Why Vaginal Oestrogen Is Changing the Way We Treat Recurrent UTIs During Perimenopause and Menopause
For many women, recurrent urinary tract infections (UTIs) seem to appear out of nowhere during perimenopause and menopause.
One UTI turns into two, then three, and before long it feels like antibiotics have become part of everyday life.
For years, recurrent UTIs were primarily managed by repeatedly treating infections as they occurred. However, growing research has shifted the focus towards addressing why these infections become more common in the first place.
One of the biggest advances has been recognising the important role of vaginal oestrogen.
Why do UTIs become more common?
Most people associate menopause with hot flushes and irregular periods, but declining oestrogen affects far more.
Oestrogen helps maintain the health of the:
Vaginal tissues
Urethra
Bladder lining
Pelvic floor tissues
As oestrogen levels fall:
The vaginal and urethral tissues become thinner and more fragile.
Natural lubrication decreases.
Vaginal acidity (pH) increases.
Protective Lactobacillus bacteria decline.
Harmful bacteria such as E. coli can grow more easily.
This collection of changes is part of Genitourinary Syndrome of Menopause (GSM), a condition affecting the urinary tract and genital tissues that becomes increasingly common during and after menopause. Symptoms can include:
Recurrent UTIs
Burning with urination
Urinary urgency
Frequency
Bladder irritation
Vaginal dryness
Pain with intercourse
Unfortunately, many women are told these symptoms are simply "part of getting older," when they are often very treatable.
What does the research say?
The evidence supporting vaginal oestrogen has grown significantly.
Multiple international guidelines, including those from the American Urological Association, now recommend vaginal oestrogen for peri- and postmenopausal women with recurrent UTIs when there are no contraindications.
A large retrospective study involving almost 1.9 million women found that women prescribed vaginal oestrogen experienced lower rates of serious complications from recurrent UTIs, including fewer hospitalisations, lower rates of sepsis and lower mortality. Researchers suggested these findings may change how clinicians think about prescribing vaginal oestrogen, particularly earlier in the course of treatment.
Earlier clinical trials have also demonstrated that vaginal oestrogen significantly reduces recurrent UTIs compared with placebo, leading many experts to describe it as the current standard of care for women with hypo-oestrogenism experiencing recurrent infections.
Some organisations estimate that after approximately 6–12 weeks of treatment, vaginal oestrogen can reduce recurrent UTIs by more than 75% in appropriate patients.
Why is vaginal oestrogen different from antibiotics?
Antibiotics treat the infection that's already present.
Vaginal oestrogen works differently by helping restore the normal environment that naturally protects the urinary tract.
It helps:
Improve tissue thickness
Increase blood flow
Restore healthy vaginal bacteria
Lower vaginal pH
Improve the natural barrier against bacteria
Rather than continually fighting infections after they occur, vaginal oestrogen helps reduce the likelihood of future infections developing.
Is vaginal oestrogen the same as hormone replacement therapy (HRT)?
Not exactly.
Low dose vaginal oestrogen works locally within the vaginal and urinary tissues, with very little absorbed into the bloodstream.
For many women, including some who cannot take systemic HRT, it may still be an appropriate treatment option, although this should always be discussed with your GP or specialist.
Could it help you?
You may benefit from discussing vaginal oestrogen with your GP or specialist if you are experiencing:
Two or more UTIs in six months
Three or more UTIs within a year
Recurrent UTIs around menopause
Ongoing urinary urgency or frequency
Burning despite negative urine cultures
Vaginal dryness or discomfort alongside bladder symptoms
Many women are surprised to learn that their bladder symptoms are related to declining oestrogen rather than simply ageing.
The takeaway
Repeated courses of antibiotics aren't always the only answer.
For women in perimenopause and menopause, restoring local oestrogen levels may address one of the underlying causes of recurrent urinary tract infections.
The evidence supporting vaginal oestrogen has become increasingly strong, and current international guidelines now recommend it as a key part of managing recurrent UTIs in women with low oestrogen.
If recurrent UTIs are affecting your quality of life, it's worth speaking with your GP to determine whether this treatment is appropriate for you.
References
American Urological Association. Recurrent Uncomplicated Urinary Tract Infections in Women Guideline (updated 2025).
Tan-Kim J, et al. Efficacy of vaginal estrogen for recurrent urinary tract infection prevention. American Journal of Obstetrics & Gynecology, 2023.
Brennand EA, et al. Urinary tract infections after menopause. CMAJ, 2025.
Bencivenga PA, et al. Vaginal estrogen and the prevention of recurrent urinary tract infections. 2026 review.
Albany Medical College study of approximately 1.9 million women with recurrent UTIs, reported 2026.