Recurrent UTIs in Menopause and Beyond

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Spencer is a Co-Founder of Uqora. Trained in biochemistry at UC Berkeley, Spencer uses his background to provide education on topics including UTIs, urinary tract health, and non-antibiotic UTI treatments.

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UTIs can become a big problem for women starting in menopause, and getting one UTI can mean a high-risk for more. In postmenopausal women, UTI recurrence rates (recurrence rate is the likelihood of getting another UTI after a first) are 55%, compared to 19–36% in younger women (1). UTIs also tend to get more severe, and more common, as women age.

In older women, UTIs are the single most common reason for antibiotics prescriptions (2). It is estimated that 10–15% of all women over the age of 60 experience recurring UTIs (rUTI) (3). rUTI in postmenopausal women can be very difficult to treat, as standard antibiotic therapies may not effectively clear the infection. Long-term prophylactic antibiotics are often recommended for rUTI in postmenopausal women, leading to high rates of antibiotic resistance.

Due to hormonal changes that impact the vaginal microbiome, postmenopausal women are at higher risk of UTIs.

During menopause, estrogen production declines, and this results in changes to the vaginal ecosystem. Estrogen promotes the growth of lactobacilli in the vagina. When estrogen declines, it leads to a loss in vaginal lactobacilli, which typically dominates a healthy vagina. Lactobacilli keep the vaginal pH low and keep other bacteria and yeast in check by releasing lactic acid and hydrogen peroxide. When lactobacilli populations decline, vaginal pH increases. This leaves more opportunity for potentially pathogenic microbes to grow in the population.

Examples of these microbes include E. coli, G. vaginalis (the bacteria primarily associated with bacterial vaginosis or BV), and Candida (yeast responsible for yeast infections). In addition to other symptoms like vaginal dryness, pelvic pain, and urinary urgency and frequency, this transformation has been shown to significantly increase the risk of UTIs (4). These symptoms affect up to 80% of menopausal women (5).

Recurrent UTIs and vaginal infections are generally treated with antibiotics, which can lead to antibiotic resistance and other issues. Now, there are alternative approaches emerging. Topical estrogen therapy is a common and often successful recommendation for postmenopausal women with rUTI (4). Vaginal estrogen therapy has been shown to improve menopausal symptoms like vaginal dryness, and generally improve vaginal health. Yet, evidence has shown that benefit will decline if the therapy is stopped (5).

Restoring vaginal lactobacillus with oral probiotic therapy is also a promising and commonly recommended approach. Oral probiotics have been shown in some studies to increase populations of healthy vaginal bacteria and decrease the presence of pathogenic bacteria (6). However, further randomized controlled trials are needed to fully establish vaginal estrogen and oral probiotics as effective therapies for rUTIs associated with menopause.

As age advances, a weakened immune system and a history of UTIs, which also means the potential for more antibiotic resistance, may lead to an increased likelihood of rUTI in postmenopausal women.

rUTI in postmenopausal women can be much more complicated than in younger women. E. coli-caused UTIs, while still the most common pathogen overall, are much less frequent in postmenopausal women than in younger women (57% compared to ~90%) (7). There are also a wider variety of bacteria, often with multiple types present during the same infection. An estimated 50% of women over 80 have bacteria in the urine, making them at constant risk of infection (8). This population is largely asymptomatic, and should not be treated unless symptoms develop, but they remain vulnerable to new infections. New research is demonstrating that urinary microbiomes change in composition from ‘healthy’ to ‘unhealthy’ states; however, much more research will be required to understand those changes and potentially identify urinary microbiomes that are “at risk”.

Additional risk factors for UTIs develop with increased age. These include catheter use, incontinence, lack of mobility, and, in men, benign prostate hyperplasia (BPH), which affects 90% of males above age 80 (9). Symptoms of a UTI in older adults or the elderly are often difficult to interpret, and can include psychological and behavioral symptoms like confusion, forgetfulness, imbalance, and irrational behavior, all of which are frequently confused with dementia. Due to difficulty of diagnoses and late-onset symptoms, UTIs can result in fevers and hospitalization before being identified.

rUTI in postmenopausal women should be carefully diagnosed and managed from a treatment perspective. Several tests for UTI should be taken into consideration, including urine test strips for leukocytes and nitrites, standard urine cultures, enhanced quantitative urine cultures (EQUC), and new-age whole microbiome sequencing techniques. You can read more about UTI testing here.

For those with chronic postmenopausal UTIs, it is important to seek advice from a specialist, if possible. Here is a high-level summary from 2018 on managing rUTI in postmenopausal women by Dr. Brubaker and Dr. Jung from UC San Diego:

"In postmenopausal women with frequent UTI, the diagnosis of acute UTI should be made using a combination of the symptom assessment and urine diagnostic studies. The choice of UTI antibiotic should include consideration of efficacy, collateral effects, and side-effects. Some women may be candidates for self-start therapy, in which the patient accurately recognizes her UTI symptoms and then starts previously prescribed antibiotics. A large component of the management of women with rUTI is prevention (10)."

1. Ikäheimo R, Siitonen A, Heiskanen T, Kärkkäinen U, Kuosmanen P, Lipponen P, Mäkelä PH. Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women. Clin Infect Dis. 1996 Jan; 22(1):91-9.

2. Rowe TA, Juthani-Mehta M. Urinary tract infection in older adults. Aging health. 2013 Oct; 9(5):10.2217

3. Glover M, Moreira CG, Sperandio V, Zimmern P. Recurrent urinary tract infections in healthy and nonpregnant women. Urol Sci. 2014 Mar; 25(1):1-8.

4. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. New England Journal of Medicine. 1993 Sep 9; 329(11):753-6.

5. Alperin M, Burnett L, Lukacz E, Brubaker L. The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause. 2019 Jan; 26(1):103-111.

7. De Nisco NJ, Neugent M, Mull J, Chen L, Kuprasertkul A, de Souza Santos M, Palmer KL, Zimmern P, Orth K. Direct Detection of Tissue-Resident Bacteria and Chronic Inflammation in the Bladder Wall of Postmenopausal Women with Recurrent Urinary Tract Infection. J Mol Biol. 2019 Oct 4; 431(21):4368-4379.8. Raz R. Urinary tract infection in postmenopausal women. Korean J Urol. 2011 Dec; 52(12):801-8.