Dr. Winter on the use of vaginal estrogen in postmenopausal women with UTIs

In this video, Ashley G. Winter, MD, highlights data on vaginal estrogen and underscores the importance of the treatment option for postmenopausal women with recurrent urinary tract infections (UTIs). Winter is the chief medical officer of Odela Health in Los Angeles, California.

Video Transcript:

There is an iconic study in the New England Journal of Medicine [published] in 1993, and it's a controlled trial of intravaginal estriol. Estriol is a type of estrogen; it's a, some would say, weaker formulation, but it's a type of estrogen. So, "A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections". That's by Dr. [Raul] Raz. This was published in the New England Journal, and what they did is they took a bunch of postmenopausal women, and they randomized them either to placebo or to this low dose vaginal estrogen. What they found is that in women who were using this intravaginal estriol, their vaginal pH, which goes up after menopause due to the lack of estrogen, actually went down and normalized. The lactobacillus that is present premenopausally in the vagina repopulated in association with the vaginal pH going back down. In conjunction with the lactobacillus coming back–this healthy bacteria that's supposed to live in the vagina–there was a decrease in colonization of bacteria that are associated with infection. So, there was a decrease in colonization of organisms such as E. Coli in the vagina. And what they found was that in women who were on the placebo, there was an average over an 8 month follow-up period of almost 6 urinary tract infections, and in the women who used this low dose topical hormone, there was on average 0.5 urinary tract infections over the follow-up period. So, that's a difference between 6 and less than 1. This is not with the use of antibiotic prophylaxis, which is incredible. This is incredible. What it showed is that this low dose topical hormone resets the vaginal pH, allows this natural probiotic milieu to exist back in the vagina, and prevents colonization of pathogenic bacteria, thus leading to lower rates of infections, which incredibly potent. This was published 30 years ago, and it holds true for whatever type of low dose estrogen you use.

In light of that, a subsequent number of studies have come out using randomization, using retrospective data of large cohorts of women, [and] this finding has been very consistent. Coming out of that we now have both the American Urological Association guidelines on recurrent urinary tract infections in women, and the European Urology Association guidelines on urinary infections both recommend the use of vaginal estrogen for UTI prophylaxis in postmenopausal women. This is in guidelines in multiple consensus organizations, which is absolutely incredible. And I really don't think there's too much more to it than that. You are addressing the root causality. Anytime as a urologist you have a patient who is peri or postmenopausal who is coming through your door, and they have a history of a urinary tract infection, this should be the first thought in your mind. This is going to address root causes as opposed to using a prophylactic antibiotic or a long course of antibiotics. This will provide the physiologic reset to allow the person to fend off the bacteria.

Now, a lot of urologists say, "I don't feel comfortable doing that; this is hormone replacement, or this is the realm of a primary care doctor or this is the realm of gynecologist. That is something that we really have to do a lot of soul searching and change that paradigm. This is intrinsic to understanding the urinary tract of our patients and understanding their physiology.

This transcription has been edited for clarity.