How your hormones play a role in UTIs

This post was guest-authored by Jessica Price of Live UTI Free. Live UTI Free is an education and research platform for all-things UTI, and you can find many more resources there. So much about the urobiome and its interconnectedness with the rest of the body is still to be explored. From breaking down how UTIs behave and encouraging discussion between patients and clinicians to working with patients and researchers, Live UTI Free is working to further understanding around UTI in an effort to discover new treatment and prevention methods. 

While a simple concept, urinary tract infections (UTI) can actually be quite complex and influenced by a variety of factors, such as stress and hormones.

What are UTIs? 

More than 404 million people suffer from at least one UTI per year, the majority of which occur in women (1). This number is an alarming increase from the 150 million annual cases determined a couple decades ago. When recurrent and persistent UTI are also considered, the amount of cases per year increases yet again. 

A UTI occurs when one or more pathogens begin dominating the environment within the urinary tract, and the body’s immune system is unable to eliminate them on its own. A round of antibiotics may be sufficient in treating the infection, however, 27-40% of UTIs in women recur within six months. For some, the infection is not eradicated and chronic symptoms can occur. Because of the physical, social, and mental impact, recurrent UTIs can be extremely debilitating (2). 

The urinary tract consists of the urethra, bladder, ureters, and kidneys, and an infection can occur at any point or multiple points along the tract. Short of sepsis (where the infection can spread to other tissues or the blood), the infection remains isolated to the urinary tract. Although the infection itself is confined, UTI symptoms can impact other areas of the body and may either remain consistent or shift with each recurrent infection. 

Symptoms of UTI

• Painful urination
• Urgency
• Frequency
• Incontinence
• Nighttime urination
• Blood in the urine
• Reduced stream
• Trouble voiding
• Double voiding 
• Post-urination dribbling
• Foul smelling urine
• Pelvic pain
• Vaginal pain
• Loin pain
• Flank pain
• Fatigue
• Fever

For women specifically, UTIs make up 25% of all infections (3), which also makes them the most common reason for emergency room visits. While they’re not commonly talked about, UTIs in women are far from uncommon. 

So why are women so prone to UTIs? Most of the medical literature focuses on anatomy, such as the female urethra being shorter than the male, and the female urethral opening being near the rectum, providing a shorter distance for bacteria to travel. 

But is it simply a matter of anatomy, or can hormones, menstrual cycles, and stress make females more vulnerable to these infections? 

Is There a Connection Between Our Periods and UTIs? 

If you’re premenopausal and have ever dealt with recurrent UTIs, there’s a chance you may have noticed a correlation with your menstrual cycle. Over 40% of females with urinary tract symptoms have a worsening of symptoms throughout their cycle, with the majority worsening just before or during their period (4). 

While researchers haven’t been able to definitively determine why this happens, individual studies around menstruation, estrogen, and the vaginal and urinary microbiomes have been completed. Using this research, theories as to why urinary symptoms fluctuate throughout the menstrual cycle have emerged. Let’s take a look at what we do know. 

What the research says about UTI and estrogen in premenopausal females

The urinary microbiome (urobiome) is the microbial environment of the urinary tract. It is the urobiome that is disrupted when an infection occurs. The urobiomes of menstruating females with both regular and irregular cycles have been mapped through a small study (5). This research revealed that each participant in the study had a unique makeup of bacterial organisms within the bladder. 

While unable to determine an ideal urobiome, because each urobiome examined in the study was unique, all participants exhibited similarities in how their microbiome responded to personal factors, such as menstruation and vaginal sex.  

One theory (that has not yet been tested) as to why symptoms worsen in response to menstruation is that the drop in estrogen before and during menstruation causes a dramatic shift in the urinary microbiome. 

It’s important to note here that while a change in the urobiome may lead to an imbalance of organisms, or dysbiosis, urobiome shifts do not always lead to dysbiosis. Furthermore, dysbiosis does not always lead to an infection and the need for antimicrobial treatment. Even in the absence of an infection, dysbiosis can result in lower urinary tract symptoms, and these symptoms may fluctuate throughout the menstrual cycle. 

In addition to estrogen levels possibly influencing the urobiome, estrogen is also a natural anti-inflammatory, which may help to keep symptoms at bay during the mid-follicular and mid-luteal phases, premenopause (6). 

To learn about UTIs postmenopause,  jump down to the section ‘Are UTIs more common during perimenopause and postmenopause?’. 

The vaginal-bladder microbiome connection

Another possible explanation as to why the risk of UTI may change with your menstrual cycle is because of the vaginal-bladder microbiome connection. Just as the urobiome shifts throughout the cycle, the vaginal microbiome fluctuates as well. 

During your period, microbial diversity in the vagina increases, while Lactobacillus (one of the primary beneficial vaginal organisms) decreases. In fact, due to either hormone or microbiome shifts, the prevalence of bacterial vaginosis (BV) is higher during the first two weeks after the onset of a period (7).  

In addition to being central to the health of the vaginal microbiome, evidence suggests that Lactobacillus is also healthy within the bladder, as it can kill some UTI-causing bacteria. Because the two microbiomes are interlinked, there is a possibility that the decrease in vaginal Lactobacillus during menstruation could impact the bladder, making it more susceptible to pathogens. 

While science has come a long way in understanding the vaginal and urinary microbiomes, more research is needed to understand the connection between UTIs and periods and how hormones may be playing a role. 

Are UTIs More Common during Perimenopause and Postmenopause?

Through perimenopause and into postmenopause, the risk of UTI increases (8). Apart from an increased risk between the ages of 14 and 24, the risk of UTI increases with age, with females over age 65 having twice the risk of developing a UTI compared to the overall female population. 

In fact, UTIs are the most common type of infection in females over 65. Unfortunately, similar to the lack of understanding around why menstruation affects UTIs or urinary symptoms, there are still many questions to be answered about menopause and UTI. 

At this time, the increased risk with age is thought to be caused by the drop in estrogen, which supports the vagina and bladder both structurally and by promoting food sources for ‘good’ bacteria. Estrogen strengthens the integrity of the vaginal and urinary walls, making bacterial penetration into the tissues more difficult. As estrogen decreases, the integrity of the epithelial tissues is compromised, allowing bacteria to burrow into the layers of the bladder (9).

Estrogen also plays an important role in the production of Lactobacillus and maintaining the health of the vaginal microbiome. Estrogen promotes production of glycogen, a food source for Lactobacillus, that sits on the surface of the vaginal walls. As the Lactobacilli consume the glycogen, they multiply and produce a by-product called lactic acid. This creates a protective environment. 

As females move through menopause and estrogen decreases, the Lactobacilli have a decreased food source, resulting in less production of the protective lactic acid. Thankfully, estrogen replacement has been shown to increase Lactoabcillus and reduce the recurrence of UTI in menopausal females (10).

While this evidence suggests that a drop in estrogen may play a role in UTI development, without further research the connection remains theoretical.

Can Stress Cause a UTI?

When discussing hormones, reproductive hormones such as estrogen, progesterone, and testosterone are commonly the focus. However, cortisol, another prominent hormone in the body, can be strongly associated with the state of your health. 

Among its many functions, cortisol is responsible for regulating how your body responds to stress, and it affects almost every organ. During short term stress, the release of additional cortisol can be beneficial, even life-saving (11). Short bursts of cortisol even give a boost to the immune system, making it easier for your body to fight off pathogens, such as those that cause a UTI.  

When chronic, long-term stress becomes a factor, cortisol levels may remain elevated (12). This continual elevation negatively impacts the health of the body, including the immune system. An infection can result from a small pathogen load that the body may otherwise be able to fight off. The risk of developing a UTI or being unable to effectively heal from a UTI is increased as the immune system is dysregulated due to stress. 

Furthermore, stress may increase the risk of UTI as a result of dysbiosis, or an imbalance in the microbiome. The bladder is not sterile, so when the urinary microbiome becomes disrupted, lower urinary tract symptoms may result (13). 

Studies examining how cortisol affects gut, oral, and vaginal microbiomes have been completed (14, 15, 16). To date, no studies have been completed looking at the relationship between cortisol and the urinary microbiome. Despite research in this area being limited, considering the vaginal-bladder interconnectedness, the dysbiosis of the vaginal microbiome in response to elevated cortisol may suggest stress-related urinary dysbiosis as well (17). 

How Can I Prevent UTIs?

While some risk factors for developing a UTI or recurrent UTIs are unavoidable, such as aging or stress, there are some steps you can take to help minimize risks associated with UTIs (18). 

Although primarily associated with menopause and perimenopause, low estrogen can occur during earlier stages of life as well. Hormone replacement therapy (HRT) can help to rebalance reproductive hormones and improve the health of the urogenital tract, decreasing the risk of UTI. For urinary or vaginal symptoms, a topical hormone cream is typically prescribed. 

The use of estrogen in HRT was long believed to increase the risk of breast cancer. However, recent studies indicate that this increased risk is likely due to the use of systemic, synthetic estrogen (19). When using bioidentical topical estrogen, no increased risk has been identified. 

HRT can be beneficial in preventing UTIs by helping to balance reproductive hormones, but it does not have a direct impact on the stress hormone, cortisol. High cortisol may be improved by taking steps to decrease stress in your life. While this is easier said than done, the list of online self-care recommendations and cortisol-lowering activities are virtually endless. You may consider speaking with a professional to help you identify the most effective ways to lower stress in your personal life.

It’s evident that hormones can play a big role in UTIs, but they’re not the only risk factor. We’d be remiss to not leave you with a few additional UTI prevention methods (18). 

UTI Prevention Methods

Sex

• Urinate after sex to flush the urinary tract 
• Avoid sex when healing from a UTI
• Consider testing yourself and your partner if UTIs occur after sex
• Avoid products that may be causing you irritation (e.g. certain lubricants, diaphragms, toys, etc.)

Urinary Habits

• Don’t hold your urine in longer than necessary
• Urinate approximately every two hours
• Develop healthy wiping habits (front to back)

Vaginal Health

• Use non-scented tampons or an alternative to tampons
• Avoid douching 
• Treat yeast infections and/or BV immediately and completely 
• Rule out STIs as a cause of urinary symptoms 

Products and Diet

• Avoid scented products with excess chemicals 
• Use a pH balanced bio-matched feminine wash
• Consider if birth control may be disrupting your estrogen levels
• Avoid the overuse of antibiotics: This can contribute to dysbiosis as well as antimicrobial resistance 
• Ensure you’re drinking enough water and limit caffeine and alcohol 
• Replace soda and sweetened drinks with water
• Consume anti-inflammatory foods and avoid foods high in histamine
• Avoid smoking

Steps to Take When Dealing with Recurrent UTIs

Whether hormones, stress, additional factors, or a combination of causes are resulting in chronic or recurrent UTIs in your life, there may be steps you can take to overcome these infections. 

Live UTI Free is an education and research platform for all-things UTI, and you can find many more resources there. So much about the urobiome and its interconnectedness with the rest of the body is still to be explored. From breaking down how UTIs behave and encouraging discussion between patients and clinicians to working with patients and researchers, Live UTI Free is working to further understanding around UTI in an effort to discover new treatment and prevention methods. 

References

1. Zeng, Z., Zhan, J., Zhang, K. et al. Global, regional, and national burden of urinary tract infections from 1990 to 2019: an analysis of the global burden of disease study 2019. World J Urol 40, 755–763 (2022). https://doi.org/10.1007/s00345-021-03913-0
2. K Maxwell, L Roberts, M Kramer, K Finlay, Using the Working Model of Adjustment to Chronic Illness to explain the burden of recurrent urinary tract infection: A survey-based study, International Journal of Pharmacy Practice, Volume 29, Issue Supplement_1, April 2021, Pages i5–i6, https://doi.org/10.1093/ijpp/riab016.006
3. Al-Badr A, Al-Shaikh G. Recurrent Urinary Tract Infections Management in Women: A review. Sultan Qaboos Univ Med J. 2013;13(3):359-367. doi:10.12816/0003256
4. Hextall, A., Bidmead, J., Cardozo, L., & Hooper, R. (2001). The impact of the menstrual cycle on urinary symptoms and the results of urodynamic investigation. BJOG : an international journal of obstetrics and gynaecology, 108(11), 1193–1196. https://doi.org/10.1111/j.1471-0528.2003.00280.x
5. Price, T. K., Wolff, B., Halverson, T., Limeira, R., Brubaker, L., Dong, Q., Mueller, E. R., & Wolfe, A. J. (2021, April 20). Temporal Dynamics of the Adult Female Lower Urinary Tract Microbiota. ASM Journals. Retrieved June 7, 2022, from https://journals.asm.org/doi/10.1128/mbio.00475-20?permanently=true 
6. Vegeto, E., Benedusi, V., & Maggi, A. (2008). Estrogen anti-inflammatory activity in brain: a therapeutic opportunity for menopause and neurodegenerative diseases. Frontiers in neuroendocrinology, 29(4), 507–519. https://doi.org/10.1016/j.yfrne.2008.04.001
7. Morison L, Ekpo G, West B, et alBacterial vaginosis in relation to menstrual cycle, menstrual protection method, and sexual intercourse in rural Gambian womenSexually Transmitted Infections 2005;81:242-247.
8. Thomas-White, K. (2022, February 26). Uti and menopause: Estrogen may improve recurrent UTI. Live UTI Free. Retrieved June 7, 2022, from https://liveutifree.com/uti-and-menopause/ 
9.   Ortega Martell, J. A., Naber, K. G., Milhem Haddad, J., Tirán Saucedo, J., & Domínguez Burgos, J. A. (2019). Prevention of recurrent urinary tract infections: bridging the gap                     between clinical practice and guidelines in Latin America. Therapeutic Advances in Urology. https://doi.org/10.1177/1756287218824089
10. Thomas-White, K. (2022, February 26). UTI and menopause: Estrogen may improve recurrent UTI. Live UTI Free. Retrieved June 7, 2022, from https://liveutifree.com/uti-and-menopause/#estrogeninbladder 
11. Dhabhar F. S. (2014). Effects of stress on immune function: the good, the bad, and the beautiful. Immunologic research, 58(2-3), 193–210. https://doi.org/10.1007/s12026-014-8517-0
12. Qin, Dd., Rizak, J., Feng, Xl. et al. Prolonged secretion of cortisol as a possible mechanism underlying stress and depressive behaviour. Sci Rep 6, 30187 (2016). https://doi.org/10.1038/srep30187
13. Hilt, E. E., McKinley, K., Pearce, M. M., Rosenfeld, A. B., Zilliox, M. J., Mueller, E. R., Brubaker, L., Gai, X., Wolfe, A. J., & Schreckenberger, P. C. (2014). Urine is not sterile: use of enhanced urine culture techniques to detect resident bacterial flora in the adult female bladder. Journal of clinical microbiology, 52(3), 871–876. https://doi.org/10.1128/JCM.02876-13
14. Farzi, A., Fröhlich, E. E., & Holzer, P. (2018). Gut Microbiota and the Neuroendocrine System. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics, 15(1), 5–22. https://doi.org/10.1007/s13311-017-0600-5
15. Duran-Pinedo, A.E., Solbiati, J. & Frias-Lopez, J. The effect of the stress hormone cortisol on the metatranscriptome of the oral microbiome. npj Biofilms Microbiomes 4, 25 (2018). https://doi.org/10.1038/s41522-018-0068-z
16. Amabebe, E., & Anumba, D. (2018, September 24). Psychosocial stress, cortisol levels, and maintenance of vaginal health. Frontiers in Endocrinology. Retrieved June 7, 2022, from https://www.frontiersin.org/articles/10.3389/fendo.2018.00568/full 
17.  Thomas-White, K., Forster, S.C., Kumar, N. et al. Culturing of female bladder bacteria reveals an interconnected urogenital microbiota. Nat Commun 9, 1557 (2018). https://doi.org/10.1038/s41467-018-03968-5
18. Kramer, M. (2022, March 2). 23 UTI prevention tips for recurrent UTIs. Live UTI Free. Retrieved June 7, 2022, from https://liveutifree.com/uti-prevention 
19.  Abenhaim, Haim A. MD, MPH; Suissa, Samy PhD; Azoulay, Laurent PhD; Spence, Andrea R. PhD; Czuzoj-Shulman, Nicholas MMA; Tulandi, Togas MD MHCM Menopausal Hormone Therapy Formulation and Breast Cancer Risk, Obstetrics & Gynecology: June 2022 - Volume 139 - Issue 6 - p 1103-1110 doi: 10.1097/AOG.0000000000004723

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