The Gap Between What We Know and What You've Been Told
On recurring UTIs, vaginal estrogen, and the distance between what the evidence shows and what women are actually told.
If you're a man — this one's for you too. You were born from a woman*, likely love one in your life, or are raising one. The women in your life are navigating a healthcare system that often lets them down. Consider this a page in your guide to showing up — and knowing how to advocate for them.
Somewhere between the cranberry supplements, being told to wipe front to back, pee after sex, and another round of antibiotics, someone should have told you there was a better answer — especially if you're navigating perimenopause or menopause.
On a population level, urinary tract infections (UTIs) are the most common outpatient infections in the United States, with a lifetime incidence of 50–60% in adult women. Consultations for UTIs account for 1–6% of all medical visits, representing roughly 7 million visits annually. The economic burden of recurrent UTIs in the United States alone has been estimated at more than $5 billion per year. In elderly populations, UTIs are associated with a significant burden of morbidity and mortality. Recurrent UTIs are independently associated with symptoms of anxiety and depression, reduced social participation, and measurably impaired quality of life.
When a woman develops symptoms of a urinary tract infection, she'll likely go into a provider's office or urgent care, pee in a cup, and if her urine shows signs of infection (also a nuance), she'll be prescribed an antibiotic — which is the appropriate treatment when there is a true infection. 57% of first-time urinary tract infections are resistant to one class of antibiotics, and we are seeing a significant rise in multi-drug resistant organisms causing UTIs. Of the two most used antibiotics for urinary tract infections, 1 in 5 UTI-causing bacteria are already resistant.
Antibiotics absolutely have a crucial role in treating significant infections. They are lifesaving and are perhaps one of the most significant contributions to life expectancy in the history of medicine AND they are not benign. They can wreak havoc on our microbiome, with some strains never returning to pre-antibiotic baseline. They can cause dysbiosis, allowing "bad" strains of bacteria in our gut to overtake the good ones. A balanced microbiome is crucial for immune system function and metabolism, and emerging evidence points to likely gut-brain axis disruption as well.
Medicine has a solution that is inexpensive, accessible, and prevents UTIs by 60% and most women are never offered it: low-dose vaginal estrogen. To put 60% in perspective: most drugs developed specifically for UTI prevention don't come close to that number. In preventive medicine, a 30% reduction in a major disease event is considered a landmark outcome — it's what the best cardiovascular drugs achieve. Vaginal estrogen reduces recurrent UTIs by 60%. That number deserves more attention than it gets and it gets there as a side effect of simply restoring what was already there.
There are two separate American Urological Association guidelines that state: "In perimenopausal and postmenopausal women with recurrent UTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication to vaginal estrogen therapy." There is nearly no contraindication for low-dose vaginal estrogen. Vaginal estrogen is safe for nearly everyone: women with high risk or history of blood clots, history of estrogen-positive breast cancers, history of cardiovascular disease, stroke — name it. It is safe. What does that mean? What many people don't know about low-dose vaginal estrogen is that it is not systemic. The dosing for low-dose vaginal estrogen is enough to affect the local tissue but not enough to raise your total body estrogen to any meaningful level. Though vaginal estrogen is often part of a toolkit in hormone optimization therapy, it is not the part that increases estrogen in your whole body. There are countless women I see on a daily basis who have had multiple urinary tract infections, who have been referred to urology, who have seen numerous other providers, and who are still not on low-dose vaginal estrogen and have never been offered it. I would argue most women in perimenopause or menopause should be on vaginal estrogen for a number of reasons, and that if a woman in that category presents with even one UTI, she should be offered it.
“There are countless women I see on a daily basis who have had multiple urinary tract infections, who have been referred to urology, who have seen numerous other providers, and who are still not on low-dose vaginal estrogen and have never been offered it.”
Why is vaginal estrogen so important for UTI prevention? As estrogen declines in our vulva and urinary tract, the pH becomes less acidic and the healthy bacteria that protect our genitourinary system from harmful bacteria disappear. The tissue also becomes less lubricated and less elastic, creating a more vulnerable barrier through which harmful bacteria (and yeast, for that matter) can infect local tissue. Applying low-dose vaginal estrogen — available in cream, vaginal pill, ring, and suppository form — can reverse all of it.
What does this look like practically? The cream form is most common and the most accessible due to price. For the sake of brevity, I won't get into the other forms now, but if you don't mind paying more or your insurance covers it, great! Some women prefer the cream nonetheless because they can apply a little to the external tissue as well — and, bonus, it can increase blood flow immediately to your clitoris, acting a bit like Viagra for women. If your insurance doesn't cover it, print out a GoodRx** coupon and you'll pay around $35–40 for a little over three months' worth of cream. The cream has to be applied inside the vagina to acidify the bladder and urethra as well. The estrogen receptors in the vagina are in the first third — about fingertip to first knuckle, or approximately 2.5 cm. The tube comes with an applicator to measure and apply the dose. My personal opinion: use it once or twice to see what 1 gram of cream looks like, then toss the applicator. It works better and doesn't leak if you simply apply it with your finger, gently rubbing it into the tissue just before bed. You can have sex with vaginal estrogen in your vagina — it won't cause a male partner to become "estrogenized." First, a little-known fact: because it has been so deeply imprinted in us that women have estrogen and men have testosterone, most people don't realize that most middle-aged men have more circulating estradiol than most women in late perimenopause or menopause. Second, again, this is not a systemic estrogen. By the time it's diluted in your vagina and transferred to your partner, it's even less than the low dose you've used. And if you're still concerned, apply it after sex. It will take about two months of use for your genitourinary system to return to a healthy microbiome and pH.
The bottom line is this: recurrent UTIs are not an inevitable tax on being a woman in midlife, and another round of antibiotics is not the only answer. If you are perimenopausal or postmenopausal and have had even one UTI, you are entitled to a conversation about vaginal estrogen — and if no one has offered it to you, ask for it by name. If they dismiss it or try to make it sound scary, you need a new provider. If they don't know, educate them. Providers can't know everything, and the gap in education surrounding hormonal optimization is enormous — but the great ones will be open to learning from their patients. And if they're not, that tells you something too. The evidence is unambiguous, the safety profile is exceptional, and the cost is less than most copays. The gap between what the research shows and what women are actually being offered is not a knowledge problem. The science got there — but the conversation hasn't caught up yet. And the first step to closing that gap is knowing it exists.
*A note on language: I use "women" throughout for readability, but this applies to anyone with a vagina and urogenital anatomy — regardless of how they identify.
**Disclosure: I have no affiliation with or financial interest in GoodRx. I recommend it because it's one of the most reliable free tools I know for helping patients access medications at the lowest available cost.
Citations:
Journal of Infectious Diseases, Kaiser Permanente Southern California, 2023 Clinical
Infectious Diseases, 2021; SENTRY Surveillance Program, 2025
