Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: a meta-analysis of randomized controlled trials

Abstract

Introduction and hypothesis

Recurrent urinary tract infections (rUTIs) are commonly encountered in postmenopausal women. Optimal non-antimicrobial prophylaxis for rUTIs is an important health issue. The aim of this study was to evaluate the use of estrogen in the prevention of rUTIs versus placebo.

Methods

Eligible studies published up to December 2019 were retrieved through searches of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. We included randomized controlled trials of estrogen therapies versus placebo regarding the outcomes of preventing rUTIs. Changes in vaginal pH and estrogen-associated adverse events were also analyzed.

Results

Eight studies including 4702 patients (2367 who received estrogen and 2335 who received placebo) were identified. Five studies including 1936 patients evaluated the use of vaginal estrogen, which resulted in a significant reduction in rUTIs (relative risk, 0.42; 95% CI, 0.30–0.59). Three studies including 2766 patients evaluated the outcomes of oral estrogen in the prevention of UTIs and showed no significant difference in the number of rUTIs compared to treatment with placebo (relative risk, 1.11; 95% CI, 0.92–1.35). Two studies reviewed changes in vaginal pH and showed a lower pH (mean difference, −1.81; 95% CI, −3.10−−0.52) after vaginal estrogen therapy. Adverse events associated with vaginal estrogen were reported, including vaginal discomfort, irritation, burning, and itching. There was no significance increase in the vaginal estrogen group (relative risk, 3.06; 95% CI, 0.79–11.90).

Conclusions

Compared with placebo, vaginal estrogen treatment could reduce the number of rUTIs and lower the vaginal pH in postmenopausal women.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Abbreviations

UTI:

urinary tract infection

rUTI:

recurrent UTI

References

  1. 1.

    Raz R, Colodner R, Rohana Y, et al. Effectiveness of estriol-containing vaginal pessaries and nitrofurantoin macrocrystal therapy in the prevention of recurrent urinary tract infection in postmenopausal women. Clin Infect Dis. 2003;36:1362–8.

    CAS  Article  Google Scholar 

  2. 2.

    Wawrysiuk S, Naber K, Rechberger T, Miotla P. Prevention and treatment of uncomplicated lower urinary tract infections in the era of increasing antimicrobial resistance-non-antibiotic approaches: a systemic review. Arch Gynecol Obstet. 2019;300:821–8.

    CAS  Article  Google Scholar 

  3. 3.

    Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. 1993;329:753–7.

    CAS  Article  Google Scholar 

  4. 4.

    Eriksen B. A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women. Am J Obstet Gynecol. 1999;180:1072–9.

    CAS  Article  Google Scholar 

  5. 5.

    Ferrante KL, Wasenda EJ, Jung CE et al (2019) Vaginal estrogen for the prevention of recurrent urinary tract infection in postmenopausal women: a randomized clinical trial. Female Pelvic Med Reconstr Surg.

  6. 6.

    Cardozo L, Benness C, Abbott D. Low dose oestrogen prophylaxis for recurrent urinary tract infections in elderly women. Br J Obstet Gynaecol. 1998;105:403–7.

    CAS  Article  Google Scholar 

  7. 7.

    Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev. 2008;2:CD005131.

    Google Scholar 

  8. 8.

    Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. Br Med J. 2011;343:d5928.

    Article  Google Scholar 

  9. 9.

    Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64:383–94.

    Article  Google Scholar 

  10. 10.

    Simunić V, Banović I, Ciglar S, et al. Local Estrogen treatment in patients with urogenital symptoms. Int J Gynaecol Obstet. 2003;82:187–97.

    Article  Google Scholar 

  11. 11.

    Dessole S, Rubattu G, Ambrosini G, et al. Efficacy of low-dose intravaginal estriol on urogenital aging in postmenopausal women. Menopause. 2004;11:49–56.

    Article  Google Scholar 

  12. 12.

    Brown JS, Vittinghoff E, Kanaya AM. Urinary tract infections in postmenopausal women: effect of hormone therapy and risk factors. Obstet Gynecol. 2001;98:1045–52.

    CAS  PubMed  Google Scholar 

  13. 13.

    Kirkengen AL, Andersen P, Gjersøe E, Johannessen GR, Johnsen N, Bodd E. Oestriol in the prophylactic treatment of recurrent urinary tract infections in postmenopausal women. Scand J Prim Health Care. 1992;10:139–42.

    CAS  Article  Google Scholar 

  14. 14.

    Lüthje P, Hirschberg AL, Brauner A. Estrogenic action on innate defense mechanisms in the urinary tract. Maturitas. 2014;77:32–6.

    Article  Google Scholar 

  15. 15.

    Meister MR, Wang C, Lowder JL, Mysorekar IU (2019) Vaginal estrogen therapy is associated with decreased inflammatory response in postmenopausal women with recurrent urinary tract infections. Female Pelvic Med Reconstr Surg.

  16. 16.

    Santen RJ, Mirkin S, Bernick B, Constantine GD. Systemic estradiol levels with low-dose vaginal estrogens. Menopause. 2019;27:361–70.

    Article  Google Scholar 

  17. 17.

    Simon JA, Maamari RV. Ultra-low-dose vaginal estrogen tablets for the treatment of postmenopausal vaginal atrophy. Climacteric. 2013;16:37–43.

    CAS  Article  Google Scholar 

  18. 18.

    Dudley R, Philip TH, Linda C. The effect of hormones on the lower urinary tract. Menopause Int. 2013;19:155–62.

    Article  Google Scholar 

  19. 19.

    Santen RJ. Vaginal administration of estradiol: effects of dose, preparation and timing on plasma estradiol levels. Climacteric. 2015;18:121–34.

    CAS  Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Contributions

Ying-Yu Chen: Protocol/project development, Data Collection and management, Data Analysis, Manuscript writing.

TH Su: Protocol/project development, Data collection and management.

HH Lau: Protocol/project development, Manuscript writing and editing.

Corresponding author

Correspondence to Hui-Hsuan Lau.

Ethics declarations

Financial disclaimer/conflict of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chen, Y., Su, T. & Lau, H. Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: a meta-analysis of randomized controlled trials. Int Urogynecol J (2020). https://doi.org/10.1007/s00192-020-04397-z

Download citation

Keywords

  • Estrogen
  • Post-menopause
  • Prevention
  • Recurrent urinary tract infection