"How can I stop these repeated urinary infections I've had in menopause?"
If you read my previously posted “Solutions for Urinary Tract Infections,” you may have easily skipped over a line that deserves an article all its own: “For menopausal women, local hormone applications can strengthen the bladder’s natural defenses against infection.” This topic comes up almost daily in my office, so I figure it’s time for a full discussion.
Both men and women develop urinary problems with age, each for different reasons. Normal age-related changes in women result in two common problems:
- loss of urinary control with exercise, coughing, or just with the urge to urinate, and
- a greater tendency to urinary tract infections.
Any individual woman may notice either one or both problems.
The symptoms considered together comprise the genitourinary syndrome of menopause, accepted as new terminology by the gynecological world in 2014. The syndrome includes but is not limited to symptoms of dryness, burning, irritation of the genitals; sexual discomfort associated with lack of lubrication, and urinary symptoms of urgency, dysuria and recurrent urinary tract infections.[i]
The age of onset varies, but if a woman lives long enough, I can pretty much guarantee she will develop some form of urinary tract weakness, as her levels of estrogen decline with age. Happily, all of those listed problems have the same, relatively simple, fix.
What's Going On
Let’s refresh a bit of normal anatomy: a woman’s bladder sits at the front of her pelvis, just behind the pelvic bone in the front, and a little above the top of that bone when the bladder is full. The bladder doesn’t open directly to the outside, luckily!, but by way of a small tubular urethra that sits at the front of the vagina. If a woman is standing, that opening is toward the front of her body; if she is lying on her back, it’s a bit toward the ceiling from the main vaginal opening. Any woman who has ever had a bladder infection can tell you the exact location of her urethra: it’s usually the part that hurts the most with an infection.
The urethra actually protects the sterile bladder from the less-than-sterile outside world. Entry of any bacteria into the bladder can result in an infection unless it is promptly rinsed out of the bladder. The urethra is a muscular tube, surrounded by soft tissue and lined with a mucous membrane, that sits in the “closed” position so long as that soft tissue and mucous membrane maintain their normal thickness. In that position, urine can accumulate in the bladder until it is overly full, when a woman feels the walls of the bladder stretch and gets the urge to urinate. Still, though, a resting urethra should be an effective barrier until she’s ready to empty her bladder, a barrier that keeps urine in and bacteria out With the added stress of a full bladder, a woman may add pressure of the muscular tube to keep the urine in the bladder until it can safely be emptied.
Here’s the key point about the health of our urinary tracts: The urethra is embedded in the anterior wall of the vagina and both the lining of the urethra and the surrounding tissues of the vagina are highly responsive to the presence or absence of estrogen. Young women’s tissues have a high level of estrogen and all the pertinent tissues are literally thicker, with greater folds in the surface, and able to close off the urethra in its full length without relying on extra contraction of the urethral or pelvic muscles. As women age, estrogen levels fall, resulting in atrophy of the urethral lining and a thinning of the mucosa. Imagine making hollow tube out of velvet (young mucosa) or paper (old mucosa). The velvet folds keep the tube closed without any extra pressure. The paper tube sits open unless you can squeeze it closed. Ditto in the human urethra.
So—whatever you think about a woman taking postmenopausal hormone therapy that affects her whole body—it’s crucial that the urethra and surrounding areas have adequate tissue levels of estrogen to resist the thinning that would otherwise come with age.
Taking Care of Your Urethra
There are three forms of estrogen available for application to this critical area. Widely available are inserts and creams made from estradiol, the predominant estrogen in pre-menopausal women. A prescription is required and is a reasonable intervention that any physician should be comfortable making. Also available are vaginal forms of premarin, a horse-derived estrogen. I do not recommend this form of estrogen, as it only loosely matches the estrogen receptors in the relevant tissue.
The third and less widely known form of estrogen is estriol, the estrogen that surges during pregnancy and one that is widely available in Europe but only through compounding pharmacies in the US. I start with this form of estrogen, but it is also a reasonable second step if commonly available estradiol doesn’t relieve the genitourinary symptoms.
Vaginal estriol is safer than estradiol: you can increase the dose for veginal and urinary benefits without risking high estradiol effects in the very-nearby-uterus!
Estriol can be compounded into suppositories (less messy but less effective) or creams, which I recommend at least at the beginning to take control of the problem! Estriol is highly effective on the local tissues and even a generous dose of estriol has little effect on the nearby uterus (doesn’t want too much of an estrogen effect) or the whole body. (Estradiol has much more of an effect on the uterine lining and thus can cause bleeding.) Topical estrogen in general, and vaginal estriol in particular has no significant impact on blood clotting that can be promoted by the use of oral estrogens in menopause.[ii]
Estriol has been studied in at least two separate trials. In a prospective, randomized, placebo-controlled study, 88 women were given 2 mg intravaginal estriol suppositories (once daily for two weeks, then twice weekly for six months) or placebo. 68% of the women in the estriol group reported improvement in symptoms of incontinence.[iii]
In another randomized, double-blind, placebo-controlled trial, women with recurrent urinary tract infections (UTI) were given either intravaginal estriol cream (containing 0.5 mg estriol, once daily for two weeks, then twice weekly for eight months) or placebo. The incidence of urinary tract infection was dramatically reduced in the estriol group compared with placebo (0.5 versus 5.9 episodes per year).[iv]
An alternative mechanism has been proposed by the same study group who sampled vaginal flora and noted that in the absence of estriol the women’s vaginal cultures yielded none of the lactobacilli that should be present in the vagina. After just one month, almost a third of the estriol-treated women had abundant colonization of lactobacillus, a return to normal vaginal pH and a lack of the UTI-promoting bacteria Enterobacteriaceae.
In My Practice
I recommend all women support their hormonal levels in menopause, and we usually have several discussions on the topic. I have general concerns about the health of women’s brains, breasts, hearts, and bones, all of which are well modulated with carefully prescribed hormone replacement therapy in menopause.
Long after we’ve had that discussion, and whether or not the women are using systemic hormones, I keep prodding about their genitourinary health. It’s all too easy for women to overlook a few urinary symptoms and slowly slip into one urinary tract infection after another, one hazardous course of antibiotics after another.
I like to start with Estriol vaginal cream, 1.0 mg per gram. I instruct the patient to insert ½ gram of the cream in her vagina each evening, applying it to the front (or upper, if she’s lying down) wall of the vagina which overlies the urethra. After 10-20 days she usually notices her symptoms are relieved, and she can switch to applying the cream 2-3 times a week. After a couple months, she can usually switch to a less messy suppository if she prefers. Although the cream should not be used before sexual contact, it will over time improve sensation and perhaps enhance sexual pleasure. I also encourage women to use the cream daily for a week or so before their annual pelvic exam.
The success has been so nearly universal that I have often said that when your local pharmacy notices that you no longer buy menstruation products, they should just hand you a tube of estriol.
The most frequent side effects are greater comfort and pleasure during sex and alteration of the vaginal discharge: increased or decreased. However, itching and any discomfort associated with the discharge usually disappear with estriol cream.
Alternative to Estriol
Seemingly unaware of the estriol option, but well aware of the limitations of estradiol therapy, the gynecological community has devised a treatment alternative. Well described in this research article , a series of three laser treatments resulted in thickened mucosa and improved symptom picture lasting twelve weeks after the laser treatments. The procedure has not been followed long-term either in practice or in research, but you might watch for it in the future.
From Dr. Deborah’s Desk
Repeated UTI's pose a particular problem. Doctors worry that the antibiotics they've prescribed haven't worked (I would like to reassure all those doctors: "It's the anatomy, not the drugs' problem!") so they tend to move on to more powerful (broad-spectrum) antibiotics, particularly Cipro and its relatives.
I’m sure you don’t need any general convincing that antibiotics are damaging to our very crucial gastrointestinal flora. What you may not recognize is that perhaps the most commonly used antibiotics for repeated UTI’s are those in the Cipro family. Cipro is an incredibly powerful antibiotic that can certainly save lives, but it can just as easily ruin them. I currently have three patients in my practice whose quality of life has been impacted for years by a single course of Cipro. The well-known side effect of tendon inflammation and damage plagues one woman; another woman—otherwise very healthy at 96—has altered flora in her oral mucosa and small intestine, causing persistent indigestion and discomfort. The third patient responded well to broad spectrum probiotics after years of Cipro-related symptoms.
I encourage my patients (and you!) to resist a Cipro prescription unless it is absolutely necessary. Many very old and milder antibiotics are effective in almost all UTI’s, If you do have a urinary infection, ask the doctor to run a “culture” on your urine specimen, and to test the infection for antibiotic sensitivity.
[i] Vulvovaginal Atrophy Terminology Consensus Conference Panel. Menopause 2014;21(10):1063–1068.
[iii] Dessole, S., et al., Efficacy of low-dose intravaginal estriol on urogenital aging in postmenopausal women. Menopause. 2004 Jan;1191):49-56.
[iv] Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. 1993 Sep 9;329(11):753-6.