The Dr Louise Newson Podcast - 151 - Unpicking UTIs and the role of hormones with Dr Rajvinder Khasriya

Episode Date: May 10, 2022

Dr Rajvinder Khasriya is a urogynaecologist who leads the Lower Urinary Tract Symptoms clinic at the NHS Whittington Hospital in North London, and is also involved in research work at University College London. In this episode, the experts discuss urinary tract infections (UTIs) and the role a lack of hormones play in their occurrence and ongoing recurrence. Dr Khasriya explains how common and debilitating UTIs can be for women in the peri/menopause, why traditional methods of testing and treatment are often unsuccessful, and she outlines the benefits of using vaginal hormonal treatments as part of a holistic approach for managing UTIs. Dr Khasriya’s tips for women with UTIs: As always, do your own research and find patient groups for support and information. Understand all the factors that can contribute to UTIs such as weight gain, your general health, your diet and stress levels, as these are also important. Be generous when using your vaginal estrogen, it is completely safe to use and in the long term. Trust yourself, you know your body best. The patient groups: Embedded/Chronic UTI Support Group Do you suffer from reoccurring UTIs? Many of us have been previously incorrectly diagnosed with Interstitial Cystitis (IC) and have come to learn our condition is actually an embedded or chronic UTI... Home - CUTIC 1 in 3. women will have a UTI by the age of 24 1. 90%. of chronic urinary tract infections are missed by the standard MSU culture test 2. 70%. the risk of recurrence within a year 3. Bladder Health UK Women asked if bladder drug should be available to buy. A pill to help treat an overactive bladder - which affects millions of women - could soon be available to buy in the UK without prescription.

Hello, I'm Dr Louise Newsom and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based, information and advice about both the perimenopause and the menopause. Today on the podcast, I'm very delighted to introduce to you Raj Kassira, who is a urogynecologist. I've known about her work for a while and I'm really excited to have

some time picking her brains and talking about urine and urinary tract infections. So welcome today. Thank you so much, Louise, and thank you for inviting me to do this podcast. It's just so important for so many women. Yeah, absolutely. And I've said on the podcast many times before, and I will say it again, I wish I was a GP again. And I wish I could go back in time. Because urinary tract infections are really, really common. And they're far more common in women. And on a Monday morning, when I used to turn up at 8 o'clock to my general practice, I could guarantee that there'd be at least six women outside queuing with their urine containers that they'd got from the practice the week before with a sample to be tested. And I can also 100% guarantee that those women would be told they haven't got an infection because their dipstick is negative. Yeah. So these women would, some of them would manage to get appointments and see me and just tell me how disabling and distressing their symptoms were of recurrent cystitis, pain, getting up in the night, sometimes leaking.

And I would sit there and say, well, your urine test is negative. And half of these women couldn't get appointments because we were so busy. so they would go home and tell their partner how distressing their symptoms were. And never once did I think, these are women. What's the difference between women and men? Is it their hormones? What could I do? How could I help them?

So I feel really sorry for all these women, and I don't think my GP practice was any different. And so hopefully you're going to explain a bit more. So before we start talking about why urinary tract infections and recurrent ureact infections are so common in women, could you just explain how you got into doing the job that you do, do you mind? Sure, no, not at all. So I started doing my obstetrics and gynecology training.

And very quickly, I knew that I liked Eurogarnacology, which is, by and large, older women who have incontinence and prolapse. I then did a research degree, a PhD with Professor James Maloney, who actually I'd known as a medical student. And a beloved professor, unfortunately, he passed away last month. but I did a PhD with him and it was very interesting because he was actually a geriatrician and he saw lots of women with incontinence but also women with refractory bladder problems i.e. women with symptoms of urgency, frequency, pain, let's say getting up at night,

that other people couldn't manage and they'd tried all the things that Nice says, you know, and they were diagnosed with things like interstitial cystitis or bladder pain, syndrome, it's called now and overactive bladder. And they'd come to us, and that's when I started to do my PhD, and they'd say things like, I think I've got a urine infection, or I think I've got a urine infection that's never gone away, or this started with a urine infection. And we sort of started to think, well, hang on, patient knows best. So these patients keep on telling us, they've got a UTI, well, something's going on here. So the first thing I did in my PhD was actually look at the tests that we use to diagnose UTI.

So we did this very big study on dipsticks and how good they are at predicting a UTI compared to, you know, what has been the gold standard, which is a urine culture. And we realized, and lots of people will not be surprised, that it's not very good. So it's not good at picking up infection. Now, that's a massive shame because it seems to be the gateway between a patient getting antibiotic or not. And I then started to look at urine culture and we started to microscope the urine fresh in the clinic at first just because we wanted to see what's in people's we because we're doing research. And the urine culture for a while we even try to, you know, make our own

or have our own technique of urine culture, but we understood something very, very quickly, which was that everybody has bacteria in their urine. So that's the beauty of research. So that's the beauty of research, you've got a healthy volunteer group that are helping you. And we realize that, oh, hang on a second, everybody's got bacteria in their wee. So the healthy volunteers do and the patients do. And in fact, there's a 90% overlap between the bacteria in the healthy people and the bacteria in the patients. So therefore, if you do grow something in a urine culture, what we don't know is if it's just there and it's part of the furniture in your bladder and it's, doing nothing and it's supposed to be there, or if it's actually causing your problem. And there's no

way you can tell that from a urine culture. Interestingly enough, because of the way that the urine culture is done, so it's the same technique that's been used for over 75 years. Because of the way that it's done, it's only positive anyway in about 30% of cases. So in our clinic, it's positive between 15% to 20% of the time. And this is a clinic that only sees people with chronic recurrent UTI. symptoms. So it's not really a great test. And, you know, we have more sophisticated tests now. So we've got PCR and genomics and they look at bits of DNA of bacteria in your urine. But again, although they may tell us and give us a bit more information about what's in the urine, again, they can't tell us what is the cause of the UTI. So, you know, to go along with that, when we look in the

urine of patients, what we find is that they have white cells. under the microscope. And in fact, healthy volunteers don't really have them or many. So that immediately told us, well, okay, well, whatever's going on in the bladder, which we don't quite understand, the patient is reacting to it, hence they have symptoms. And we were then able to treat patients with antibiotics, follow the course of their symptoms and the white cells in their urine, and then start to build a picture of what happens to the white cells over time, how they go up and down when you treat patients. But we also found another cell in the urine, which was cells that look like skin cells. And for ages, we ignored them because Louise, you'll know at medical school, we were taught

that cells in the urine are contaminants from the vagina. Absolutely. Yes. We were blamed by the way that us as women wiped ourselves after having a wee. That was the real problem, wasn't it? Exactly. And then the beauty of research, of course, is that you've got a volunteer group. So when we look at their weed, they don't have lots of those cells. So, you know, either it's being washed from everyone's vagina or it's not. So we stained those cells with a protein that you only find in the bladder called uroplaken. And lo and behold, 80% of those cells are actually from your bladder. So we then realize, though, well, hang on, patients with UTI, they've got white cells in their urine, and they're exfoliating the inside of their bladder. Hmm. I don't know why they're exfoliating

the inside of their bladder, but they are. And then we've gone on to under understand a lot more about bacteria and how they behave in your bladder. So we used to think they just float around in your wee, but we now know that they can go into the lining of the bladder, invade that lining, stay there. And that's not great because antibiotics can't get into there very well. And they can also become dormant. So when they stop dividing, antibiotic can't kill them. So very clever.

And then for some reason, they'll start to divide again. But importantly, there's a huge question around why does this happen, why this particular group of patients, the majority of the patients that we see are postmenopausal. So the average age of patient in our clinic is 56 and they've been seeking help for about six years before they come to us. So since they were 50, so by default, every woman in their 50s is either menopausal or perimenopause or the average age, not the only one's average is 51 of the menopause. So unless someone is, I spoke to a lady the other day actually who has had IVF and she was pregnant age 51. That's very, very unusual. So she will have high levels of estrogen in her body. But other than her probably, everyone else in the world will have low hormone levels of that age, won't they? Absolutely. So there's definitely

something is happening around the menopause. And, you know, unfortunately, research, it's not in this area. So we believe that there's something going on in terms of hormones and they're affecting the bacteria in the genital tract and in the bladder, but also there might be a local tissue effect of, you know, what estrogen, etc. Testosterone, progesterone, what they do in the genital tract and how that can then predispose to UTI. So that's been an important factor. Yeah, it's so interesting, isn't it? Because I think there's so many levels to this really. If you think about having an infection, we know that estrogen affects immunity. So when people don't have estrogen, they can't fight disease in the same way.

They can't fight infection the same way. And so a lot of people when their menopause will find that they get more infections, whether they're viral infections or bacterial infections. So just not having estrogen is going to increase the risk of any infection. But then also the tissues really change without estrogen, don't they? So the tissues lining the vagina, the vulva, but also the bladder and the urethra, that little short tube, that we're only blessed with a very short tube unlike men, who's a lot longer.

So that tube is affected. So the tissues are thinner, they're more friable, they're easier to be damaged, so friction can cause more discomfort. And so any bugs that are around, because we've got bugs all around our system, are they're more likely to get into those tissues, aren't they? And then if you're less likely to fight an infection, Even just those two factors can make a difference. But then some women might not have an infection.

Like you say, just the presence of these cells doesn't mean that the infection is causing their symptoms. So we know that a lot of women develop symptoms of urine increased frequency, discomfort, pain, passing urine. And they haven't got an infection. But they might or might not have, like you say, white cells in their urine test. But often these women are given antibiotics. because as clinicians, I've done it in the past because I didn't know how else to help women and they might improve a little bit. But then what's really worrying is that you're going to increase resistance.

And so when they have a really bad infection, the antibiotics you might have given might not help, might they? Yes. I think, you know, this is a very big area about our work in terms of antimicrobial resistance. And it is very important. It's one of the leading concerns in our. time in clinical medicine. And looking at the patient holistically is very, very important. You know, we can't isolate, you know, well, you've got this symptom and therefore, you know, you've only got a UTI. There's a continuum. So biology is a continuum, isn't it? And unfortunately, we are all

into our categories. You've got that. You've got that. And it's not quite like that. No, and no one joins the dots often, and it can be very difficult, and very frustrating, actually. And, you know, I speak to a lot of women, and I'm sure a lot of women who come to your clinic, if you say that average length of time is six years. They won't have been six years at home on their own. They would have been seeking help and trying to get help. You've got a tertiary referral centre, which means that people come usually from other hospitals. So they've been to their GP, who's referred them to the local hospital,

who've then finally referred them to you. And we see a lot of women who have been seen by gynaeconology, and urologists, they've often sometimes been seen by psychiatrists and psychologists as well because people think they have mental health issues. And they often do because, you know, if any of you are listening, I've had a urine infection, it is horrible. It is really disabling. It's not only uncomfortable, but it's also very distressing because you don't know when you're going to next need the toilet. You can't go out. You become a prisoner in your own home. It's absolutely degrading and it's just exhausting as well actually if you're up all the time at night time you

can't sleep it has really big impacts so these women have often been labelled and we've seen people who are on antidepressants and they give the antidepressants to try and calm the nerve pain down which may or may not help they haven't been given a diagnosis no one's helped these people so they're actually in real crisis and when we see the people i obviously am not a urogynaecologist i don't know how much of their symptoms are related to their hormones, but I also do know that they are menopausal or perimenopausal. So I will give them treatment for their future health, for their other menopausal symptoms,

but I will also often nine times out of day and give them vaginal estrogen from the start because they've often got symptoms of vaginal dryness and soreness and irritation and what have you. And these women often really, really do improve. And I've been doing the clinic long enough that it's just not a coincidence, you know. and their symptoms improve, but also their need for antibiotics really, really reduces.

And, you know, it must be because they're fighting the infection better, but also their tissues are better. They're more estrogenized. And then their quality of life improves. Their future health improves. And then their need to be referred to someone like you reduces. But I'm just seeing the tip of the iceberg. And I'm sure you are as well.

I don't know. What are the figures? How many people have recurrent urinary tract infections, Raj? So if you look at NHS digital data, year on year, from their own figures, the number of patients presenting acutely and to outpatients with recurrent infection or interstitial cystitis is going up and up and up. But we know from Cochrane Review various studies that half of women will get a UTI in their lifetime. about 35% of those will fail standard treatment. So they are coming back recurrently. Now, that's a huge number of women.

So we've got nice guidelines that say, okay, if you've got recurrent infection, give a prophylactic dose, etc. However, 35% of women will fail that. And, you know, we have asked nice, well, what should we do with those women that fail that treatment? you know, and that's the question, and that's a huge number of women. And also, you know, what I will say about women and UTI, you know, coming back to that AMR, is that, you know, we've got protocols about three-day prescribing,

which actually that three-day prescribing is from a study of 80 patients. And we've got to remember that and that, of course, everyone wants to reduce prescribing of antibiotics. And in fact, by and large, we have. So if you look at data from primary care, we've hit all our target. to reduce prescribing. But actually, antimicrobial resistance hasn't gone down.

Isn't that interesting? Very interesting. And let's not forget, women are pushed back on a lot. And if you have a man, let's say with prostititis, you give them two weeks of a broad spectrum antibiotic.

Yeah. But a woman, she will be told three days, at most seven days. If you've got acne, you can get a broad spectrum antibiotic for months, years.

Yes. You know, and when it comes to AMR, we never put those people in that discussion. But somehow women with a UTI are so much in that, we're blamed, don't we? We're blamed. When you say AMR, that's antimicrobial resistance just for those who aren't sure. And I think this is a real problem. Young women who have an uncomplicated UTI, three days is probably fine, actually, or a lot of them don't need antibiotics, but some of them do.

And three, but actually there are others who do and others that do need longer term. antibiotics or some people, there's a pattern to their urinary symptoms. So if it's just after sex, for example, some women having antibiotic just before or after intercourse, that might be enough to prevent a urinary tract infection. So antibiotics can be used very cleverly and there's definitely a role for them. But we shouldn't be just blanket treating because we don't know what else to do for women. And like I said, I'm very embarrassed to say that I have done it before because I didn't know how else to help these women. I didn't even think. And we all have. about their hormones. And like we said, we've got to move to holistic approach and certainly

think about hormones. You know, we know that good bacteria like lactobacillus go down after the menopause as well. So, you know, there's a lot of factors. Yes. And I think the other thing that's worth sort of exploring is that, you know, there are a lot of women who take HRT, but they still have urinary symptoms or symptoms of urinary tract infections. And about one in five women who take HRT still need vagina and estrogen. And just as a person, experience, I'm quite happy to disclose. I had a hysterectomy three years ago and I was on HRT. I had real problems. Of course I did because I'm married to a surgeon with my bladder afterwards. I had to have a catheter in for three weeks after the operation, which was horrendous.

It was awful having a catheter, but I had to be catheterized a few times and so understandably I had many urinary tract infections after this and it was really horrible. It was worse than having the catheter in by far. But actually, no one. told me that, I mean, obviously, I'm a medic, so maybe they spoke to me differently, but no one really sat down and said, well, you are more likely to have an infection, and no one gave me the right course, so I had to speak to a specialist, and it went on for a long time. But also, no one actually said to me, well, actually, you've had a hysterectomy, you might really need some vaginal hormonal treatments.

And I'm very embarrassed again, you know, I'm not my own doctor. It took me a little while to realize that actually, perhaps if I started using some vaginal hormonal treatment, that might reduce my risk of getting more urinary tract infections because I was getting the cycle that I kept getting urinary symptoms. Not always with an infection, I wasn't always febrile. I sometimes had pain in my kidneys. I sometimes didn't. But I didn't want to keep taking antibiotics. Yeah. And I take a probiotic. I'm as healthy as I can be. And so then I thought, oh, actually, there is something missing. I'm going to try some vaginal hormonal treatment. The first one I tried, actually did nothing. I just used some vagina and estrogen, didn't do anything. So I changed

to a different product, which contains DHEA, which converts to estrogen and testosterone, and it's a daily pezzary. And actually, within about six weeks of using that, I wish I'd started it three months before. Absolutely. This is it. And I think, you know, I'm surprised. So the average number of years, a patient has been seen by clinicians before they come to see us in our specialist clinic is six years. And I'm surprised at how many women are not on any HRT or vaginal eustrogen. And in fact, like you, you know, 90% of my patients probably I will recommend that they use a vaginal eustrogen at least. And it comes down to then nuances that, you know, sometimes this particular product works or it doesn't work. And then if it doesn't work, it seems to be a dead end because no one's then gone on to

say, well, hey, look, try this. No, and there were other alternatives. I mean, I went from one type of point it's for another, but actually even with the estrogens, a lot of women, we use quite a lot of this estring, which is a flexible ring that is a slow release estrogen, can be really good, especially for elderly women who don't want to fertile around inserting something in their vagina. It's not messy, it's not a cream or a gel, it's not a pezzary. It just is inserted and lasts for three months. And some people find using externally a gel or a cream, even just a rubbed around their urethra, the area can really make a difference, can't it? Yeah, no, I absolutely agree. And you brought up DHEA, and I think that this is very interesting. And again, not enough studies about the use of DHEA and, you know, how it can improve. Because like you said, it's, you know, how it can improve symptoms. It's got estrogen, testosterone, all of those things that are missing and can make a huge difference in terms of symptoms. Yeah, absolutely. I mean, we've known a while about estrogen, but testosterone in women is less researched. Most of the research is looking at libido, but actually, you know, even with

the urinary symptoms and even does it help with urinary tract infections, we don't know because the studies haven't been done. Anecdotally, I can tell you that a lot of women find the testosterone can make a massive difference to their urinary symptoms. But we also know that vaginal estrogen is safe, even in women who've had breast cancer. And so every woman actually on your waiting list should be given vaginal estrogen. And it can be given in the long term. So there's no maximum length of time. Women should have it on a repeat prescription and they should continue.

There is some people that say, stop it and then see. I know some of the urology guidance say you should stop it and see how symptoms are and then consider restarting. Well, anyone who has symptoms, they're going to recur, aren't they, if you stop using vaginal estrogen. Absolutely. And I think, you know, it's not absorbed into the circulatory. very well. So it's local. You can use it continuously. You know, there's very little harm. So, you know,

why not use it and see, you know, the impact that it can have can be, you know, huge. Well, it can absolutely be transformational. And as you say, there's no harm. And if I had a choice of trying a localized vagina hormonal treatment compared to taking antibiotics all the time or having, you know, some of the bladder treatments you use, you know, they're quite a invasive, aren't they? They can cause side effects. So they obviously have a role. Of course they do. But you want to start with the simple things first in medicine, I think. Yeah. I would agree. And, you know, antibiotics, particularly, you know, on our protocols, we're giving patients antibiotics for a long time. That is no easy ask of a patient. Anyone who's taken antibiotics will

understand this. They're not very nice. You know, they're horrible. And we're asking patients to take them for a long time. You know, you can get side effects, particularly GI side effects, thrush. it really isn't easy. And obviously, patients take them because they're helping, you know, and they're struggling. But if I never had to prescribe anyone on antibiotic ever again, I would be delighted. And hence, you know, using eustrogen, using hormones, DHEA is pivotal and crucial in trying to unpick what's going on. Absolutely. And also, it's about doing more research in this area, as you say. And I've said many times on this podcast before researching, women, is really neglected. Research in menopause women is even more neglected, isn't it? And, you know,

I think research in urinary tract infections has been really neglected. It's not well funded, is it? Compared to other research, for example, in diabetes or cardiology or cancer medicine. Absolutely. You know, it's not sexy, as they say, you know, but it affects so many women. There is not a single clinician probably that has not treated someone for a UTI. It's so common, but You know, we struggle with funding. I have a part-time academic contract actually at UCL and the focus of our research in our group, BII, which is bladder infection immunity group. And the focus of our research is UTI. You know, we don't even understand what causes it actually. The host response to it, you know, why particular people get recurrent infections, the hormonal aspect diagnosis of UTI, how can we improve that

treatments. So, you know, there's so much work to be done, but like you said, funding, unfortunately, is not forthcoming in women's health issues, particularly menopause and UTI. No, and that totally needs to change, doesn't it? Something that affects, like you say, most women in the course of their lifetime will either have had a urinary tract infection or urinary symptoms. And so, you know, something as common as that really deserves to have more funding for more research. and to improve future health of women because you're only healthy. And it's not just a UK problem. It's a worldwide problem, isn't it?

It is a worldwide problem. So if you look at patient groups, there are a number of chronic UTI patient groups. And there's one called QTIC, there's one called Chronic Embedded Infection Group. Now, their numbers are massive. You know, one of those groups has got 8,000 patients. That's phenomenal. I think that's probably one of the biggest patient groups in the world. But, you know, every woman is going to have.

have menopause, every single one. So, you know, again, research in that area, that has to be forthcoming to improve the health of women generally. Yeah, totally. Well, I couldn't agree more, and I'm hoping that we can be involved in some research together, and you can come back and we can report our findings. So I'm very grateful for your time today. So just for three take-home tips, if that's okay, for women or people who are listening to the podcast who think they might have some urinary symptoms and maybe they've been diagnosed with recurrent urinary tract infections. What would be the three tips for them to try and improve their symptoms and receive treatment that they need?

So I would say, you know, and unfortunately I've heard this on your podcast, actually, Louise, is do your own research, unfortunately, you know. So a lot of women are finding that they might go to their doctor and know more than the doctor, sadly. But, you know, do your research. So think about all of those things, you know, hormones, what is available to me is the diagnosis correct in terms of UTI? And to support that, there are lots of patient support groups and they are brilliant. They have so many bits of

information on their websites, research papers, and they share stories. And that's when women begin to realize, oh, hang on, I'm not alone. And this is a thing. This is a real thing. So I think that's important. The second thing I would say is, you know, we forget about all the different as women get older. So hormones, obviously, is a massive factor. But lots of other things, weight gain, general health, diet, stress, you know, these are all important factors in any illness and particularly chronic illness. The other thing I would say is be generous with vaginal eustrogen.

You know, and I've probably gone over my three, but be generous with, you know, it's of low risk. and it's definitely part of the armamentarium in helping women with chronic UTI. Yes, which is great advice. So even people who aren't sure if they're perimenopausal or menopausal, people can still have vagina and estrogen. There are lots of women who have hormonal changes who are having regular periods. Some women postpartum will experience symptoms, but it's still definitely worth asking about vagina and estrogen,

and there is some information on the website and the app. And hopefully a lot of you, will have learned a lot about this, and we look forward to welcoming you back to talk more about your research and what we've found going forward. So thanks ever so much for joining me today. Thank you very much. What I would say, one last thing I'd say to women is trust yourself. So we published a big paper about symptoms and how they correlate with quality UTI. So trust yourself, you know yourself, you know your body. And, you know, lots of women are told, well, it's in your head or it's to be expected at a certain age of life.

but trust yourself. But thank you so much for inviting me. And certainly I'd love to come back and report on menopause work and UTI. Great. Thank you ever so much. Really empowering work. So thanks very much indeed. Thank you, Louise.

For more information about the perimenopause and menopause, please visit my website, balance, hyphen, menopause.com, or you can download the free balance app, which is available to download from the app store or from Google Play. Thank you.