Why You Should Consider Vaginal Estrogen

I hate to admit this, but it was only recently–and I mean embarrassingly, 6 months ago recently–that I learned how devastating and sometimes deadly urinary tract infections (UTIs) could be. I was at the New Pause Symposium in Brooklyn and urologist Ashley Winter, MD got up to speak, evangelize really, about the benefits of vaginal estrogen in women–especially once we hit the menopause transition and beyond.

She explained how UTIs are not just painful and annoying, but can have serious consequences like bladder infection/damage, kidney infection/damage, and even sepsis and death. A 2021 study in The Lancet also reported a connection between serious infections leading to hospitalization and cognitive impairment. 

Obviously the more infections you have, the higher your risk for serious complications. As women, our short urethra makes it easy for bacteria to contaminate the urinary tract and reach the bladder. So, we have more UTIs than men. By some estimates, 60% of females will have at least one UTI in their lifetime compared with 12% of males. Our risk for them shoots up as our estrogen levels decline, and we’re more likely to have recurrent UTIs postmenopause. A 2019 study found that even with antibiotic treatment, 19% to 36% of premenopausal and 55% of postmenopausal women have a high rate of recurrence. 

Why? Estrogen keeps the vaginal-area tissues thick, elastic, and moist, so the region is more resilient in general. Estrogen also promotes the growth of beneficial bacteria like lactobacilli, which help maintain the vagina's normally acidic pH. When estrogen declines during and after the menopause transition, these tissues thin, dry out, and become more fragile, muscles weaken, and protective bacteria decrease—making it easier for harmful bacteria to cause UTIs.

As active women, our risks may be even higher. We run, ride, swim, jump, lift, hike, and expose our vulvovaginal tissues to all kinds of friction, chafing, dehydration, and hot, damp environments where bacteria thrive (PSA: if you’re a cyclist, get out of those shorts asap after every ride).

This is where, along with the usual good health, hydration, and hygiene practices, it’s worth considering vaginal estrogen as an active midlife woman, especially once you get into the menopause transition and those tissues start to change–and they change for most of us, as up to 85 percent of women will experience some form of the genitourinary syndrome of menopause (GSM). 

More Comfort, Lower Infection Risk, Better Health

Vaginal estrogen, which is available in a ring, vaginal insert, tablet, or cream, is considered the gold standard, most effective treatment for GSM. It improves the quality of the tissues in and around the vagina, thickens the skin of the canal, increases natural lubrication, and restores normal pH of the vagina. 

According to experts at the American College of Obstetricians and Gynecologists, over time, vaginal estrogen can reduce risk of UTIs by more than 75%. It can also alleviate dryness, soreness, irritation, and other symptoms of GSM in 80 to 90% of cases. 

If you want to get mad, we’ve actually had great evidence of this since 1993, when this paper was published in the New England Journal of Medicine, concluding: “The intravaginal administration of estriol prevents recurrent urinary tract infections in postmenopausal women, probably by modifying the vaginal flora.” 

But vaginal estrogen has carried a “black box” warning since the WHI fallout that scares women (and sometimes their doctors) away even though vaginal estrogen is local and has a low to negligible effect on blood levels and has been deemed safe by The Menopause Society and can even be considered for breast cancer survivors. In fact, a 2025 study found that older women with breast cancer who were using vaginal estrogen had a 47% decrease in breast-cancer mortality and a 44% drop in overall mortality; the risks were lower even among those with hormone-sensitive tumors. 

Winter puts it this way (per an Instagram post), “Using vaginal estrogen for UTI prevention is like brushing your teeth for cavity protection.” And you can use it forever to keep that active vagina healthy and protected throughout your life. I, for one, intend to do just that.