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Compared with women older than 55 years with recurrent urinary tract infections (rUTIs) who do not use vaginal estrogen, those who use have significantly lower rates of sepsis (19.4% vs 10.6%) and mortality (1.54% vs 0.42%), according to new data presented at the American Urological Association (AUA) 2025 Annual Meeting in Las Vegas.

Lead author Brennan A. Wells, a fourth-year medical student at East Virginia Medical School at Old Dominion University in Norfolk, Virginia, presented findings on a study that analyzed real-world information in the large database Epic Cosmos from more than 2 million electronic health records over 3 years and multiple health systems. The abstract was published in the May issue of The Journal of Urology.

Fewer Hospitalizations With Vaginal Estrogen

Rates of hospitalization were also lower for the older women with rUTIs who used vaginal estrogen (4.06% vs 5.16%; P < .001).

Differences in the sepsis and mortality rates were not significant for the women younger than 55 years whether they did or didn’t use vaginal estrogen. Hospitalization rates were slightly higher for the younger women who used vaginal estrogen than those who didn’t use it (3.86% vs 3.03%; P < .001).

The incidence of rUTIs is particularly high in postmenopausal women because of physical changes including low estrogen, which can alter the microbiome, pH changes, and cell structure, all of which can make them more susceptible to UTIs, the authors wrote.

The data shed light on an understudied topic, Wei Lee, MD, director of Female Pelvic Medicine and Reconstructive Surgery at The Smith Institute for Urology, Northwell Health, in New York City, told Medscape Medical News.

Vaginal estrogen is effective in treating many symptoms of menopause — such as pain; itching and burning; pain with intercourse; urinary, vaginal, and yeast infections; and urinary urgency, noted Lee, who was part of an AUA committee who chose to feature the poster in the oral presentations.

However, “there’s not a lot of research that looks at the next step — is this protecting women from getting really sick and going to the hospital or dying,” he said. “These data offer insight into preventing some of these infections.” 

He said he sees a surprising number of older women in his office who have had rUTIs and have been hospitalized and may have pain with sex and “no one has ever offered them vaginal cream.”

Prevention Benefits Often Overlooked

He said he hopes these data encourage clinicians to ask patients about vaginal dryness or pain with intercourse and added that the focus sometimes is just on treating an infection with antibiotics and not determining the cause and looking at how to prevent future infections.

These data will be of interest to a wide variety of clinicians, including hospitalists, who see postmenopausal women who may get severely ill from their UTIs; emergency medicine physicians; gynecologists; primary care doctors; and urogynecology and pelvic medicine specialists as well, he noted.

The cost of the cream can be a barrier, Lee acknowledged, but “a savvy doctor can still get the patient the medication through other sources such as a compounding pharmacy…and get the medicine to patient in the $20-$30 a month range.” 

From guidelines and a wealth of data, he said, “We understand there is safety in using (estrogen) as a topical vaginal cream. When you take it as a pill or skin patch, you may have an elevated risk for things such as cancer or blood clots, but when used as a vaginal cream all the studies have shown that it is safe to use.”

“It’s rare in medicine where we can prescribe and give a patient something with benefits and really no downside in risk,” Lee said. “It’s a little extra time — three times a week before bedtime inserting a vaginal cream. But the benefits, especially what this study is showing in terms of keeping patients out of the hospital, are very impactful.”

Wells and Lee reported no relevant financial relationships.

Marcia Frellick is a Chicago-based healthcare journalist who regularly covers primary care, cardiology, pediatrics, oncology, and infectious disease.