The Menopause Exchange Blog


Women often get genitourinary symptoms around the time of the menopause, frequently due to mild infections such as cystitis and thrush. At the menopause, you may be more prone to these infections, as reduced oestrogen production causes a rise in your vaginal pH. This affects your vaginal ‘microbiome’, the balance of bugs that live harmoniously inside you.

This article was included in issue 86 (autumn 2020) of The Menopause Exchange newsletter.

Falling numbers of harmless lactobacilli may make your lower genitourinary tract more susceptible to infections by ‘harmful’ organisms. The yeast-like fungus Candida can also overgrow, leading to vaginal thrush. The linings of your bladder, urethra and vaginal wall are sensitive to falling oestrogen levels, so they also become thinner (atrophy) and more easily irritated or invaded by bacteria.

Cystitis literally means ‘inflamed bladder’. Pain on peeing, frequent daytime peeing and getting up at night are common symptoms. Passing blood, fever and feeling generally unwell indicate cystitis is getting worse. Loin pain indicates the cystitis has spread to your kidneys.

Cystitis is most likely to be caused by a urinary tract infection (UTI), usually from common gut bacteria such as E. coli. You may be more prone to cystitis if you’ve had recurrent UTIs, bladder and vaginal wall prolapses or a urethra prolapse. These can cause other symptoms, including pain during sex, vaginal irritation, itching, pain and urgency.

Incomplete bladder emptying, with urine remaining in your bladder, can lead to increased bacterial growth and UTIs. Ageing-related conditions, such as diabetes, strokes and other neurological disorders, are increasingly common after the menopause and can lead to incomplete bladder emptying.

Interstitial cystitis is a rarer and poorly understood bladder wall inflammation that may be caused by an immune reaction. It causes similar symptoms to cystitis caused by an infection.

Diagnosis and treatment
UTIs can be diagnosed with a simple urine dip-test. If positive, your GP can send off a urine sample to find out which specific bacteria is causing the infection and which antibiotic(s) it’s sensitive to. Increasingly, doctors try to target specific infections with appropriate antibiotics to avoid resistance developing. Long-term low-dose antibiotics may be prescribed if you get recurrent cystitis.

If there’s no infection, your doctor will decide whether you have interstitial cystitis, which is hard to treat, or menopause atrophy, which will respond to, for example, local oestrogen creams or pessaries or HRT tablets.

Self-help measures for cystitis

  • Painkillers, such as paracetamol or ibuprofen, may ease symptoms.
  • Drink plenty of clear fluids to flush out the infection (reduce this before bedtime to avoid night-time peeing).
  • Cranberry juice or supplements may help, as may other drinks (such as potassium citrate) that reduce urine acidity – ask your pharmacist.
  • Certain foods, such as tomatoes, alcohol or caffeine, may make symptoms worse.
  • Stop smoking, as some tobacco chemicals can cause bladder irritation.
  • Avoid perfumed bubble bath or soap and take showers rather than baths.
  • Make sure you fully empty your bladder generally, but especially after sex.
  • Wipe your bottom from front to back.
  • Wear loose cotton underwear and clothes.

If you have interstitial cystitis, you may ease your symptoms with painkillers and anti-histamines (e.g. cetirizine) and by managing stress. Your GP may prescribe medicines such as gabapentin or bladder muscle relaxants, or suggest other treatments that can ease pain or heal your bladder lining. There’s currently no cure.

Vaginal thrush is an overgrowth of Candida. This yeast-like fungus lives harmlessly on your skin, inside your nose and mouth and on your vaginal wall. It doesn’t usually cause symptoms and protects against more-invasive infections.

Candida numbers can increase if your microbiome changes, such as after the menopause, after courses of antibiotics or other infections, if you have diabetes (your vaginal fluid may contain more sugar) or if you’re on cancer chemotherapy.

Candida overgrowth is considered to be an infection if it’s causing symptoms. Thrush causes vaginal itching and irritation and a lumpy creamy discharge. It can make you feel like you need to pee frequently if it affects the area around your urethra, but it doesn’t cause bladder infections.

For most women, thrush is no more than a temporary nuisance. If it’s mild, you can wait for your Candida balance to return. Even with treatment, you’ll soon recolonise your Candida levels from other areas of your body or even other people.

Diagnosis and treatment
Thrush is usually diagnosed through a clinical history and examination, but it can be confirmed by a vaginal swab. A urine sample dip-test can exclude cystitis.

Thrush is treated with either an anti-fungal (clotrimazole) vaginal cream or pessary or a single oral antifungal tablet such as fluconazole. You can have longer courses of other medicines, but these have a higher risk of side effects.

Self-help measures

  • To prevent frequent thrush, clean your vulva with an emollient soap substitute no more than once a day and use moisturiser to protect your vaginal skin.
  • Don’t use perfumed soaps or shower gels.
  • Don’t wear tight-fitting nylon underwear or tights; choose natural fibres, such as cotton or silk, instead.
  • Ask your doctor to check your blood count and blood sugar levels.
  • Probiotic yoghurts or supplements may prevent vaginal thrush by boosting your microbiota; some women use yoghurts vaginally (it’s messy but may help!).

About the author
Dr Gill Jenkins is a GP in Bristol with 30 years experience and an interest in women’s health, lifestyle management in health and travel health.


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