If you’re in perimenopause or menopause, you’re probably already experiencing at least one symptom like hot flashes, sleep disturbances or weight gain. But wait, there’s more: Recurrent urinary tract infections (UTIs) and UTI-like symptoms are also common in menopause.

The good news? With the right care, you may be able to prevent them.

We asked ob-gyn and urogynecologist Dr. Timothy Chase of Novant Health Glen Meade OB/GYN:

• Why are UTIs more common for women in this life stage?
• What else might cause these symptoms?
• Can women in this life stage prevent recurrent UTIs — and if so, how?
• What’s the next step if you’re dealing with symptoms?

Recurrent UTIs in menopause and perimenopause

What is a UTI?

A UTI is an infection anywhere in the urinary system. In case you need a refresher, your urinary system includes your kidneys, ureters, bladder and urethra.

UTIs happen when bacteria enter the urethra and begin spreading.

UTI symptoms include:

• Urinating more often than usual
• Feeling a persistent urge to urinate
• Feeling pain or burning when urinating

Why are UTIs common during perimenopause and menopause?

The vaginal and urethral tissues are covered with estrogen receptors, and they’re dependent on estrogen to stay healthy.

As women go through perimenopause and menopause, their estrogen levels decrease — causing these tissues to become dry and fragile, weakening urethral tissues and making it easier for bacteria to enter the bladder, and changing the pH balance of the vagina. These changes make them more susceptible to UTIs.

It’s also common to have recurrent, or chronic, UTIs in this life stage; as a urogynecologist, Chase sees at least one woman a day who’s struggling with recurrent UTIs since entering menopause.

What are ‘recurrent’ UTIs?

Recurrent UTIs are when you’ve had had two separate UTIs within six months, or three UTIs within 12 months, confirmed by symptoms and positive urine cultures.

Why is a urine culture important when diagnosing UTI symptoms?

It’s important to distinguish whether you truly have recurring bacterial infections or if something else is causing the symptoms. “Not everything that looks like a UTI is a UTI,” Chase said.

If you go into your doctor with UTI symptoms, they’ll often order a urinalysis, a quick screening test that checks your urine for signs of infection. If your urinalysis is positive for signs of infection, and you’re having significant symptoms, many providers will go ahead and prescribe antibiotics.

But UTI symptoms and a positive urinalysis only suggest that you have a UTI. They don’t confirm the presence of bacteria in your urine or tell you what type of bacteria it is. There’s another test, called a urine culture, that can confirm whether you have a UTI and give you this additional information.

In a urine culture, a laboratory technician puts a small sample of your urine into a petri dish. In a positive urine culture, more bacteria grow in the sample over the next one to three days, and the type of bacteria causing the infection can be confirmed. This is important because different types of bacterial infection are susceptible to different antibiotics. The majority of UTIs are caused by E. coli bacteria.

In a negative urine culture, bacteria won’t grow at significant levels — indicating that something else, other than a UTI, is causing your symptoms.

A urine culture takes a few days, which is why providers may begin treating UTIs without a positive urine culture if symptoms are bothersome.

But if you’re having recurring UTIs, “be sure your provider orders a urine culture in addition to your urinalysis,” Chase said. “It gives us the best information.”

What should I do if I have a UTI?

Most UTIs require antibiotics to go away. Seek same-day treatment if you have a fever, nausea and vomiting or chills; seek emergency treatment if you have a high fever, blood in your urine or aren’t able to urinate at all.

If you’re having recurrent UTIs, tell your primary care provider. They will review your symptoms, medical history and test results; order more tests if necessary; and perform a physical examination to rule out other causes. If you need specialty care, your doctor may refer you to a urogynecologist like Chase.

Preventing recurrent UTIs during perimenopause and menopause

A UTI is almost always treated with antibiotics.

If you’re having recurrent UTIs, some doctors will prescribe low-dose antibiotics taken for months to prevent future UTIs from developing — but there are downsides, including antibiotic side effects and the possibility of the bacteria that is causing your infection to develop antibiotic resistance. So Chase often recommends these four options instead:

Estrogen cream: Chase’s “first and best” recommendation

Applying a topical estrogen cream to the area around your vagina and urethra can restore healthier tissues and a more normal vaginal environment — reducing your risk of recurrent UTIs.

Chase recommends that women with recurrent UTIs use estrogen cream three times a week for the rest of their lives: “The lack of estrogen and the changes in the genitourinary track and vaginal areas are lifelong, so you’re going to have to make a lifelong commitment to it,” Chase said.

Using vaginal estrogen reduces the risk of UTIs by more than 75% in post-menopausal women, the American College of Obstetricians & Gynecologists reports.

And you don’t have to have UTIs to get started: If you’re already dealing with symptoms like vaginal dryness, irritation and painful sex from the hormonal changes of menopause, estrogen cream often improves these symptoms while preventing future UTIs from developing.

Non-hormonal supplements

Non-hormonal treatments that may reduce the risk of UTIs include:

• Cranberry juice or supplements: Cranberries contain a substance called proanthocyanidins (PACs) that can prevent bacteria from sticking to bladder walls. Research shows that cranberry products such as 100% cranberry juice or cranberry pills may help prevent UTIs in women with a history of recurrent UTIs.
• D-mannose: This is a supplemental carbohydrate available as a tablet that prevents bacteria from sticking to the bladder walls. Published research is mixed, but Chase has seen great success with patients who take it. Because it is a carbohydrate, patients with diabetes should check with their doctor before taking D-mannose.
• Probiotic supplements: Probiotics have also been shown to prevent recurrent UTIs, and there is little downside: “A good-quality probiotic is not just good for your vaginal health — it’s also good for your gastrointestinal health,” Chase said.

What doesn’t work to prevent UTIs

• Improving your hygiene: “UTIs at this age are typically not the result of poor hygiene, wiping differently after going to the bathroom, or changing clothes more often,” Chase said. “That’s an oversimplification and can make women blame themselves for having a UTI. There's usually not something that they did that caused it; it’s happening because of their hormones.”
• Drinking more water: Although staying hydrated is important, drinking water doesn’t address estrogen levels, Chase said.

Other causes of UTI-like symptoms

“If a woman is repeatedly having UTI symptoms but her urine cultures are negative, the answer isn't just giving her a stronger antibiotic — we need to figure out together what the real diagnosis is and treat that accordingly,” Chase said. Some common diagnoses that your doctor needs to rule out include:

• Overactive bladder: This condition causes urinary urgency, frequent urination and leakage. Treatment options include pelvic floor physical therapy, medication, nerve-targeted procedures and Botox injections into the bladder wall.
• Pelvic organ prolapse: This happens when weakened muscles of the pelvic floor cause pelvic organs to drop out of position and into the vagina. It can affect bladder emptying. Surgical and nonsurgical treatment options exist; Chase typically recommends minimally invasive surgical options if symptoms are bothersome or getting worse.
• Interstitial cystitis (also known as painful bladder syndrome or IC): This chronic condition causes bladder pressure and pain, frequent urination, and a persistent urge to urinate — but urine cultures are negative for a UTI. To reduce symptoms, Chase recommends a specific anti-inflammatory diet that eliminates food and drinks that trigger bladder irritation.
• Asymptomatic bacteriuria: This happens when a person has a positive urine culture — indicating the presence of a UTI — but doesn’t have symptoms; most of the time, they don’t require any treatment.

Four key takeaways about UTIs during menopause

1. UTIs are common in women who are in perimenopause or menopause.
2. UTI symptoms don’t always mean you have a UTI.
3. If you have UTI symptoms, seek help — and make sure that your doctor orders urine cultures.
4. You can often prevent recurrent UTIs; estrogen cream is particularly effective at addressing the hormonal changes that lead to higher risk for UTIs.

The takeaway: “This is something we talk about and deal with every day,” Chase said. “My message to women is that they're not alone — and I‘d encourage them to get the care that they need and they deserve.”