Is it a UTI … or Menopause?

Dr. Suzanne Gilberg explains why urinary symptoms in midlife aren’t always caused by infection—and the treatment too few women hear about.

By Meghan Rabbitt

It happens to far too many of us, especially in midlife and beyond: One day you’re happily living your life, the next you’re wincing in pain every time you urinate, canceling plans, and wondering if you’ll make it through the night without waking up ten times to use the bathroom.

Then comes a familiar pattern: You call your doctor, maybe get lab work done, hope you receive a prescription for an antibiotic, and finally feel some relief—until it happens again. You wonder if you’re doing something wrong. Should you be taking cranberry supplements? Wearing different underwear? Drinking more water? 

The truth is that these are the wrong questions, because for many women—especially during perimenopause and after menopause—symptoms that feel just like a urinary tract infection (UTI) have nothing to do with your hygiene habits or diet and everything to do with hormonal changes that affect the bladder, urethra, and vaginal tissues. Yet too many of us don’t know this, and our healthcare providers aren’t connecting the dots. 

That’s why Modern Prairie called ob-gyn and menopause specialist Suzanne Gilberg, MD. Here, she shares the facts we need to know about UTIs in midlife, the best ways to prevent and treat uncomfortable symptoms, and the overlooked therapy more women need to know about.

Fact #1: Your UTI symptoms may not actually be due to a UTI, but rather the Genitourinary Syndrome of Menopause (GSM).

If you’ve ever had a UTI, you know the symptoms—that burning feeling when you urinate, the strong, sudden, and frequent urge to go, discomfort and bloating, passing small amounts of (possibly cloudy, bloody, smelly) urine—all too well. But before you call your doctor and ask for a prescription for an antibiotic, it’s important to know that in midlife, those UTI-like symptoms may not be due to a bacterial infection. In fact, they may be due to the drop in estrogen that happens during and after the menopause transition, says Dr. Gilberg.

Here’s why: Estrogen keeps the tissues of the female urinary tract, vagina, and vulva plump, elastic, and moist. When estrogen levels drop during perimenopause and after menopause, the lining of the urethra and vagina gets thinner, blood flow to the area decreases (causing cells to produce less fluid and become dry), and the tissue loses collagen and elasticity, which can lead to a narrowing and shortening of the vagina. Low estrogen also impacts the balance of good and bad bacteria in the vagina, creating a scenario where the bad bacteria are more likely to prevail.

These changes result in a collection of symptoms known as the Genitourinary Syndrome of Menopause (GSM), which includes genital and vulvovaginal symptoms (such as vaginal dryness; burning, itching, or irritation in the vulva and vagina; tissue fragility, soreness, or small tears; and unusual discharge), sexual symptoms (such as pain during sex; shortening or tightening of the vagina; and low desire or difficulty with orgasm), and urinary tract symptoms (such as urgency, pain or burning when peeing, incontinence, and recurrent UTIs). 

Starting to see why so many of us might assume we have a UTI when really, it’s GSM caused by a lack of estrogen?

“For anyone who’s had UTIs in the past, it’s understandable that the minute you feel these symptoms, you’ll want to get on top of it to prevent getting really sick,” says Dr. Gilberg. “In perimenopause and menopause, the body we recognize changes, which can feel very disconcerting.” 

The antidote is information. When you know your symptoms might be a result of GSM and not a UTI, it can help you ask better questions and advocate for yourself.

Fact #2: It’s important to have a conversation with your healthcare provider about your symptoms.

Years ago, you may have felt the telltale signs of a UTI coming on, called your doctor for an antibiotic, and that was that. In midlife, it’s important to make an appointment with your healthcare provider to specifically talk about your symptoms and to ask if what you’re experiencing may be GSM.

GSM is widely underdiagnosed, and one reason for this is because patients don’t bring up these symptoms proactively with their doctors, says Dr. Gilberg. “I get it—doctors are really busy, which is why so many patients self-diagnose or use an over-the-counter UTI strip and make a call for an antibiotic.” However, this isn’t how you’ll get the best care. 

If you have a relationship with your primary care physician or ob-gyn, make an appointment specifically to talk about any changes you’ve noticed in your vulvovaginal anatomy and any symptoms you have. 

“Think of your doctor as your partner, and go into that appointment assuming they want to provide the best care,” says Dr. Gilberg. 

If you feel like you’re getting the brush-off, make an appointment with a menopause specialist or a urologist who specializes in women’s health care, adds Dr. Gilberg.

Fact #3: Women do become more susceptible to UTIs in midlife.

While many women are diagnosed with UTIs when really what they’re dealing with is the symptoms of GSM, it’s important to realize that GSM does put women at increased risk for recurrent UTIs. One reason is because in a low estrogen state, the tissues of the urinary tract and genitals become thinner, which means you have less of a barrier to fight off bacteria from entering the urinary tract, explains Dr. Gilberg. 

“Add to that the fact that the vaginal microbiome shifts so that bad bacteria are more likely to thrive, and it’s a perfect storm for inflammation, irritation, and infection.”

Fact #4: Any time a woman experiences a loss of hormones, her risk of urinary tract symptoms goes up.

If there’s a younger woman in your life struggling with recurrent urinary tract symptoms, know this: There are a number of scenarios that can prompt a loss of hormones to the vulvovaginal tissue and urinary tract, which can ultimately cause inflammation and symptoms that look and feel like a UTI even when there’s no infection. 

For example, the postpartum period and breastfeeding can cause hormonal changes that deprive the genitourinary tract of the hormones it needs to thrive. So can taking oral birth control, medication for acne (such as isotretinoin, aka Accutane) or hair loss (such as minoxidil, aka Rogaine), or hormone therapies for cancer, fibroids, and endometriosis. 

Fact #5: Vaginal estrogen is a safe and effective medication for the prevention and treatment of UTIs and urinary tract symptoms—and too few women know about it.

If you are experiencing urinary tract symptoms or recurrent UTIs, the use of low-dose vaginal estrogen is an effective treatment that can also help prevent symptoms and infections from returning. What’s more, it’s safe for most women to use—even those who may not be a good candidate for systemic hormonal therapy.

“It’s important to talk to your healthcare provider proactively about vaginal estrogen, as we know that using it early and often can be helpful when it comes to preventing and treating genitourinary symptoms,” says Dr. Gilberg.

If your clinician hasn’t talked to you about vaginal estrogen, bring it up at your next appointment. The most recent guidelines by the American Urological Association clearly state that low-dose vaginal estrogen is an effective treatment for GSM, recurrent UTIs, and overactive bladder. You can print out the guidelines or have them handy on your phone to help you jumpstart a conversation with your clinician.

“Too often, women can feel victimized by their own experience because they’re not educated about their bodies and don’t have the resources they need,” says Dr. Gilberg. “When we have this information, we realize we have more power than we thought.” And that can help us reclaim our agency to recognize what’s happening, advocate for ourselves, and become true partners in our care.

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Meghan Rabbitt is a journalist and author of The New Rules of Women's Health.