WHY DO WOMEN GET RECURRENT UTIS? (AND HOW TO PREVENT THEM)
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Episode 333:
Show Notes
This episode busts the biggest myth about urinary tract infections: recurrent UTIs are not a hygiene problem. Dr Lucy and Dr Mary explain why women are so much more prone to UTIs, what changes in perimenopause and menopause, how blood glucose plays a part, and the evidence-based ways to prevent them.
Episode summary
Fresh from her advanced life support training, Dr Mary joins Dr Lucy to talk about something far more common than a near drowning: the humble UTI. Mary starts with the message she wants every woman to hear. Recurrent UTIs are not a hygiene issue. Large-scale epidemiological studies have looked at behavioural risk factors, including the old advice to wipe front to back, and found no statistically significant link. If you get recurrent UTIs, it's not your fault. Dr Lucy even apologises to all the women she once told to wipe front to back, because that was what doctors were taught.
So why do women get them so much more often than men? Mostly anatomy. In women the urethra is very short and sits close to the vagina and anus, which both normally carry plenty of bacteria. Urine itself doesn't usually contain bacteria, so it's only a hop, skip and a jump for bacteria to reach the urethra and travel up into the bladder. In boys and men, a UTI is less common and usually prompts more investigation.
Dr Mary walks through the other risk factors. Genetics plays a part, possibly through the cell receptors in the bladder that E. coli can bind to. The vaginal microbiome matters too, with more lactobacillus creating a more acidic, less welcoming environment for UTI-causing bugs. Then there's the drop in oestrogen in perimenopause and menopause, which thins the urogenital tissue, changes the vaginal pH and makes it harder to hold on to healthy lactobacilli. No amount of wiping changes any of that. Douching and feminine wipes don't help either. As Dr Lucy says, the vagina is like a self-cleaning oven.
There's a metabolic link as well. High blood glucose spills sugar into the urine, and bacteria love sugar, so people with type 2 diabetes are more likely to get UTIs. Doctors will often check blood sugar in someone with recurrent UTIs. SGLT2 inhibitors, medications used for type 2 diabetes and heart failure, work by letting more glucose leak into the urine, so recurrent UTIs are a common side effect for both men and women who take them.
For prevention, Dr Lucy's number one is vaginal oestrogen. She discusses a large recent study of almost 1.9 million women with recurrent UTIs, which found that across every age group, not just women in perimenopause and menopause, being prescribed vaginal oestrogen was associated with lower rates of sepsis, hospital admission and death. It's cheap, easy to use and has very few side effects, and the black box breast cancer warning it used to carry has been removed. Dr Mary points out that oral and transdermal oestrogen don't do the same job. It needs to be applied to the vagina. The doctors also cover drinking enough water, emptying your bladder properly, cranberry products and a non-antibiotic antiseptic option to discuss with your doctor.
Key points
- Recurrent UTIs are not a hygiene issue. Large-scale studies of behavioural risk factors, including wiping front to back, have found no statistically significant link.
- If you get recurrent UTIs, it's not your fault and you're not dirty.
- Women get UTIs far more often than men, mainly because the female urethra is very short and sits close to the vagina and anus.
- Urine doesn't usually contain bacteria. The vagina and bowel normally do, and that's healthy.
- In boys and men, UTIs are less common and usually prompt further investigation. In children, a common cause is ureteric reflux, which can cause kidney damage if it isn't diagnosed.
- Genetics plays a role, possibly through the cell receptors in the bladder that E. coli binds to.
- A vaginal microbiome with more lactobacillus is more acidic and less friendly to the bugs that cause UTIs.
- The drop in oestrogen in perimenopause and menopause thins the urogenital tissue and changes the vaginal pH, which makes UTIs more likely.
- Douching and feminine wipes don't help and can make things worse. The vagina is self-cleaning.
- High blood glucose spills sugar into the urine, which feeds bacteria. People with type 2 diabetes are more likely to get UTIs, and recurrent UTIs are a reason to check blood sugar.
- SGLT2 inhibitors, used for type 2 diabetes and heart failure, increase glucose in the urine, and recurrent UTIs are a common side effect.
- Vaginal oestrogen is the doctors' number one non-antibiotic prevention for UTIs.
- A 2026 study of almost 1.9 million women with recurrent UTIs found that, in every age group from 20 to 99, being prescribed vaginal oestrogen was associated with lower rates of sepsis, hospital admission and death.
- Vaginal oestrogen is cheap, easy to use and has very few side effects. The black box breast cancer warning has been removed.
- Oral and transdermal oestrogen don't prevent UTIs in the same way. It needs to be applied to the vagina, as a cream or pessary.
- Drinking water, around one and a half litres a day or more depending on your climate and activity, lowers the bacterial concentration in the bladder and increases flushing.
- Take an extra moment on the loo to empty your bladder properly.
- Standardised cranberry products containing about 36 mg of proanthocyanidins (PACs) may reduce recurrence by around 30 to 40% by stopping E. coli sticking to the urinary tract wall. Check with your doctor or pharmacist about drug interactions.
- Methenamine hippurate (Hiprex) is a non-antibiotic antiseptic option to discuss with your doctor.
Practical takeaway
If you get recurrent UTIs, let go of the shame. It isn't about how clean you are. It's about anatomy, genetics, hormones and, sometimes, blood glucose.
Prevention starts with the basics: drink enough water, take the extra second to empty your bladder fully, and look after your metabolic health so your blood glucose stays in the normal range. If you're in perimenopause or menopause, or you keep getting UTIs at any age, ask your doctor whether vaginal oestrogen is right for you, along with options such as cranberry products or methenamine hippurate.
Read the study discussed in this episode
LaClair J et al. Vaginal Estrogen Prescription is Associated with Reduced Risk of Serious Adverse Outcomes in Women of All Age Groups with Recurrent Urinary Tract Infection: An Epic Cosmos Database Analysis. Urology 2026. https://pubmed.ncbi.nlm.nih.gov/42269780/
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Episode 333:
Transcript
Dr Mary Barson Hello lovely friend, I am Dr Mary Barson.
Dr Lucy Burns And I'm Dr Lucy Burns.
Both We are doctors, weight management and metabolic health experts. We are the creators of My Metabolic Action Plan, your two-step map to real health and weight loss, which is in fact the name of this podcast. Join MyMap now at rlmedicine.com.
Dr Lucy Burns (00:00) Good morning, lovely friend. Happy... I was about to say Tuesday, but it might be Wednesday, Thursday, Friday, whenever you're listening to this. Happy day, happy days, happy week. I am here with my gorgeous friend Dr Mary. Hello, friend, how are you?
Dr Mary Barson (00:14) I am good. I just did my advanced life support training. That was good fun to do, but also kind of stressful, as you're there dealing with these dummies that die and you have to resuscitate them.
Dr Lucy Burns (00:27) Yes, well, it's a good skill to have really, isn't it? Resuscitating people.
Dr Mary Barson (00:30) It is. It's useful out there in the world of medicine, no doubt.
Dr Lucy Burns (00:37) Yes. And this week we're talking about something that is not quite as dramatic, although it could be, and definitely much more common than perhaps a near drowning. And that is the humble UTI, or urinary tract infection. There are some links with metabolic health, but really this is a predominantly female issue, although men definitely get UTIs in later life related to prostate problems. But we're just going to bang on about UTIs today, because I think there's lots we don't know about them and there's lots that we can do about them. So let's just dive right in.
Dr Mary Barson (01:23) I would like to say that the first thing is it's not a hygiene issue. I can't count how many times I have seen women with recurrent UTIs who come in and just want to reassure me that they're very clean, that they do look after themselves, because they have this sense that they're dirty because they're getting recurrent UTIs. It is not a hygiene issue. There's that old adage to always wipe front to back. There is no evidence to support that. Large-scale epidemiological studies have actually looked at behavioural risk factors in women who repeatedly have UTIs, and there is absolutely no statistically significant link. So it's not a hygiene issue. If you get recurrent UTIs, it's not your fault. You're not dirty. You're just a bit unlucky, and we can talk about the ways in which you're unlucky now.
Dr Lucy Burns (02:21) Yeah, absolutely. And to all the women I told to wipe from front to back, I'm sorry. That was our training. That was what we were taught. And really, it was probably very unhelpful and perpetuated that myth of shame and uncleanliness. So basically there are things that predispose people to UTIs, particularly being female, and a lot of that is just the anatomy. All the bits are quite close together.
Dr Mary Barson (02:51) Yes, they are. The urethra, the vagina and the anus are all in really close proximity in female anatomy. And in women, the urethra, that is the little tube between the bladder and the opening, is very short. That is one of the main reasons why women are so much more prone to UTIs. And by UTIs we mean urinary tract infections, in case we didn't quite clarify that. Women just get them so much more commonly than men, purely because of the length of the urethra and anatomy.
Dr Lucy Burns (03:22) Yeah. And it's interesting, because urine itself is sterile. Urine doesn't have any bacteria in it, which again is a bit weird, because I'm pretty sure most people think wee is something very dirty. Wee has nitrates, which get a bit stinky when they're dried, and that's the ammonia smell. But it doesn't have bacteria in it usually. The vagina has lots of bacteria, and that is normal. The anal region obviously connects to the bowel, which is full of bacteria, good bacteria. It's all very normal, but they are all very close together. So you can imagine, as a little bacterium, it's only a hop, skip and a jump over to the female urethra and up into the bladder. Whereas for blokes, their urethra is miles away anyway, so it's much less common. And particularly with boys or men who get UTIs early, we tend to investigate that a lot more, because it usually indicates that there is something more significant going on.
Dr Mary Barson (04:31) That's right. We'd almost never do a urine test on a boy with a fever unless we really thought there was something going on. And then when we find a boy with a UTI, we're like, what is going on? So yes, just being a girl makes you far more likely to have them.
Dr Lucy Burns (04:46) Yeah, absolutely. And again, in kids who get UTIs, the most common cause is something called reflux, which is ureteric reflux, so urine refluxing from the bladder up the ureters into the kidney. Again, that's just unfortunate, not uncommon, and left undiagnosed can cause permanent kidney damage. So we do look for that. Any doctors who work with kids will know all about that and be treating it. But let's fast forward a bit and talk about your grown-up woman. What are her risk factors for getting UTIs? Because certainly some women do get recurrent UTIs. They're annoying. Tell us about it.
Dr Mary Barson (05:36) Yeah, so certainly the main one is being a woman. That's the biggest one. But genetics also plays a role. There are some women who are more genetically predisposed to UTIs, and it's possibly to do with the different types of cell receptors they have in their bladder that help defend the bladder against UTIs. Again, there's not much you can do about it. If they're there, they're just there. Some people have got receptors that the main bacterial culprit, E. coli, can just bind to better, and it can just have more fun in there. So genetics is definitely part of it.
The vaginal microbiome also plays a role, and there's a fair bit of genetics in that too. Some vaginal microbiomes can make UTIs more or less likely. Having more lactobacillus is good. It's more acidic, and it just makes the E. coli a little bit less happy, a bit more hostile to those bugs that would cause a UTI.
And then I think a big one is the hormonal changes that happen during perimenopause and menopause. A drop in oestrogen in particular changes what we call the urogenital tissue. It gets a bit thinner, and the vaginal pH also changes. That makes it harder to hang on to that healthy lactobacilli I just talked about, and it allows different types of gut bacteria to thrive closer to the urethra, which can then make urinary tract infections more likely. And there's no amount of wiping or anything that's going to change that. It's not a hygiene issue. It is just something that happens, and it gets worse with that hormonal shift and that relative drop in oestrogen.
Dr Lucy Burns (07:28) Yes, exactly. And I think it's interesting, isn't it? Because I know we're banging on about it not being a hygiene problem, but so many women are kind of paranoid about hygiene down there. Back in the olden days there was douching, and even still there are really unscrupulous companies selling feminine wipes and all that sort of stuff. To be honest, none of that is helpful. The vagina is like a self-cleaning oven.
Dr Mary Barson (07:49) Yeah. They can make it worse.
Dr Lucy Burns (07:58) It sorts itself out unless something has come in to disrupt it. So antibiotics, douching, sometimes medications, things like that, and sexually transmitted infections. But in general, if all of those are managed, the rest of it just sorts itself out. We don't need to go in there and clean it.
There are certainly some other things that can set women up for UTIs. You mentioned the drop in oestrogen, but we also know about things like increasing blood glucose. So just to bring a little metabolic lens to it, people with type 2 diabetes are more likely to get UTIs because they get glucose in the urine. Glucose shouldn't be in your urine unless you've got high blood sugars, in which case it sort of spills in. And as you can imagine, bacteria love sugar. Imagine a sugary liquid just sitting in there. So it is often a red flag, or something we will screen for. In somebody who presents with recurrent UTIs, we will check blood sugars. But there's also some medication that can artificially add glucose to the urine. Mary, would you like to tell us about that?
Dr Mary Barson (09:21) Yes, the good old SGLT2 inhibitors. Those medications are used in type 2 diabetes. They're also used in heart failure, so they're sometimes used to treat conditions other than diabetes, and they can be very helpful medications. They absolutely can be. But one of the main mechanisms by which they work is they prevent the kidney from reabsorbing the glucose. As the kidney filters the blood, it's all very complicated, going through different tubules, and things are excreted and absorbed, and excreted and absorbed. Right towards the end, the glucose is usually reabsorbed back into the blood. These medications prevent that step, so more glucose is leaked from the blood into the urine. That is helpful for multiple disease processes, but it can cause significant problems. They will have side effects, and one of those side effects is that you've got lots of sugar in the wee, and that is a happy, yummy medium for bugs that can cause urinary tract infections. So recurrent urinary tract infections are really common in both men and women who are on the SGLT2 inhibitors.
Dr Lucy Burns (10:50) Yes. So there are a couple of things that will increase the risk. Let's talk about things that decrease the risk, or can help improve the situation. By far and away, I think the most profound thing that we can do for women who get UTIs, particularly in perimenopause and postmenopause, but not exclusively them, is vaginal oestrogen. Whether you get a UTI or not, actually, my thoughts are that the majority of women could, I don't want to say should, because that sounds like I'm being bossy, but could benefit from vaginal oestrogen.
There was a study released only a couple of months ago that looked at women who use vaginal oestrogen, and this was women of all ages. That was what blew my mind. It wasn't just perimenopausal and postmenopausal women. This was younger women who get UTIs as well. It reduced the incidence of UTIs, which we kind of know, but even more profound, it reduced the risk of sepsis and death from UTIs.
Dr Mary Barson (12:11) Totally. Brings us back to that advanced life support training. People can die from sepsis from urinary tract infections.
Dr Lucy Burns (12:21) Absolutely. And certainly as you get older, the risk of that happening is more and more. We get urosepsis, and it is a big problem in older people, where it can cause confusion and delirium, and people get profoundly sick very quickly from something that ideally should be preventable.
So the thing about vaginal oestrogen is it's cheap. It is really cheap. It's easy to use, and it has very few side effects. There are people who get concerned about breast cancer. Another big thing that's happened in the last 12 months is that vaginal oestrogens all used to come with a big black box warning saying do not use if you've had breast cancer. So there were all these women who were denied, or weren't using, vaginal oestrogen, getting recurrent UTIs and becoming sick with sepsis, because of this theoretical risk, which has now been largely disproven, and the black box warning has been removed.
Vaginal oestrogen can come as a pessary or a cream. Occasionally women are allergic to the base that the cream comes in, and they may need a compounded formulation. But really there are very few women who can't use vaginal oestrogen, and most of them will benefit. Again, this is general advice. You would need to discuss this with your healthcare professional. But certainly in our menopause clinic, that is one of the most basic things that we will advise women to do.
Dr Mary Barson (14:10) I think it's important to note too that oral oestrogen and transdermal oestrogen are not effective for this purpose. We are talking about the topical application of oestrogen to the vagina here.
Dr Lucy Burns (14:23) Yes, absolutely. And even that blew my mind. I'm thinking, how could a tablet not be helpful for down there? Down there! What am I, a hundred?
Dr Mary Barson (14:32) We don't talk about that, Lucy. Not down there.
Dr Lucy Burns (14:35) But yes, I used to think, how could an oral, systemic medication not be useful in the genitourinary region? But it doesn't penetrate the skin to the level that we need. The topical oestrogen is going straight to the source. It plumps up the tissue, so it makes the tissue more robust. And when the tissue's all thin, the anatomy changes, again making us more susceptible, because we talked about this being an anatomical, not a cleanliness, issue. So the evidence is pretty overwhelming.
Dr Mary Barson (15:17) Yes. So that's the number one, if we're talking about evidence for what we can do to prevent urinary tract infections with non-antibiotic treatments. There are a few other things which are helpful to know about. They may or may not be right for you, but they do also help. One is a pretty safe, cheap intervention, and that's just increasing your fluids. You don't need to go absolutely crazy with this, but drinking water has been shown to decrease the bacterial concentration in the bladder and increase the flushing frequency. It seems obvious to say, but it is a really sensible thing to do. Probably drinking somewhere around one and a half litres or more a day is right. If you live in a hot, dry desert and you're walking 40,000 steps a day, you're going to need more. If you're in an air-conditioned office all day, not moving very much, then the 1.5 litres is probably going to be enough. So you obviously need to tailor it to you, but it does help, and we've got evidence to back that up.
Dr Lucy Burns (16:26) Absolutely. And it makes sense. People forget, or don't realise, that the body has its own immune system. One little bacterium doesn't overwhelm us and cause major sepsis. We have immune functions that can kill bacteria. It's just when the system is overrun by it. So it's a quantity concern as well. When there's a lot of bacteria, the immune system goes, "I need some help." So that's where the antibiotics might come in. But if we can flush it, keep the bacteria low, flush them all out and give your body's own system time to react, then that can be really useful. And again, there are lots of things that affect immune function, as we know.
The other thing, while we're talking about flushing the system out, is to spend that extra second on the loo and empty your bladder properly. We're often so busy, in a hurry doing all the things, that we're in, out, whoop, off you go. So good emptying is really helpful. And tell me, Miss, what are your thoughts on cranberry tablets?
Dr Mary Barson (17:43) Yeah, look, the evidence shows that they can be helpful. We've got some evidence that they can help reduce recurrence by around 30 to 40%. But you want to be careful what we're talking about when we talk about cranberry products. We're not talking about some dried craisins here. We want a standardised cranberry extract or juice containing proanthocyanidins, so PACs, and the dose is probably about 36 milligrams of the PACs. Taking those regularly, for most people, is not going to be harmful, and is possibly helpful. It helps stop the E. coli, the bacteria, from being able to stick to the walls of the urinary tract, so it stops them from being able to really get a hold and get their biofilm going. So I think that is a very reasonable thing to try, and it's going to be safe for most people. There are occasional drug interactions you need to think about, so just quickly pull your doctor or your pharmacist aside before you buy them. But I think they are a really, really reasonable thing to try.
Dr Lucy Burns (18:50) And then the other non-antibiotic option, which you would talk to your doctor about, is a product called Hiprex, which is an antiseptic, if you like, not an antibiotic. So antibiotics kill bacteria, antiseptics sort of...
Dr Mary Barson (19:11) Kill everything. They break down to formaldehyde and ammonia in the bladder, and ammonia and formaldehyde, as we might know, are really powerful antiseptics. But the concentrations are quite low, so they're unlikely to be harmful, and they can be quite good at killing the bacteria.
Dr Lucy Burns (19:30) So I guess the take-home message from this is that UTIs can be mild, but they can definitely be serious and can even kill people. What we want to do is prevent UTIs by looking after our hydration, emptying the bladder, using vaginal oestrogen if you're female, and considering whatever other things you need to do, such as cranberry tablets or Hiprex. But also remember that bacteria love glucose. So if we keep our glucose levels stable and within the normal range, that is also a powerful intervention to prevent UTIs.
Dr Mary Barson (20:21) Fabulous. I think that'll be extremely helpful.
Dr Lucy Burns (20:22) Indeed. All right, lovelies. Have a great week. We will talk to you next week. Bye for now.
Dr Mary Barson (20:29) Ta-ta, bye.
Dr Lucy Burns The information shared on the Real Health and Weight Loss Podcast, including show notes and links, provides general information only. It is not a substitute, nor is it intended to provide individualised medical advice, diagnosis or treatment, nor can it be construed as such. Please consult your doctor for any medical concerns.
