Remedying recurrent UTIs in menopause

Posted on October 01, 2025

Hormonal changes must be taken into account for recurrent urinary tract infections associated with menopause.

Urinary tract infections (UTIs) are among the routine issues primary care doctors see in their practices, and more often than not, they can be addressed with a single course of antibiotics.

But when UTIs become frequent enough to meet the American Urological Association's definition of recurrent—two or more infections in six months, or three or more infections in a year—physicians should take a step back and look at the bigger picture, experts say. This is especially true when the patient is a postmenopausal woman.

That's because in this population, “it's very obvious that the increase in urinary tract infections is due to the lack of estrogen and androgen in their system, which changes the microbiome and the health of the genital and urinary tissue,” said Rachel Rubin, MD, a urologist and sexual medicine specialist in Bethesda, Md. She noted that it's imperative for doctors to start thinking about diagnosis and treatment through a different lens: “Is there anything hormonal that could be explaining these patients' urinary tract infections?”

Understanding risk

“Many [postmenopausal women] are atrophic, and they have thin, delicate mucosa of not just the vagina and the vulva, but the urethra and the base of the bladder, which is embryologically derived from the same tissue,” explained Holly Thacker, MD, director of the Cleveland Clinic Center for Specialized Women's Health and professor at the Cleveland Clinic Lerner College of Medicine.

“We used to call it vaginal atrophy, which is still a descriptive term, but it's a lot more than just the vagina. It is that whole area, and everyone needs a bladder that functions properly,” she said.

While hormonal changes put all postmenopausal women at heightened risk of recurrent UTIs, there are some subpopulations who may be particularly susceptible, such as immunocompromised women.

“For example, women with rheumatoid arthritis are often on medication that downregulates their immune system, making them more susceptible to UTIs,” said Sara Beth Cichowski, MD, a professor of urogynecology and reconstructive surgery at Oregon Health and Science University (OHSU) in Portland.

Diabetes plays a role as well. “When a patient doesn't have well-controlled blood sugar, this excess sugar concentrates in the bladder and urine. Sugar in the urine is exactly what bacteria love and this sets up an easy environment for a UTI to develop,” Dr. Cichowski said.

Poorly controlled diabetes and certain neurologic conditions can also impair bladder emptying. “That stasis and that urinary retention also predisposes this population to recurrent infections,” said Kate Renkosiak, MD, a third-year urogynecology and reconstructive pelvic surgery fellow at OHSU.

Postmenopausal women who are sexually active can also be at higher risk because they are introducing other microbiomes and friction into the system, Dr. Rubin added.

Prolapse, ureteral reflux, kidney stones or disease, or bowel or urinary incontinence can increase risk too, experts said. For women in that last group, “sometimes treating urinary leakage so they're not wearing pads or in moist clothing can also reduce UTIs. And I think it's important to look globally at the health of the urinary and bowel systems when treating UTIs,” said Dr. Cichowski.

Identifying the issue

Older women with UTIs usually present with the same symptoms as younger women: pain while urinating or above the pubic bone, and increased urinary urgency and frequency, explained Nazema Y. Siddiqui, MD, MHSc, a urogynecologist at Duke Health and an associate professor at Duke University School of Medicine in Durham, N.C.

However, because sensory fibers that detect pain might change with age, older adults might not always perceive the same painful sensations as younger people. “There are times where, certainly in older patient populations, you can have something presenting as a urinary tract infection because they have a profound worsening in urgency, frequency, maybe associated with an odor, maybe some weird pains that are coming and going but not consistent, and that could be a UTI,” she said.

Older patients can also present with confusion and mental status changes that could be the result of a UTI, Dr. Siddiqui noted.

More rare reasons for recurrent UTIs include urethral diverticulum, a stone in the upper or lower tract, or ruptured diverticuli causing colovesical fistula, said Dr. Cichowski. Recurrent UTIs might also be confused with other conditions, like an overactive bladder, lichen sclerosus, vulvodynia, chronic interstitial cystitis, or chronic pelvic pain.

Optimizing antibiotics

For treating UTIs, two antibiotics have recently been added to the armamentarium. Pivmecillinam (Pivya) was approved by the FDA in April 2024 to treat women with uncomplicated UTIs caused by E. coli, Proteus mirabilis, and Staphylococcus saprophyticus, and in March 2025, the FDA approved gepotidacin (Blujepa) for UTIs caused by E. coli, Klebsiella pneumoniae, Citrobacter freundii complex, Staphylococcus saprophyticus, and Enterococcus faecalis. Gepotidacin is a first-in-class oral triazaacenaphthylene antibiotic.

“It's always exciting to have new options, especially in this age of antibiotic resistance,” Dr. Thacker said.

However, the threat of resistance makes responsible antibiotic stewardship especially important in this patient population, and in most cases, physicians should wait to prescribe until they receive results of a urine analysis.

“We don't always have to start with antibiotics right away, because you may not need an antibiotic, and it would be better to have never started it than to have started it inappropriately,” cautioned Dr. Siddiqui.

Dr. Renkosiak stressed that UTIs should not be diagnosed based on symptoms alone. “If it's repeated symptoms of a UTI but always a negative urine culture, our management of that is not with antibiotics. There's lots of other ways that we manage interstitial cystitis or bladder pain syndrome,” she said.

Dr. Cichowski conceded that patients with recurrent UTIs may worry about getting an infection on vacation or while traveling, so some physicians may want to prescribe antibiotics for them to have ready for self-treatment, particularly if cultures have not been drug-resistant.

She noted that this practice gives patients a sense of control and reassurance in a situation where they might feel discouraged trying to find care.

However, it's important to remind patients that even with antibiotics on hand, it's optimal to get a medical evaluation, a urine test, and a urine culture if they experience unusual symptoms, like shaking, chills, mental status changes, and gastrointestinal problems. “They may have another infection, something else besides just a bladder infection,” said Dr. Thacker.

“Most of the time, our patients also don't want to be on daily antibiotics,” said Dr. Renkosiak. “They're looking for other ways of managing the problem.” She recommends finding a single antibiotic a patient is sensitive to and prescribing it for the shortest possible duration.

“There have been lots of studies that have shown that you don't need to do seven or 10 days of nitrofurantoin. The outcomes aren't different than doing it twice a day for five days,” she said.

Physicians should also be sure to ask women if and when they've previously received care for the infections, Dr. Siddiqui said.

“Some women will go to an urgent care, then they'll go to a different urgent care, then they'll go to their [primary care physician] and their doctor may not always be situationally aware that they've been treated and tested at several other places in a short period of time,” she noted.

Proactive prevention

Because the risk of recurrent UTIs is so high in postmenopausal women, catching the infections early and being proactive about prevention can significantly improve quality of life. “We should not be waiting for the third, fourth, or fifth [infection] to happen,” said Dr. Siddiqui.

While the lifetime incidence of a UTI in all adult women is 50% to 60%, prevalence in women ages 65 years and older is approximately double the rate of the general female population, according to research published by Therapeutic Advances in Urology in 2019.

Over-the-counter preventive supplements that might help include D-mannose, which can be particularly effective for E. coli-driven infections, said Dr. Cichowski. Dr. Siddiqui also recommended cranberry products that have at least 36 mg of proanthocyanidins (PACs), the active compound in cranberry. Probiotics containing Lactobacillus crispatus may help, too.

“We often pair or stack supplements and bundle them together to optimize the microbiome, optimize the local environment,” Dr. Siddiqui said.

Another recommendation is for patients to increase their water intake. “A stagnant pond is not as good as a flowing, rushing river, and so this is where a little bit of extra hydration can sometimes be helpful for women who are starting to get recurrent UTIs,” Dr. Siddiqui said.

One of the most effective ways to prevent UTIs in postmenopausal women is local vaginal estrogen, the experts said. Dr. Renkosiak explained that it re-establishes a healthy vaginal microbiome and “boost[s] the tissues in a way that makes it more possible to prevent the next infection …. Vaginal estrogen can reduce the rate of UTIs by 50% to 60%, and it doesn't matter the formulation that a patient is given.”

An analysis Dr. Rubin co-wrote, published by Urology Practice in 2024, showed that Medicare could save between $6 and $22 billion annually in UTI-related costs if women used vaginal hormones for prevention.

The intervention is also endorsed by multiple medical societies. In 2022, the American Urological Association, Canadian Urological Association, and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction released a guideline for recurrent uncomplicated UTIs in women, recommending clinicians offer vaginal estrogen therapy to peri- and postmenopausal women to reduce the risk of future UTIs.

A 2022 position statement from the North American Menopause Society also supports the use of local vaginal estrogen over oral systemic therapy for recurrent UTIs.

This year, the American Urological Association, the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, and American Urogynecologic Society, released a guideline on genitourinary syndrome of menopause (GSM), which supports the use of vaginal estrogen to prevent UTIs and offers prescribing information for clinicians.

Patients with a history of breast cancer may worry about taking hormonal therapy, but low-dose vaginal estrogen is not contraindicated in this population, experts said. Still, primary care physicians should be sure to discuss it with their patient's oncologist “to make sure everyone's on the same page,” said Stephanie S. Faubion, MD, MBA, FACP, who, along with Dr. Rubin, served on the GSM Guideline Panel.

To further assuage concerns about breast cancer risk, Dr. Thacker cited a systematic review and meta-analysis published in the American Journal of Obstetrics & Gynecology in March, which found that the use of vaginal estrogen in women with a breast cancer history is not associated with an increased risk of recurrence, breast cancer-specific mortality, or overall mortality.

Some practical tips can help women get the most out of the treatment, as very frequently they're not given proper instructions and adherence becomes an issue, according to Dr. Faubion, who is a professor and chair of the department of medicine at Mayo Clinic in Jacksonville, Fla., and medical director of The Menopause Society.

Vaginal estrogen, whether in ring, tablet, insert, or cream form, needs to be used consistently for eight to 12 weeks for patients to get the full effect. “Some women will use it for two weeks and say it didn't work. It takes longer than that to be effective,” Dr. Faubion said. She added that the treatment only works as long as it's used.

“Clinicians need to check back in with their patients, make sure that the symptoms actually did resolve and there's nothing else that's contributing to these symptoms, like a vulvar dermatosis, but also understand if their patients are having any problems with the medication, need to switch to a different form, etc., to make sure that they're getting adequately treated,” she said.

Experts stressed that physicians don't need to be women's health specialists to prescribe vaginal estrogen. “In the primary care world, I think people should be very conscious of how to prescribe locally applied vaginal estrogen for anyone who's peri- and postmenopausal,” said Dr. Siddiqui.

Dr. Thacker agreed. “Local vaginal treatment for somebody who's menopausal, who's had a bladder infection, is a no-brainer.”