Vaginal Estrogen, UTIs, and GSM: Why Label Changes Matter for Women’s Health

For clinicians and patients who routinely witness the devastating impact of recurrent urinary tract infections (UTIs) on women’s lives, recent updates to vaginal estrogen labeling are long overdue. For decades, fear—not science—has prevented one of the most effective, safest treatments from being widely prescribed.

The root of the issue lies in a misunderstood condition known as genitourinary syndrome of menopause (GSM) and outdated warning labels that have discouraged appropriate care.

What Is Genitourinary Syndrome of Menopause (GSM)?

GSM is a chronic condition caused by declining estrogen levels during perimenopause and menopause. Estrogen receptors are abundant in the bladder, urethra, vagina, and pelvic tissues. When estrogen declines, these tissues undergo structural and functional changes (Portman & Gass, 2014).

Symptoms of GSM include:

• Urinary urgency and frequency

• Recurrent urinary tract infections

• Pain with intercourse (dyspareunia)

• Vaginal dryness and irritation

• Burning with urination

• Increased risk of urosepsis in older women

(Portman & Gass, 2014; NAMS, 2022)

GSM is progressive if left untreated and does not resolve on its own.

Why UTIs in Menopausal Women Are a Serious Health Issue

UTIs are not just uncomfortable. In postmenopausal women, they are associated with:

• Increased antibiotic exposure

• Rising antimicrobial resistance

• Emergency room visits and hospitalizations

• Sepsis and, in severe cases, death

(Recurrent UTIs cost the U.S. healthcare system billions of dollars annually) (Foxman, 2014).

Postmenopausal women are especially vulnerable because estrogen deficiency alters the vaginal microbiome, reduces lactobacilli, raises vaginal pH, and weakens the urogenital epithelium—creating an environment where pathogenic bacteria thrive (Raz & Stamm, 1993).

Vaginal Estrogen Treats the Root Cause of GSM

Unlike systemic hormone therapy, low-dose vaginal estrogen works locally to:

• Restore urogenital tissue integrity

• Improve blood flow and epithelial thickness

• Normalize vaginal pH

• Reestablish protective lactobacilli

• Reduce recurrent UTIs by up to 50–70%

(Raz & Stamm, 1993; Perrotta et al., 2008)

Vaginal estrogen does not significantly raise systemic estrogen levels and is considered first-line therapy for GSM by major medical organizations.

The Problem With the Old Warning Labels

In 2003, following misinterpretation of data from systemic hormone studies (such as the WHI), vaginal estrogen products were assigned boxed warnings implying increased risks of:

• Breast cancer

• Stroke

• Blood clots

• Heart attack

• Dementia

These warnings were never supported by scientific evidence for low-dose vaginal estrogen (Crandall et al., 2020).

As a result:

• Clinicians avoided prescribing vaginal estrogen

• Patients were unnecessarily frightened

• Medical training programs failed to emphasize GSM treatment

• Millions of women were undertreated

What the Evidence Actually Shows

Large observational studies and systematic reviews demonstrate that low-dose vaginal estrogen does NOT increase the risk of:

• Breast cancer

• Cardiovascular disease

• Stroke

• Venous thromboembolism

• Dementia

(Crandall et al., 2020; Bhupathiraju et al., 2018)

Because systemic absorption is minimal, vaginal estrogen is considered safe for women of all ages, including those well beyond menopause, and is often appropriate even when systemic hormone therapy is contraindicated (NAMS, 2022).

Why Label Changes Are So Important

Labeling matters. It shapes prescribing habits, medical education, and patient trust. When warnings are inaccurate, they create barriers to care.

Correcting vaginal estrogen labeling helps:

• Improve UTI prevention

• Reduce antibiotic overuse

• Lower hospitalization and sepsis risk

• Improve quality of life and sexual health

• Educate a new generation of clinicians

This is not about convenience—it is about preventing serious harm.

Expert Care for GSM at Hormone Treatment Centers

At Hormone Treatment Centers, we recognize GSM as a medical condition, not an inevitable part of aging that women must endure. Our clinicians evaluate urinary, vaginal, and sexual symptoms comprehensively and offer evidence-based treatments, including vaginal hormone therapy when appropriate.

Treating GSM early can prevent years of discomfort, infections, and unnecessary medical complications.

References

Bhupathiraju, S. N., et al. (2018). Vaginal estrogen use and chronic disease risk. Menopause, 25(11), 1284–1291.
Crandall, C. J., et al. (2020). Breast cancer risk after use of estrogen plus progestin and estrogen alone. JAMA, 324(4), 369–380.
Foxman, B. (2014). Urinary tract infection syndromes. Nature Reviews Urology, 11(9), 513–525.
North American Menopause Society. (2022). The 2022 hormone therapy position statement. Menopause, 29(7), 767–794.
Perrotta, C., et al. (2008). Oestrogen for preventing recurrent UTIs in postmenopausal women. Cochrane Database of Systematic Reviews, (2), CD005131.
Portman, D. J., & Gass, M. L. S. (2014). Genitourinary syndrome of menopause. Menopause, 21(10), 1063–1068.
Raz, R., & Stamm, W. E. (1993). A controlled trial of intravaginal estriol in postmenopausal women. New England Journal of Medicine, 329(11), 753–756.