By Amanda Doyle 
Medically Reviewed by Ashley Winter, M.D. It’s a scenario many women in perimenopause and menopause know too well: a burning sensation when you pee, an urgent need to go again minutes later, and the realization that another urinary tract infection (UTI) has set in. Up to 55% of menopausal women experience recurrent UTIs, defined as three or more infections in a year or two or more within six months. 1
These infections are a hallmark of genitourinary syndrome of menopause (GSM), a condition describing a collection of menopause symptoms like vaginal dryness, thinning tissues, and shifts in the microbiome. While antibiotics can treat UTIs once they develop, they don’t solve the underlying problem. Prevention of menopause UTIs is key—and that’s where vaginal estrogen comes in.
Research published in the New England Journal of Medicine in 1993 found that vaginal estrogen helps prevent recurrent UTIs in post-menopausal women. 2 Frustratingly, it’s taken decades for this to become a mainstream practice.
About the Experts
Kimberly Hood, M.D., a board-certified OB-GYN in Destin, Florida.
Christine Vaccaro, DO, FACOG, a board-certified urogynecologist and sexual medicine specialist practicing in Bethesda, Maryland.
Estrogen Prevents Recurrent UTIs in Perimenopause and Menopause
In younger women, UTIs often stem from bacteria entering the urethra during sex. But in menopause, declining estrogen is the primary driver of infections.
Estrogen receptors are abundant in the tissues of the vagina and urinary tract. When levels of the hormone are sufficient, it helps maintain an environment that discourages harmful bacteria from colonizing the urethra. Estrogen also supports blood flow and tissue elasticity, ensuring that the urinary tract remains robust and less susceptible to irritation and infection. 3
This is why vaginal estrogen is the standard of care: The American Urological Society recommends that clinicians offer vaginal estrogen to all perimenopausal and postmenopausal women with recurrent UTIs. 4
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Let’s Get StartedHow Declining Estrogen Causes Menopause UTIs
Estrogen declines in perimenopause and menopause can cause physical changes to the urinary tract and vaginal microbiome that increase risk of UTIs.
A healthy vagina is colonized by lactobacilli, beneficial bacteria that thrive on glycogen produced by vaginal cells and act as a defense against UTI-causing bacteria, explains board-certified urogynecologist Christine Vaccaro, D.O. Lactobacilli create lactic acid, maintaining an acidic vaginal pH that prevents infection.
Declining estrogen leads to a less hospitable environment for lactobacilli, weakening a woman’s defenses against UTIs. Fewer glycogen-producing cells remain, lactobacilli levels plummet, and the vagina becomes more alkaline, which allows infection-causing bacteria like E. coli to flourish and make their way to the urethra from the surrounding skin, leading to UTIs, says Vaccaro.
Estrogen loss also leads to thinning and weakening of vaginal and urinary tract tissues, making it easier for bacteria to take hold. 5 6 Key changes include:
- Shortening of the urethra, increasing the risk of bacteria reaching the bladder
- Thinning of the lining of the urethra, making it easier for bacteria to travel
- Thinning vaginal walls, reducing glycogen production, and further disrupting the microbiome.
Vaginal Estrogen for Menopause UTIs
Unlike systemic estrogen therapy, which circulates throughout the body, vaginal estrogen is a localized form of menopause hormone therapy (MHT). It’s the gold standard treatment for preventing recurrent UTIs during menopause because it works directly on the tissues of the vagina and urinary tract, strengthening tissues and restoring vaginal microbiome balance to reduce the risk of infection. 7
Reduces UTI frequency and recurrence
Research consistently shows that vaginal estrogen significantly reduces UTI frequency. In one large study, menopausal women who used vaginal estrogen saw their average number of UTIs drop from four per year to just one—and a third had none at all. 8
Rebalances the vaginal microbiome
Vaginal estrogen fights UTIs by restoring a healthy pH balance and encouraging the growth of lactobacilli. 9 Recent studies confirm this: In one trial, 80 percent of women using vaginal estrogen experienced improved lactobacilli levels and vaginal acidity, compared to just 26 percent in the placebo group. 10
Improves vaginal and urinary tract tissue health
Restoring estrogen levels also supports vaginal tissue health, improving elasticity and lubrication that make UTIs less likely. Vaginal estrogen also helps with UTIs because it strengthens the lining of the urethra and bladder to improve muscle tone and urinary control. 11
Estrogen cream for interstitial cystitis
Interstitial cystitis (IC) is a chronic condition often mistaken for recurrent UTIs due to overlapping symptoms like bladder pain and frequent urination. Some research suggests vaginal estrogen may help reduce IC symptoms, though findings are mixed. 12 13
Types of Estrogen for UTI Prevention
Vaginal estrogen cream is often a top choice for preventing recurring UTIs in menopause, because it can also be applied directly to the area around the urethra with your fingertips. Two types of estrogen are available as cream: estradiol cream and estriol cream. Your healthcare provider will determine the best type and dosage for vaginal HRT, typically starting with daily use at bedtime and tapering off after the first few weeks, says Hood.
Other forms of vaginal estrogen for UTI treatment include:
- Estrogen rings: Vaginal estrogen rings are inserted and left in place for up to three months. They’re low maintenance (you can even have sex with one in), and less messy than estrogen cream.
- Estrogen tablets: Vaginal estrogen tablets like Vagifem are suppositories that you insert with an applicator. Like estrogen cream, they’re typically used daily at first, then reduced to twice weekly, says Hood.
The type of vaginal estrogen you opt for usually depends on personal preference—research doesn’t indicate that one type works better than another for UTI prevention. 14
When can you expect results?
Many women notice improvements like reduced UTIs and relief from vaginal dryness within about four weeks of trying vaginal estrogen, but it might take three to four months for it to reach peak effectiveness.
Side effects and warnings
Vaginal estrogen may cause mild side effects like itching, clear or white discharge, or nausea.
While vaginal estrogen carries an FDA black box warning about the potential for increased risk of stroke, blood clots, or probable dementia, this warning is based on data from clinical trials of high-dose systemic estrogen—the type that enters your bloodstream. 15
“If we were testing blood levels, there’s almost zero absorption of estrogen [in the whole body] when placed vaginally,” says Vaccaro.
She notes that vaginal estrogen is safe for all women, including those with a history of breast cancer. Research confirms this: A study published in the American Journal of Gynecology in 2025 concluded that vaginal estrogen was safe and effective in treating genitourinary syndrome of menopause in women with breast cancer. 16
Vaginal Estrogen vs. Antibiotics
Vaginal estrogen won’t treat an active UTI—antibiotics are necessary for that. Some doctors prescribe low-dose antibiotics to prevent recurrent UTIs in menopause, but overuse of antibiotics can also lead to antibiotic resistance, which makes future infections more difficult to treat. 17
If you need an antibiotic to treat an active urinary tract infection, take the entire prescribed course to avoid complications from undertreatment, says Hood.
Other Prevention Options for UTIs in Menopause
Beyond vaginal estrogen, other options may help prevent recurrent UTIs in menopause, including DHEA cream and lifestyle measures.
DHEA cream
Vaginal DHEA cream has been shown to reduce the number and frequency of recurrent UTIs within a year. 18 DHEA is an estrogen precursor that increases vaginal blood flow and improves the integrity of the vaginal lining, which can help prevent bacteria from entering the urinary tract.
Women who prefer to avoid vaginal estrogen may consider DHEA, which improves estrogen levels and decreases vaginal pH.19 However, DHEA cream shouldn’t be used alongside vaginal estrogen cream, as combining both can lead to excessive estrogen levels and side effects like insomnia and headaches.
Lifestyle approaches
Certain lifestyle measures can also help prevent UTIs, especially when used alongside local estrogen therapy. These include:
- Probiotics: Studies suggest that vaginal probiotics, particularly those containing Lactobacillus can reduce the incidence of recurrent urinary tract infections (UTIs) 20.
- Cranberry extract and D-mannose: A 2022 review found both may help prevent UTIs by preventing bacteria from adhering to the urinary tract. 21
- Staying hydrated: A 2018 randomized clinical trial found that increasing daily water intake significantly reduced recurrent UTIs in women, likely by flushing bacteria from the urinary tract. 22
The Bottom Line
Recurrent UTIs are common in menopause due to estrogen loss and its effects on vaginal and urinary tract health. Vaginal estrogen is a safe, effective way to restore balance, strengthen tissues, and reduce the risk of chronic infections—offering real relief for many women.
