Not using vaginal estrogen? Might be time you did.

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One benefit is it significantly cuts the risk of urinary tract infections. That alone could make it worthwhile.

Vaginas have their own microbiome. They’re colonised with bacteria that keep a healthy pH and protect against infection.

Estrogen is what ensures a good balance of this bacteria, as well as plumping up the vaginal tissue.

This handy hormone also supports the vagina’s close neighbour, the urinary system, keeping the bladder and the urinary tract (the urethra) functioning well.

Then along comes menopause and now we have way less estrogen.

Things change for the vagina: the bacterial balance might not be as healthy as it used to be, and the tissue gets thinner, maybe drier, less elastic.

But it’s not just the vagina. The urinary system is affected too, so we might need to pee more often, or with greater urgency, or we’re getting up more than twice a night to do it.

It’s only recently that the effect of estrogen loss on the urinary tract has been recognised.

You’re probably familiar with the delightful term ‘vaginal atrophy’. That’s been replaced by ‘Genitourinary Syndrome of Menopause’ (or GSM).

Clearly, it’s someone’s job to make sure medical language is universally awful, but this new terminology was meant to indicate that menopause affects both our genitals and our urinary anatomy.

While we don’t all experience the same symptoms, a 2020 study estimated that between 50-70% of us have some of them.


That’s a long introduction to talking about UTIs, but less estrogen and a changed microbiome mean less protection against infection, and a more vulnerable urinary system.

Not surprisingly, our risk of UTIs increases post-menopause, and some women get one infection after another.

This can spread to other areas such as the kidneys and the bladder, or cause sepsis, which is potentially fatal. And anyone whose immunity is compromised is at greater risk.

You might’ve also seen signs of delirium and disorientation in older people with UTIs. Sometimes, if an infection is particularly bad, cognition is affected long-term.

Estrogen aside, women are more susceptible to UTIs than men because of our anatomy. Our urethra, which carries urine from the bladder out of the body, is short and straight, so germs can easily travel from outside the body to the bladder.

Typical UTI symptoms include a burning sensation when we pee, abdominal or low back pain, cloudy urine, or blood in the urine, and possibly fever.

Treatment is with antibiotics, though some women can have strains that are resistant to the common ones. Antibiotics are a necessary evil, but none of us needs to take more of them than we need to.

We’re told that the way to avoid these infections is to stay hydrated (it’s true that summer is a busy time for UTIs), and to wipe ourselves from front to back, not the other way.

Both sensible pieces of advice, but we should also be told that using vaginal estrogen pessaries can reduce our risk of infection by 50% because these help to re-establish a healthy vaginal microbiome. They also help plump up the vaginal tissues.

A low dose (10 micrograms) is inserted into the vagina two or three times a week using an applicator the size of a small pen. The pessary itself is a tiny pellet.

Since this use of estrogen is localised it’s safe for breast cancer patients and can be used in conjunction with other forms of hormone treatment.

For women whose fingers aren’t as nimble as they used to be, there are other options, such as a soft estrogen ring that can be inserted in the vagina and lasts for about three months.

So far so good. Then, being a diligent patient, you read the ‘consumer medicine information’ that comes with your box of pessaries and wonder what horror you’re about to foist upon yourself.

Who knows what year that text was written, but the information seems wildly out-of-date and outlines all the possible negative consequences ever attributed to any type of hormone therapy.

It implies that if you use a low dose vaginal pessary, you’re at risk of everything from jaundice and high blood pressure to breast and endometrial cancer, blood clots and stroke.

Some forms and doses of certain types of hormone treatment have in the past been found to be problematic in women over 60. But not 10 mcg vaginal pessaries, for Heaven’s sake.

What it doesn’t talk about is the number of older women wearing incontinence pads, who curtail their lives for fear of wetting themselves, or the women who gave up on sex because it hurt, or those who think they get UTIs because they don’t wipe themselves properly, and assume it’s just their lot.

Estrogen pessaries won’t solve every woman’s issues: pelvises won’t go back to the way they were before childbirth and vaginas are never returning to their pre-menopausal state. But estrogen can certainly improve the health of the tissues.

Many GPs are proactive about recommending vaginal pessaries to their female patients, but not all. If you’re not already using them, it’s a conversation worth having.

And if your GP isn’t up to speed on menopause and all that it entails, talk to another one who is.


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