lundy: Head of the Complex Menopause Service at the National Maternity Hospital, Holles Street. Pic: RollingNews

Dr Deirdre Lundy, head of the Complex Menopause Service at the National Maternity Hospital, Holles Street, sees many women struggling with this problem.

“It’s not just the pain of the infection,” she says. “As their microbiome changes, the skin in their vulva and vagina becomes drier and less supple. This can reduce sexual arousal, diminish orgasms and make sex painful. Lots of women put up with UTIs, but they shouldn’t have to.”

There are two reasons why they shouldn’t. The first is that UTIs can deteriorate if untreated. “The infection can travel to the kidneys which is far more serious and may require hospitalisation,” says Smyth. “At its most extreme, it can lead to sepsis which can cause tissue damage, organ failure and death.”

HSE figures show that 20,870 women were hospitalised with UTIs in 2022, 14,990 of whom were aged over 55. Some 2,226 of those were also treated for sepsis, including 1,909 women in the over-55 cohort.

A 2021 study published in The Lancet suggests that serious UTI infections may even lead to cognitive impairment. Based on data from 989,800 individuals between 2004 and 2018, it concluded that common infections, particularly those resulting in hospitalisation, were associated with an elevated risk of developing dementia.

The second reason why women shouldn’t put up with UTIs is that vaginal oestrogen can help prevent them. “Taken as a cream or as a pessary, it’s a wonderful medication for perimenopausal and postmenopausal women who need help with preventing UTIs and treating issues like vaginal dryness,” says Smyth.

Prevention is better

In a 2023 study published in the American Journal of Obstetrics and Gynaecology, 5,600 women with an average age of 70 reduced their rate of UTIs by more than half after a year on vaginal oestrogen, with a third experiencing no UTIs whatsoever.

Antibiotics continue to be prescribed for recurrent UTI infections. “I regularly hear from women who’ve been given antibiotic after antibiotic to no avail,” says Lundy. “Antibiotics don’t address the underlying cause. Only vaginal oestrogen does.”

Winter puts it starkly. “Prescribing antibiotics without vaginal oestrogen is like catching the burglars after a break-in but then leaving the doors unlocked,” she says. “It clears the acute infection but sets women up for future failure. Not to mention antibiotics further disrupting a woman’s vaginal microbiome and contributing to the increasing problem of antibiotic resistance.”

Lundy believes that older women in nursing homes are likely to find vaginal oestrogen particularly helpful. “These women often wear continence pads, which make them even more vulnerable to infection,” she says. “Some are given long low doses of antibiotics to keep those infections at bay. But if they were given vaginal oestrogen, UTI rates would drop and so would related antibiotic use.”

Dr Ashley Winter

Protecting women’s health

Kate Muir is best known for producing Davina McCall’s C4 documentaries about the menopause and for writing Everything You Need to Know About the Menopause (But Were Too Afraid to Ask) and the forthcoming Everything You Need to Know About the Pill (But Were Too Afraid to Ask). She was shocked when the National Health Service in Britain recently issued a press release advising women on how to prevent UTIs.

“It completely omitted vaginal oestrogen,” she says. “When I think of all the women out there who are suffering and, in some cases, dying in hospital, it makes me angry. They deserve better.”

This issue is personal for Muir. When her late mother was in her 80s and living with Alzheimer’s, a carer visited her twice a day. One August day, when Muir was away and that carer was off, the replacement carer never turned up.

Muir’s mother became dehydrated and delirious and was eventually hospitalised with a UTI.

“She never fully recovered mentally after that and had to move into a nursing home,” says Muir. “Now, I don’t know if it would have made any difference if she had taken vaginal oestrogen, but I wish I’d known then what I know now — vaginal oestrogen protects women’s health.”

Winter wonders why this information has yet to make its way onto the medical school syllabus. “Is it because we still have the heebie-jeebies about women’s vaginas?” she asks.

Muir speculates that vaginal oestrogen may have been conflated with hormone replacement therapy (HRT) and the now-disproven claims that HRT increased the risk of blood clots, stroke and breast cancer.

“Those claims made people fearful of taking HRT and doctors afraid of prescribing it,” she says. “But subsequent research showed those claims to be unfounded. Vaginal oestrogen has always been safe, even for most breast cancer patients.”

A 2023 study led by Queen’s University Belfast demonstrated this conclusively. In 49,237 females with breast cancer, there was no evidence of an increase in early breast cancer-specific mortality with the use of vaginal oestrogen.

Despite such findings, vaginal oestrogen product packaging still lists these risks, scaring medical professionals off dispensing it and women from using it.

“Women who have had breast cancer often suffer from vaginal dryness, for which I prescribe vaginal oestrogen,” says Lundy. “But patients come back to me saying that pharmacists refuse to hand it over. Because of outdated pharmaceutical guidelines, women are unable to access the solution to their problem.”

This is why we all need to be made aware of the safety and efficacy of vaginal oestrogen, says Winter. “Doctors and healthcare providers have to be educated. The information leaflet included in the packaging has to change. And women have to be reassured that it’s safe.”

Muir would like to see posters about it in doctor’s surgeries. Lundy suggests a campaign spearheaded by the medics who administer smear tests. “They are the ones looking at vulvas every day and can immediately tell when a vulva is starved of oestrogen,” she says. “Imagine the difference they could make to women if they recommended vaginal oestrogen.”

Contraceptive pill and UTIs

It’s not just older women who get UTIs due to low oestrogen levels either. Younger women who take the contraceptive pill can also be affected.

“Some pills work by suppressing the oestrogen produced by your ovaries and replacing it with a level lower than your body would make naturally,” says Winter. “This could explain the extraordinary number of young women who get recurrent UTIs and suffer from bladder inflammation and painful sex. Those women should consider switching to a different pill or another form of contraception.”

Vaginal oestrogen is now available over the counter in Britain but is still prescription only in Ireland. “I’d love to see us offering it over the counter,” says Lundy.

There may even be an argument for dispensing it for free. According to a report published in 2014, the annual estimated primary care costs of treating UTIs was €19.2m. Adjusting for inflation, that would amount to over €23m today.

But this issue is more important than economics, says Muir. It’s about the toll that UTIs can take on women’s bodies and lives. “Generations of women have suffered and continue to suffer unnecessarily,” she says. “All because of a lack of knowledge about the female body. News about vaginal oestrogen needs to spread and it needs to spread fast.”

Minimising risks

Women become more susceptible to urinary tract infections (UTIs) as they age. One of the things they can do to minimise their risk is to monitor the effects of declining oestrogen and take vaginal oestrogen products if necessary.

Dr Lisa Smyth, a consultant urologist surgeon at Tallaght University Hospital and St James’s Hospital in Dublin, shares some other tips:

• It’s important to have a good water intake. Aim for two litres a day.
• Good hygiene measures are crucial too. Try to keep the vulval area clean by washing daily and wipe from front to back after using the toilet.
• Help prevent constipation by eating a healthy balanced diet that contains sufficient fibre. “Constipation is known to trigger infection,” says Smyth.
• Taking a regular probiotic can also make a difference. A side effect of declining oestrogen levels is a reduction in the production of vaginal lactobacillus, a beneficial bacteria that helps fight infection. Antibiotic use can reduce its levels even further, making women more susceptible to UTIs. “UTI-specific probiotics that encourage the production of lactobacillus can be purchased over the counter and ingested orally,” says Smyth. “They have been shown to help.” 
• If you apply vaginal oestrogen, it takes time to notice the effects.  “It takes up to six weeks to see its effectiveness,” says Smyth. “I usually advise my patients to take it every night for two weeks and then twice a week over the long term.”