Why UTIs Increase During Menopause—And What You Can Do About Them

Jul 1, 2022
Medically reviewed by: 
Dr. Leah Millheiser, MD

As you enter menopause, you may find that urinary tract infections (UTIs) become more common. This is due to natural hormonal changes that affect your vagina, urethra, and bladder. The good news is that you can ward off UTIs with a range of treatments, including vaginal estrogen therapy and smart hygiene practices. Here’s what you need to know.

What Is a UTI? The Basics

A UTI is simply the growth of harmful bacteria in your urethra or bladder. Most commonly, it is E. coli bacteria, which migrates into your urinary tract. The symptoms of a UTI typically include a frequent need to urinate, a painful or a burning sensation when you urinate, the sensation that you aren’t completely emptying your bladder, and cloudy appearance to your  urine. If you have three or more infections within a year or two or more in six months, your doctor may diagnose you with recurrent UTIs. If not treated, a UTI can progress to your kidneys and become very serious—even life-threatening. 

“UTIs are common, especially during the menopause transition and beyond,” says Dr. Leah Millheiser, Clinical Professor of OB/GYN and Chief Medical Officer of Evernow. “They can be incredibly distressing and take a toll on your quality of life and relationships.”

The Estrogen-UTI Connection

Like every part of your body, the vagina is colonized by bacteria (aka flora) that live with you in healthy harmony. Before menopause, this vaginal bacteria is predominantly Lactobacillus—a family of “good” bacteria found in our digestive tracts as well as probiotic supplements and fermented foods like yogurt. Lactobacillus protects the vagina by creating an acidic environment that fends off the “bad” bacteria which cause UTIs and other illnesses.

During menopause, this microbial ecosystem changes. As your estrogen levels fall, the cells lining the vagina (called the epithelium) produce less glycogen—a sugar compound that feeds Lactobacillus. With fewer protective flora thriving in the environment, infection-causing bacteria begin to get a foothold. They make their way into your urethra and bladder potentially causing a UTI.

This change in vaginal flora is part of a more general trend during menopause called vulvovaginal atrophy (VVA). The tissue of the vagina and urinary tract are rich in estrogen receptors, and thus very sensitive to changes in your hormones. Falling estrogen levels during menopause cause the lining of the vagina to become thinner, drier, and more fragile and may prevent complete emptying of the bladder, both which contribute to the development of UTIs. 

First Step: Rule Out Complications

If you’re having UTI symptoms during menopause, check in with your healthcare provider to be screened for a UTI.

“Menopause comes with a lot of changes,” says Dr. Millheiser. “And this is one you shouldn’t ignore. If you’re having more frequent UTIs during menopause, check in with your healthcare team to identify the cause and appropriate treatment course.”

The Role of Antibiotics

If you have a UTI, a course of antibiotics will be prescribed to treat it. And for people with recurrent UTIs, “prophylactic” antibiotics may be necessary. This typically means taking a dose of antibiotic every time you have sex (because sex frequently triggers UTIs). 

For many patients and doctors, however, this kind of antibiotic use is a last resort. Antibiotic medications can cause side effects that may be very uncomfortable in their own right, such as nausea, cramps, diarrhea, and vomiting. Their use also contributes to the growing trend of antibiotic resistance we are now seeing in bacterial infections. Fortunately, there are other approaches to UTI prevention that do not require antibiotics.

Preventing UTIs With Hormone Therapy

As we discussed above, UTIs during the menopause transition can be caused by vulvovaginal atrophy. Thus, the best way to prevent these UTIs is by addressing VVA and strengthening your genital tissues. This is possible with vaginal estrogen therapy.

Vaginal estrogen therapy uses a topical cream, tablet, insert, or insertable ring to slowly administer a low dose of estrogen directly to the vagina. This estrogen replaces your natural hormones and rejuvenates vaginal tissue. It also creates a more nourishing environment for Lactobacillus—the healthy flora that stabilize your urinary tract and prevent dangerous bacteria from taking hold. Research has shown that this treatment works to lower your risk of UTI after menopause.

Systemic hormone therapy—i.e. oral estrogen medications that improve the symptoms of menopause—may also help prevent UTIs by creating similar benefits for your vaginal ecosystem. But estrogen delivered vaginally typically offers greater benefits. 

Finally, an FDA-approved vaginal medication containing DHEA as well as the oral treatment ospemifene (a Selective Estrogen Receptor Modulator) both act like an estrogen, improving the health of vaginal tissue. These treatments have been endorsed by the North American Menopause Society as effective in helping prevent UTIs due to vulvovaginal atrophy.

Other Tips to Prevent UTIs

As you enter menopause, hygiene may become more important than ever in preventing UTIs. These best practices can be extremely helpful:

  • Wash before sex. Having sex can push bacteria into your urethra, where it takes hold. So take a quick shower beforehand and gently clean your genitals and the area around your anus with soap and water to reduce the amount of bacteria present. 
  • Urinate before & after sex. Flushing out your urethra before and after sex will help remove harmful bacteria before they cause problems.
  • Use a silicone-based lubricant. After menopause, you may have less natural vaginal lubrication and the tissue may be more easily injured during sex, which can lead to a UTI. Using a silicone-based lube can minimize friction during sex better than a water-based version. See Dr. Leah Millheiser's informative "Lubricant 101" video for more information.
  • Wipe from front to back. After using the toilet, always wipe front to back to avoid bringing germs to the vulvovaginal region.

Final Thoughts

Urinary tract infections aren’t just inconvenient and painful. They can have a real negative impact on your long-term health—and thanks to the hormonal shifts of menopause, UTIs may happen more frequently as you age. But with some simple treatments and preventive strategies, you can stave off UTIs during the menopause transition and beyond.