Many women begin to suffer with urinary tract infections when they become peri-menopausal (from around the age of 35 onwards), menopausal or have premature menopause.
Being in peri-menopause or menopause can cause vaginal dryness, vulval and vaginal burning or pain and vaginal atrophy due to the thinning of the vaginal and vulval mucosal lining as a result of declining oestrogen levels.
Let’s start by looking at the vaginal microbiome and the associated role of oestrogen
The vaginal microbiome
During your pre-menopausal years, the vaginal passage is high in oestrogen which thickens the vaginal epithelium (lining), leading to a healthy vaginal micro-environment. It stimulates the proliferation of epithelial cells and the accumulation of glycogen in these cells. Glucose is the main source of fuel for our cells. When the body doesn’t need to use the glucose for energy, it stores it in the liver and muscles of the body including the vagina and bladder. This stored form of glucose is made up of many connected glucose molecules and is called glycogen.
When healthy, this vaginal ecosystem consists of microorganisms that colonize surfaces with positive bacteria, the most common and “friendly” of which are Lactobacilli. In pre-menopausal women this natural process is stimulated by oestrogen, which initiates the release of glycogen from the walls of the vagina via natural epithelial cell shedding. This glycogen is then metabolized by Lactobacilli to produce lactic acid and hydrogen peroxide. This balances the pH between 3.8 and 4.5, providing natural resistance to potential health risks such as bacterial vaginosis (BV), aerobic vaginitis (AV) and common anaerobic pathogens and fungal infections such as candida/thrush.
In addition, this acidic environment promotes the growth of more Lactobacillus strains allowing the cycle that creates this protective environment to continue. Vaginal and vulval tissues remain well hydrated, moisturised and appear a healthy pink in colour.
So how does this vaginal microbiome alter?
During menopause, the level of oestrogen declines in the vagina, bladder and pelvic floor. This in turn affects the growth of vaginal epithelial cells and the availability of glycogen. This reduction leads to the level of lactobacilli in the vagina decreasing alongside the production of lactic acid and hydrogen peroxide. The decreased oestrogen level also results in thinner, drier and less elastic genital tissues.
When the level of lactobacilli is disrupted and the vaginal flora becomes imbalanced, the risk of developing an infection is increased. If the vagina is not acidic enough due to a shortage of lactobacilli, lactic acid and hydrogen peroxide, then fungi such as candida, vaginal infections such as bacterial vaginosis (BV), aerobic vaginitis (AV) and ‘bad’ bacteria such as coliforms, enterobacter, gardnerella, mycoplasma, streptococci and staphylococci are able to reproduce more than they usually would. Because glycogen is the main nutritional source for lactobacillus, this results in lower production of lactic acid and a higher more alkaline vaginal PH in which lactobacilli strains cannot survive.
Additionally, the following can alter the vaginal microbiome:
- medications such as antibiotics or steroids
- menstruation as the vaginal PH becomes more alkaline in the 10 days up to and including menstruation. Periods in the peri and menopausal years become irregular leading to sometimes shorter gaps between menstruation.
- bacteria from the gut which transfers to the vagina from the nearby rectum
- bath creams and products used for feminine hygiene
- vaginal douching
- tampons and sanitary towels
- sexual intercourse and oral sex
- use of contraceptives
This may lead to an increase of UTIs and recurrent UTIs because of the proximity of the vagina to the urethra and bladder allowing easy bacterial transfer.
Thinning of mucosal linings
Thinning of the vaginal and vulval mucosal lining also affects the mucosal wall of the bladder allowing bacterial permeability – in other words it becomes easier for bacteria to become established on or within the cells of the bladder and vaginal walls. Further, the walls of the vagina, urethra and bladder rely on oestrogen as one way to stay toned and able to manage the flow of urine from the bladder. With less oestrogen, these organs lose tone and some degree of function.
Declining oestrogen levels – how it affects the vagina & bladder
Oestrogen (or estrogen) is needed for the vagina to maintain its natural flora and lubrication. Declining oestrogen levels lead to changes to vaginal PH. A normal vaginal pH level is between 3.8 and 4.5, which is moderately acidic. However this ‘normal PH’ level can change based on your stage of life. For example, during your reproductive years (ages 13 to 49), your vaginal pH is around or below 4.5. But before menstruation and after menopause, a healthy pH tends to be higher than 4.5. This matters because an acidic vaginal environment is protective. It creates a barrier that prevents unhealthy bacteria and yeast from multiplying too quickly and causing infection. Thus a high vaginal pH level — above 4.5 — provides the perfect environment for unhealthy bacteria to grow and these bacteria can transfer from the vagina to the urinary tract causing ongoing infection problems.
A study published in Science Translational Medicine in 2013 noted that oestrogen also encourages production of natural antimicrobial substances in the bladder. The hormone also makes the epithelium of the bladder stronger by closing the gaps between cells that line the bladder wall. By “gluing” together the cells of the bladder wall, it helps to prevent bacteria from penetrating to the deeper layers of the wall. Conversely it will also help prevent too many cells from shedding from the top layers of the bladder wall thus preventing exposure of the deeper bladder wall tissues to bacteria.
This diagram shows the areas of the urogenital tract that require oestrogen. The darker the colour, the more oestrogen is required. The lower third of the bladder and urethra have a high concentration of oestrogen receptors.
A small study and the first of its kind presented by the University of Texas at the European Association of Urology Congress in 2020 showed that for some women who took hormone replacement therapies, they had a greater variety of beneficial bacteria in their urine, possibly creating conditions that discourage urinary infections.
Progesterone and testosterone levels
Progesterone and testosterone levels should be checked as these too can impact on the bladder and general health. Whilst some women experience relief using oestrogen, others find relief using progesterone especially if oestrogen dominant.
The sacral nerve which controls the pelvis and its organs is full of oestrogen receptors. Research published in The International Urogynecology Journal in 1993 showed a change in hormone levels, in particular that of progesterone, may affect the excitability of the nerves and make you feel like you have to urinate more frequently. This may also be the reason for frequent urination during the second half of the menstrual cycle as progesterone levels are higher than those of oestrogen.
Testosterone after the age of 50 has been noted in a research paper published in 2011 in the Global Library of Women’s Medicine to reduce because of declining production within the ovaries. It is vital to bone density, muscle mass, energy levels, libido and general mood but is often overlooked with concentration on oestrogen and progesterone HRT supplementation.
Getting hormone levels tested & recognising menopausal symptoms
If you think hormones are contributing to your urinary tract infection symptoms, or you think possible onset menopause or hormone deficiency are causing systemic issues, ask your GP for an oestrodial blood test to check oestrogen levels and a Follicle Stimulating Hormone test (FSH). This test checks the condition of the follicles producing oestrogen and progesterone in the ovaries which help maintain the menstrual cycles in women.
Ask for a copy of the results and discuss them with your GP or an appropriate hormone specialist in relation to the symptoms you are experiencing. More details of UK and US specialists can be found further down this page.
A recent amendment to The National Institute of Clinical Excellence (NICE) Guidelines for HRT published in the UK in 2015, noted that women over 45 should not be sent for blood tests to check for FSH & Oestrodiol levels. This is because FSH and oestrodial fluctuates considerably over short periods during the years leading up to menopause and so blood levels are not a helpful addition to a clinical diagnosis.
During perimenopause or menopause, hormone levels can fluctuate daily so blood tests should not be assumed to be the rule of thumb to determine hormone status. Go by symptoms such as:
- a change in periods
- vaginal/vulval dryness
- vulval or vaginal pain
- unusual vulval or vaginal bleeding
- mood swings
- energy levels
- loss of libido
- hot flushes
- memory lapse
- increased levels of thrush or bacterial vaginosis
- frequency of urination or increase in UTIs
- bone and joint pain
These symptoms can indicate low hormone levels and must be mentioned to the GP or specialist when seeking advice. Keep a diary tracking daily and monthly symptoms.
Additionally, check family history, when did family members go through menopause? Is there a history of hormone/vaginal/urinary issues in the immediate family? This plus your own medical history and any existing health conditions must always be considered before a decision should be made about using HRT. This includes a history of breast, ovarian or womb cancer, liver disease, blood clots and high blood pressure.
To further understand hormones and their importance, the book “Screaming to be heard” by Dr Elizabeth Vliet is an excellent source of information.
In the UK, Menopause Support is a useful tool with factsheets covering various aspects of menopause as well as an active campaign to bring greater menopause care to the forefront of medicine & society for women during their middle years. Menopause Matters has an online support forum and the Menopause Cafe, is a global women to women organisation that allows women to meet in a supported environment.
What type of HRT treatments are available?
When HRT is administered for menopausal symptoms, it is primarily to restore oestrogen. Supplementing oestrogen levels through oral and transdermal routes alone can cause the lining of the womb to thicken which can increase the risk of breast and uterine cancers. For this reason, progesterone is given in combination with oestrogen in the majority of cases (unless the someone has had a hysterectomy).
HRT is prescribed in different formulations, these being:
- Synthetic – older types of HRT such as Premarin and Premique contains equine oestrogens. All combined HRT patches or oral tablets contain synthetic progestogens, not natural progesterone.
- Bio-identical or body identical – these are derived from yams and soy but are licensed for use in HRT. These hormones can best be described as body identical rather than bio-identical as their molecular compounds resemble hormones produced within the body. Oestradiol, the type of oestrogen that decreases at menopause, progesterone and testosterone are all available as body identical hormones.
- Natural progesterone cream. A widely-available cream but not recommended as it is not absorbed into the body well and also many contain too little amounts of hormone to be effective.
HRT is available to use via the following options:
- Oral tablets – Oestrogen and progesterone are available separately or as combined tablets
- Patches – Some patches contain oestrogen, while others contain a combination of both oestrogen and progesterone
- Gels – oestrogen and testosterone is available as gels
- Creams – oestrogen can be prescribed as a topical cream and natural progesterone is also available as a cream
- Localised pessaries or rings inserted into the vagina containing oestrogen or progestogen (a synthetic version of progesterone)
- Hormonal implants – oestrogen or progesterone formulations which last around 3-6 months.
As previously mentioned, these can be provided in synthetic, bio-identical/body identical or natural formulations.
HRT – Standard versus Compounded formulations
Most HRT provided is made to a standard, regulated, licensed formulation and thus cannot be individually tailored to the specific needs you may have.
However there are private clinics in the US, Australia and the UK where more tailored treatments are available. These clinics use compounding formulations where the levels of hormone added can be balanced to your own specific needs and provide options for different base additives should you have any allergies. As these are private clinics and pharmacies, costs can be considerable and balancing hormones can take several changes in prescription thus increasing the cost.
It is important to note that these compounded hormones are not regulated, licensed or monitored and there is no requirement to provide efficacy, quality, safety or purity measures. These concerns have been raised by the Medical Advisory Council of the British Menopause Society and other internationally recognised menopause organisations who continue to petition for their regulation. Read the 2019 statement of the Medical Advisory Council of the British Menopause Society here.
Check that any HRT prescribed is licensed and regulated and where an individualised (or compounded), unregulated version is necessary, you are aware of the risks through a detailed discussion with your specialist.
HRT can produce differing side effects for each individual. Creams and gels often have chemical preservatives added so discuss with your HRT specialist or GP any concerns you may have if there are vulval/vaginal skin issues or you have a skin allergy that may prevent you using a patch.
Read more about options for HRT via Menopause Matters.
Localised oestrogen treatment
For localised oestrogen treatment for the urogenital tract, Vagifem body-identical pessaries have been found to beneficial. They are entirely topical and will treat the vagina and bladder with minimal systemic absorption although some women still report symptoms despite the low dosage. They sit at the top of the vagina and there is no messy leak unlike other HRT topical treatments. However, if fillers within a pessary are an irritant, the Estring can be used. This is a synthetic soft rubber ring which slowly releases oestradiol and can be introduced into the vagina and replaced at three monthly intervals.
Topical oestrogen creams are also available for use in the vagina and vulval area. If skin is highly sensitive, then discuss their usage with your specialist as the additives within some creams can cause inflammation and burning. A small patch test may be the best option if considering using a cream.
Always discuss localised oestrogen therapies and any risks associated with your GP or specialist. As with systemic oestrogen, one size does not fit all.