PHYSICIAN SPOTLIGHT: Dr. K. Lauren de Winter talks UTIs and menopause

For the 1.3 million women entering menopause each year, the emergence of frequent bladder infections is an unwelcome rite of passage.  The familiar discomfort can create frustration and interruption to daily life and can easily ruin a vacation with a spouse.  It can be confusing to determine what is causing the painful symptoms to persist, when symptoms of menopause and a UTI overlap, PLUS the added opinions from Google on the subject. We spoke to Dr. Lauren de Winter (formerly Barnes), a urogynecologist at Complete Women Care in California, to better understand in this area, and provide some clarity on how menopause and UTIs intersect.

Q: Thanks for answering some questions for us, Dr. DeWinter! Can you tell us about your clinical background and about your work with women in menopause?

A: I received my medical training at Baylor College of Medicine and my residency in Obstetrics and Gynecology at Harvard’s Partners program. I completed fellowship training in Urogynecology at the University of New Mexico. My specialty is pelvic floor conditions, so most of my patients are in perimenopause transition or full menopause. I have a special interest in menopause related health conditions and have presented at national conferences on the topic.

Q: How do you know if you are in perimenopause, menopause, post-menopause? What are the symptoms?

A: A few years before your menstrual periods stop, the perimenopause transition begins. That is when the classic symptoms of menopause begin; hot flashes, night sweats, emotional lability, and changes in libido are the big ones. When no menstrual periods occur for more than 12 months, that’s menopause. So, for those years before menopause, vaginal bleeding can be erratic or heavy and all of those previously mentioned symptoms can continue. In the post-menopause phase, the loss of estrogen causes changes in the vaginal tissues which can lead to vaginal dryness, pain with sex, or recurrent bladder infections.

Q: So, when will most women start to experience these symptoms?

A: The average age of menopause is 51 in the US, but the symptoms can start 3-5 years before that as estrogen levels begin to drop. Unfortunately, menopausal symptoms can last for up to 10 years. The changes to the vaginal tissue can start anywhere from 5-10 years after estrogen levels decrease. These are reversible with estrogen treatment.

Q: It seems like there is some overlap there with common UTI symptoms?

A: It can be confusing. That loss of estrogen can cause changes in normal vaginal tissue and can make overactive bladder symptoms more common. Changes in vaginal discharge and urinary frequency and urgency can also easily be confused with a UTI.

Q:  Do these changes during menopause make women more susceptible to UTIs?

A: They absolutely do. Estrogen receptors are present in the bladder and urethra so atrophy occurs in those tissues as well, making the bladder more vulnerable to bacteria around the vaginal opening traveling into the bladder. The urethral length actually decreases, which increases the risk.

Q: Does this mean that you see a lot of menopausal/perimenopausal patients who are dealing with recurrent UTIs?

A: I see these women every day! One study demonstrated that 19% of urogynecological patients have recurrent UTIs. Most of these women are perimenopausal or postmenopausal since my typical patient is in her late 40s-60s.

Q: So a woman is entering the menopause age range and she’s dealing with recurrent UTIs. What do you usually recommend as a course of action?

A: In this age group, I’d recommend an evaluation including a pelvic exam to look for vaginal atrophy and a discussion of the possible risk factors. For some women, lifestyle changes or supplements work well, but many women require treatment with vaginal estrogen, antibiotics or urine acidifying agents. If their infections continue, sometimes we need to have a look into the bladder itself (with a camera or cystoscope) so we can rule out other causes of infections.

Q: What testing can you do to rule out a UTI or other infection (like candida/yeast infection)?

A: Traditional urine cultures are the most common test I use for straightforward UTIs (giving a urine sample in the clinic and then growing it in the lab). For other vaginal infections that can have similar symptoms (including Candida species, bacterial vaginosis, etc.) are evaluated using a PCR test from a vaginal swab (or they can sometimes be seen under the microscope). Another option that is becoming more widely available is an advanced diagnostic test (PCR and antibiotic sensitivity) that can differentiate between multiple types of bacteria or fungi for those with recurrent infections.

Q:  What more can you tell us about these advanced UTI diagnostics?

A: I am actually very excited about the advanced diagnostics as an additional tool in the kit. Advanced UTI diagnostics can look at a spectrum of bacteria and fungi from a single urine sample, which gives a better representation of what may be occurring within the bladder/lower urinary tract microbiome. Since menopausal women are at the highest risk of developing UTIs and often have atypical or hard to grow organisms, advanced diagnostics are going to be a powerful tool in helping them. Women in the perimenopause age range are also more likely to develop painful bladder syndrome or overactive bladder, so correctly diagnosing a UTI in these women is extremely important, since those symptoms can overlap.

I’m also really excited about the research potential of this technology. It will be so interesting when we can better understand the differences in the bacterial flora in postmenopausal women (that can manifest as bacteria in the urine even without symptoms or actual infections) versus the bacteria in a younger woman so that we can treat every patient appropriately.

>>Learn more about advanced diagnostics, like the MyUTI Test, and share information with your clinician about this testing for a recurrent UTI or vaginal infection, check out these resources for more information on testing.

Q: Sometimes women with recurrent UTIs are given hormone creams - why? Do they actually work?

A: Yes! Topical vaginal estrogen a couple of times a week has been shown to be as effective as daily antibiotics for UTI prevention. For one thing, thinning skin can be an issue for women in menopause and perimenopause and estrogen helps thicken those vaginal and bladder tissues.

But it can also help restore the microbiome to a more premenopausal state. The vagina becomes more acidic and the bladder is able to defend itself against infections.

Q: Let’s say someone has a history of UTIs, whether they are pre or post-menopausal. Is there anything you recommend that they do on their own, such as dietary changes or supplements?

A: Of course, you should always ask your doctor what is right for you, since everyone is unique. If a perimenopausal patient has recurrent UTIs, I will usually start with vaginal estrogen since it is low risk (the amount a woman absorbs keeps her estrogen in the menopausal range). It also works for vaginal dryness, and it works as well as systemic antibiotics.

Unfortunately, there’s no specific diet or cranberry product that has been conclusively proven to prevent UTIs. I’m often asked about direction of wiping after urinating or urinating after sex but there’s no real data backing that up either. Eating acidic foods or taking cranberry does work for some, but it can worsen overactive bladder in mature ladies. Several interventions are often necessary to find the right balance to prevent infections.

Q: Can we go back to antibiotics? What’s been your experience with patients overusing antibiotics to manage UTI symptoms?

A: Overuse of antibiotics is a huge problem and it’s led to many of my patients developing infections that are resistant to almost all treatment by the time I see them. Patients go to urgent care, primary care providers, other gynecologists and may be getting different antibiotic recommendations from each one in an attempt to feel better. Other women have been on daily antibiotic suppression for years, which can have severe health ramifications. Women feel like they have a UTI, they get treated with medications, but then cultures return negative over and over again, making treatment very difficult. These women are the ones who may benefit most from advanced UTI diagnostics.

BIG THANK YOU TO DR. DeWinter — Now you know!

Make sure to check in with your gynecologist or a urogynecologist if you are experiencing frequent UTIs and are entering into (or already there!) the next phase of life.  There are many tools in their diagnostic handbag to find a solution that is right for you.