If you’ re in your 40s and beyond and you constantly feel like you have to pee—even right after you pee—but peeing is difficult (especially at night), if you feel the need to scope out the nearest restrooms no matter where you are like when you were 8+ months pregnant “just in case,” or if you’re getting UTI after UTI, even when you’ve been on antibiotics, you’re experiencing one more symptom that’s common during this perimenopause season of life, my friend, and it can be so frustrating and even painful.
Since I’ve also had times when I was constantly on an antibiotic and still getting recurring UTIs, and since so many of you have said, “Oh my gosh, ever since I’ve been in perimenopause, I have gotten UTI after UTI after UTI, which sucks,” I knew it was time to dive deeper into what’s actually going on in our beautiful bodies.
Why are we getting so many UTIs?
Ep. 94: Hormones, Sex & Health at 44
Host: Heidi Powell | Focus: Recurrent UTIs, GSM, HPV Advocacy, & Vaginal Estrogen.
🚀 TL;DR (TOO LONG; DIDN’T READ)
Can perimenopause cause UTIs?
Yes. Declining estrogen thins the urogenital tissue, disrupts natural pH and protective vaginal flora, and leaves the bladder highly susceptible to persistent bacteria like E. coli.
The Estrogen-Bladder Connection: Why Recurrent UTIs Spike in Perimenopause
What causes that bladder pressure or the urge to pee when your bladder isn’t even full? What’s the deal with all of those UTIs? It’s all about the drop in estrogen levels during perimenopause. As estrogen levels fall and as you get closer to menopause, the linings of your urethra and bladder become drier, less elastic, thinner, and more fragile, a condition called Genitourinary Syndrome of Menopause (GSM) or urogenital atrophy. When this happens, your nerve receptors become hypersensitive, resulting in that phantom urge to go pee.
Another side effect of GSM can be frequent UTIs. Here’s what’s actually going on:
- 🔬 One of the many roles of estrogen is to stimulate cells in the urogenital lining to produce glycogen. Good bacteria, known as Lactobacillus, feed on this glycogen to produce lactic acid, keeping this area naturally acidic (pH 3.8–4.5) to ward off harmful bacteria.
- 📉 When estrogen drops during perimenopause and those tissue changes occur, the lining loses its glycogen supply. This causes local pH levels to become less acidic and weakens your natural defense barrier.
- ⚠️ All of this makes it easier for opportunistic gut bacteria like E. coli to move in and adhere to the unprotected walls of your urethra and bladder, leading to repeat UTIs.
The Defense Arsenal: D-Mannose, Vaginal Estrogen, and Probiotics
While recurrent UTIs can be more common during perimenopause, there are some products you can add to your anti-UTI toolbox that can help reduce the frequency of UTIs: D-Mannose, Vaginal Estrogen, and Probiotics.
A caution: You’ve probably heard of a product called AZO, which can help reduce any UTI-caused pain you might be feeling. But…AZO DOES NOT treat UTIs—it does not kill the bacteria or cure the infection. If you rely solely on AZO, any infection can continue to multiply and spread, potentially resulting in a kidney infection and even sepsis, which can be life-threatening. Please keep this in mind: AZO is only for pain relief.
D-Mannose
Most UTIs are caused by E. coli bacteria, which use microscopic, finger-like projections (called type 1 fimbriae) to latch onto the bladder wall, causing a UTI. Taking D-Mannose introduces free mannose sugar into the urinary tract to act as a decoy. The E. coli bind to the D-Mannose supplement instead of to your bladder lining and are safely flushed out when you pee. Taking D-Mannose can also increase the length of time between UTIs.
Vaginal Estrogen
Local, low-dose vaginal estrogen (creams, inserts, or rings) delivers micro-doses of estrogen directly to where it’s needed, offering a non-antibiotic treatment to help prevent UTIs. Vaginal estrogen can also thicken vaginal tissues, increase moisture, and improve elasticity in your bladder, urethra, and vaginal lining tissues. Plus, it won’t significantly affect your estrogen levels in your bloodstream. Ladies, our vagina is our power center, but we have to take care of it!
Vaginal Probiotics
I’m a huge advocate of probiotics. While probiotics formulated to help in the digestive tract are amazing, they don’t always contain the specific bacterial strains (specifically Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14) needed to keep your urogenital tract healthy and your pH balance where it needs to be to keep that harmful bacteria from causing UTIs. Vaginal probiotics can accomplish these tasks, helping to reduce the risk of and recurrence of UTIs.
I’m often asked: “If I’m already taking HRT, do I really need vaginal estrogen too?”
Here’s the simple truth: While systemic HRT (like oral pills or patches) circulates throughout your entire body to tackle hot flashes, brain fog, sleep issues, and other perimenopause symptoms, it doesn’t always deliver enough support directly to your urogenital tissue to stop repeat UTIs.
Systemic HRT treats the whole body, but vaginal estrogen acts as a targeted rescue mission. It goes straight to work right where it’s needed: Rebuilding the lining of your bladder and urethra, restoring your protective good bacteria, and reducing the recurrence of UTIs. Yes, please!
Click below to access three of my favorite perimenopause guides that can help you better understand the connection between hormonal changes, your gut microbiome (and how it shifts during this stage of life), estrogen detoxification, and balancing cortisol and metabolic changes.
All three of these tools in your anti-UTI toolkit can be used together, creating the ultimate defense system for your perimenopausal pelvic health.
Becoming the CEO of Your Own Health (Pap Smears, HPV, & Advocacy)
I cannot repeat this enough: Ladies, YOU need to be the CEO of your own health. Especially when a healthcare provider—even a well-meaning provider—advises something that goes against your gut.
Full disclosure: I have HPV—Human Papillomavirus, and I’ve had HPV since I was around age 25. Almost every single time I get a Pap smear, I remind my doctor that I have HPV. My body does not seem to be able to rid itself of the virus! Since my 20s, I have had at least three Pap smears where I’ve had abnormal cells pop up that require a colposcopy to make sure my cervix is okay. I’ve even had a colposcopy after an abnormal Pap smear that showed precancerous cells.
When it comes to Pap smears, here are the current recommendations from the American College of Obstetricians & Gynecologists:
- 🗓️ Age 21-29: Pap smear every 3 years
- 🗓️ Age 30-65: Pap smear + HPV test every 5 years OR a Pap smear alone every 3 years + an HPV test alone every 5 years. This is also the guideline if you’ve had HPV in the past but your immune system cleared the virus AND your recent Pap/HPV tests are normal. If you have persistent HPV or an abnormal history, your doctor should recommend more frequent testing.
- 🗓️ Age 65+: You do not need screening if you have zero history of cervical changes and either three negative Pap smears in a row, two negative HPV tests in a row, or two negative co-tests results in a row within the past 10 years. The most recent test should be performed within the past 3 or 5 years, depending on the type of test.
- **If you’ve been vaccinated against HPV, you still need to have Pap smear screenings.**
With my history of HPV and abnormal Pap smears, I’ve had to push back when providers suggest waiting three to five years between screenings. I tell my doctors point-blank: “Nope. I want one in a year.”
I never go more than a year. Ever. If I have to pay out of pocket to make sure I don’t have precancerous cells growing inside me, I will. I value my life far more than a doctor’s opinion, even a well-intentioned one.
If you ever find yourself facing pushback from a provider who tries to talk you out of a screening (a Pap smear or any other screening) you know you need, here is a powerful script you can use to advocate for yourself:
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“Would you mind putting in my record that when I told you I felt like I needed to get checked, your strongest recommendation was that I not get checked? Can you please put that in my record that way?”
This immediately shifts the conversation. It forces the provider to pause and reconsider their stance, knowing they are now accountable for documenting that they refused a screening if a health issue surfaces later. You are the CEO of your own health. Never hesitate to insist on the care and answers you deserve.
The Hard Conversations: Intimacy, Hysterectomy Fears, and Aging Gracefully
Solving the physical puzzle of repeat UTIs is crucial, not just for your bladder, but for your quality of life, your confidence, and your relationship.
It’s time for a candid conversation about that last one. When you experience Genitourinary Syndrome of Menopause (GSM), your tissues thin, lose their elasticity, and become drier and more fragile. This can lead to painful intercourse, micro-tears, and post-coital UTIs. There’s more: As estrogen levels shift, blood flow and nerve sensitivity decrease, making it harder to achieve orgasm or for sex to feel the way it used to.
Because of your powerful mind-body connection, these physical shifts—along with mood changes, body composition shifts, loss of fertility, or surgical procedures like a hysterectomy—can trigger a loss of sexual self-esteem. Fear, frustration, and physical pain can also create unintentional distance between you and your partner, because if it hurts to have sex, guess what? You’re not going to want to have sex. And then your partner might think you don’t love him or you don’t want to be intimate with him, and then it causes a rift in your relationship. You have to be open and honest with your partner. Try using this script to get the conversation started:
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“Hey, my body is changing, tissue is thinning, and sex is uncomfortable right now. But I want to fix it because I love you and I value our intimacy.”
These real, vulnerable conversations are essential to help you both understand this season of life and strengthen your bond.
Another thing I’ve experienced in this season of life is deep emotional grief and even shame. We spend so much time feeling ashamed of the changes taking place within our bodies, when all of those changes are literally biology. Here’s a powerful reminder for all of us: You are not broken. It is completely okay to grieve the body you used to have, and it’s okay to feel sad that things aren’t working or looking the way they used to. Give yourself grace. Lots of grace.
And please remember this: You are simply in a new season, and you don’t have to navigate it empty-handed. Here is your midlife intimacy defense kit:
✨ Your Midlife Intimacy Defense Kit
- 🌸 Topical/Vaginal Estrogen Therapy: Restores tissue mucosal thickness, elasticity, and natural moisture right where you need it.
- 🥥 High-Quality Lubricants & Moisturizers: Significantly reduce friction during intercourse. Coconut oil is my personal favorite!
- 🧘♀️ Targeted Pelvic Floor Physical Therapy: Helps maintain nerve response, muscle tone, and vascular blood flow.
- 🗣️ Honest + Open Communication: Being open with your partner is one of the most powerful tools in your arsenal.
Navigating perimenopause requires a different strategy than in past years, and you don’t have to live with repeat UTIs, painful intimacy, or dismissed symptoms. YOU are the CEO of your own health, so use this power to create the perimenopause plan that will serve you and your beautiful body for decades to come!
Xo,
Related reading:
Reclaiming Midlife Intimacy: Beyond the 30-Day Sex Challenge
Clearing Perimenopause Brain Fog: How to Recharge Your Mind
Stop Gaslighting Yourself: Is It Life Stress or Perimenopause? (How to Tell the Difference)
Sleep and Hormones: Why It’s Important For Weight Loss + Health