It is common for patients with vulvas who are older than 50 years of age to present to the emergency department with symptoms of urinary tract infections (UTIs). They complain of urinary frequency, urinary urgency, pelvic pain, pain with urination, vaginal dryness, and constipation. Some have scary-looking urinalyses, and others never have positive cultures. We know from the “Choosing Wisely” campaign that we should (a) not treat asymptomatic bacteriuria and (b) not run urine cultures on asymptomatic patients, but as some of these women present again and again, what’s an emergency physician to do?

The answer should never just be antibiotics.

The answer should be antibiotics if there is an infection and treatment of the underlying problem to prevent the symptoms from happening again. This is a condition called genitourinary syndrome of menopause (GSM). As if hot flashes and night sweats weren’t enough, the lack of hormones after age 50 causes these significant genital and urinary symptoms. And unlike hot flashes, they don’t magically get better or go away with time. In fact, they just keep getting worse.

But all of this is not only treatable—dare we say, it is preventable.

What Is GSM and Why Does It Matter?

In a recent study, 68 percent of postmenopausal women with recurrent UTIs treated with vaginal estrogen alone did not go on to receive additional therapy.¹

GSM is a relatively new term that was established around 2014 to replace the diagnosis of vulvovaginal atrophy/atrophic vaginitis.² Not shockingly, describing anything as atrophic is deeply concerning to patients, and just as important, the term atrophy doesn’t describe the signs and symptoms of what actually happens to the genitals and urinary tract after hormone withdrawal.

GSM is essential for an emergency physician to understand, diagnose, and treat.

GSM is a chronic and progressive condition that has the potential to pose significant morbidity and even mortality to patients. Think about the 90-year-old nursing home patient with urosepsis. The source of the urosepsis is much more likely from her GSM than her 2-mm nonobstructing stone. And you can bet we would place her on FDA-approved vaginal estrogen or dehydroepiandrosterone, with refills lasting forever.

Without circulating estrogens and androgens, there is a loss of collagen and elastin, diminished blood supply, and a loss of an acidic environment, which changes the entire ecosystem of the genital and urinary tract. Because of these changes, women develop urinary frequency, urgency, dysuria, pelvic pain, and recurrent UTIs. Additional symptoms include vaginal dryness; dyspareunia; and difficulties with desire, arousal, and orgasm.³

Approximately 50 percent of postmenopausal women experience GSM symptoms, and 10 to 15 percent of women over 60 years old have recurrent UTIs.^4,5 Among women who are experiencing GSM symptoms, less than 10 percent are prescribed therapies; this discrepancy between prevalence and treatment is due in part to lack of patient education regarding GSM and the lack of physician-initiated assessment.⁶

There Is Hope for Patients and Prescribers

A promising development is the 2019 guidance of the American Urological Association (AUA) to include vaginal estrogen as a prophylaxis for peri- and postmenopausal women with recurrent UTIs to reduce future UTI risk (moderate recommendation, evidence level: Grade B).⁷ These treatment guidelines are an important initial step toward the medical community introducing the assessment and treatment GSM in its clinical practice.

The problem is that few women with GSM are prescribed vaginal estrogen, and many who get the prescription don’t use it properly, can’t afford it, stop using it, or fear using it because of misinformation and inappropriate FDA boxed warnings.⁸ 

But the crazy thing about this is that vaginal estrogen is a local treatment. It’s completely safe for essentially all women.⁹ In fact, there are very few women over 50 for whom we wouldn’t recommend the use of local vaginal estrogen. For hormone-sensitive cancers (breast and some endometrial), we always pick up the phone and talk about it with the patient’s oncologist, and after a collegial discussion, most of these women are encouraged to use it. 

Figure 1: Pharmacological Treatments for GSM

There are no data—none—showing that local vaginal estrogen causes cancer, cardiovascular problems, stroke, dementia, or any other issues. In fact, two decades of research show just the opposite. Even studies in women who have gynecological cancers show no issues using local vaginal estrogens.^10,11 We prescribe and encourage this therapy in our patients with breast cancer or a family history of breast cancer as well as those who are worried about breast cancer.

Let’s Look at a Quick Example

At one point during gestation, pregnant patients will have systemic estrogen levels of roughly 3,000 pg/mL. At the same time, if we measured the estrogen level in the biological fathers of these pregnancies, we would expect levels of roughly 25 pg/mL. Menopausal women’s systemic estrogen levels are less than 5 pg/mL, and on vaginal estrogen, they remain at roughly 5 pg/mL. Our point? Local vaginal estrogen does not impact the amount of estrogen in your bloodstream. How is it going to cause tumor growth, dementia, or blood clots? It’s not, and it doesn’t.12 A birth control pill has different risks than an IUD, which has very different risks from local vaginal estrogen. All hormones are not the same.

Perhaps now you are sold on this diagnosis and its treatment, but how do you do it because standard emergency medicine training does not include this particular therapy? Starting local vaginal hormone therapy is easy and should be started in the emergency department. There are some key points to remember when explaining the therapy to patients:

1. There are lots of options out there, including inserts, gels, and rings.
2. If cost and insurance coverage are issues, generic estradiol 10-mcg inserts are typically $40/month with a cash price and GoodRx coupon. Advise one vaginal insert daily for two weeks, then twice weekly indefinitely.
3. It may take as long as two to three months to see maximal benefit (remember the tissue must heal, which takes time).
4. It will only keep working if you keep using the therapy. For a woman who needs vaginal estrogen therapy, asking when the therapy should stop is like asking, “When can I stop brushing my teeth?” or “When can I stop wearing my seat belt?” Never. The answer is never.

The next time you encounter a postmenopausal women with recurrent UTIs, think about GSM, an essential and easily treatable diagnosis for emergency physicians who care for older women.

Dr. Ashley Winter (@AshleyGWinter) and Dr. Rachel Rubin (@drrachelrubin), two renowned urologists who focus on sexual medicine, joined forces with emergency physician Dr. Howie Mell (@drhowiemell) to compose this article after a productive conversation sparked on Twitter about a better approach to patients presenting with recurrent urinary tract infections.

References

1. Chang E, Kent L, Prieto I, et al. Vaginal estrogen as first-line therapy for recurrent urinary tract infections in postmenopausal women and risk factors for needing additional therapy. Female Pelvic Med Reconstr Surg. 2021;27(3):e487-e492.
2. Portman DJ, Gass MLS, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):106-1068.
3. Simon JA, Goldstein I, Kim NN, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women’s Sexual Health (ISSWSH) expert consensus panel review. Menopause. 2018;25(7):83-847.
4. Simon JA, Kokot-Kierepa M, Goldstein J, et al. Vaginal health in the United States: results from the Vaginal Health: Insights, Views & Attitudes survey. Menopause. 2013;20(10):1043-1048.
5. De Nisco NJ, Neugent M, Mull J, et al. Direct detection of tissue-resident bacteria and chronic inflammation in the bladder wall of postmenopausal women with recurrent urinary tract infection. J Mol Biol. 2019;431(21):4368-4379.
6. Kingsberg SA, Krychman M, Graham S, et al. The Women’s EMPOWER survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment. J Sex Med. 2017;14(3):413-424.
7. Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU Guideline. J Urol. 2019;202(2):282-289.
8. Why the product labeling for low-dose vaginal estrogen should be changed. The North American Menopause Society website. Accessed Dec. 30, 2021.
9. Crandall CJ, Hovey KM, Andrews CA, et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. Menopause. 2018;25(1):11-20.
10. Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Vaginal estrogen use and chronic disease risk in the Nurses’ Health Study. Menopause. 2018;26(6):603-610.
11. Chambers LM, Herrmann A, Michener CM, et al. Vaginal estrogen use for genitourinary symptoms in women with a history of uterine, cervical, or ovarian carcinoma. Int J Gynecol Cancer. 2020;30(4):515-524.
12. Manson JE, Goldstein SR, Kagan R, et al. Why the product labeling for low-dose vaginal estrogen should be changed. Menopause. 2014;21(9):911-916.