PCOS and UTI – What’s the Connection?

Hormones are known to influence the health of the urinary tract, which makes the connection between the hormonal condition of PCOS and UTI worth exploring.

Polycystic ovary syndrome (PCOS) is a hormonal condition commonly associated with irregular periods, infertility, and polycystic ovaries in people of reproductive age. Although the condition is frequently underdiagnosed, PCOS is reported to afflict 2.2-26% of people with ovaries.

While the research between PCOS and UTI is limited and there is no clear overlap of PCOS and urinary tract symptoms, there is evidence of a link between the two conditions. In this article, we will be exploring the PCOS and UTI connection.

Quick Links:

• PCOS Crash Course  >>>>
• Hormones, Vaginal Health, and UTI >>>>
• The Role of Systemic Inflammation, Mast Cells, and Histamine for PCOS and UTI  >>>>
• How Metabolic Issues Increase Risk for PCOS and UTI  >>>>
• Learn more About PCOS  >>>>

As mentioned, PCOS is a very common hormone imbalance. It is the most common cause of infertility, As mentioned, PCOS is a very common hormone imbalance. It is the most common cause of infertility, and for this reason, it is largely known as a reproductive disorder. However, PCOS is a chronic metabolic condition that can lead to other serious health issues beyond infertility. People with PCOS are at heightened risk of a variety of health issues:

• 50% chance of developing diabetes by 40 years old 
• 5 times increased risk of endometrial cancer 
• Increased risk of heart disease, depending on age
• Increased risk of mental health conditions

When diagnosed, PCOS may be effectively managed through a combination of targeted lifestyle approaches and medication, if necessary or desired. However, having a base-level understanding of PCOS symptoms and the diagnostic process can support day-to-day management and help reduce long-term health risks.

Symptoms of PCOS

The symptoms of PCOS will differ for every individual, and can vary with age. In younger individuals, PCOS tends to manifest mainly through reproductive symptoms, such as irregular menstrual cycles. Metabolic symptoms, such as insulin resistance, tend to increase with age or in younger individuals who are overweight.

Typical symptoms include:

• Irregular or absent periods
• Hirsutism (excess growth of dark or coarse hair on the face, chin, chest, back or stomach)
• Thinning hair and hair loss from the head, found with high levels of androgens
• Infertility or subfertility
• Psychological symptoms such as depression, anxiety, psychosexual dysfunction or eating disorders
• Metabolic changes such as excessive weight gain or loss, dyslipidemia, or diabetes

Similar to chronic and recurrent UTI, there are still many unknowns and much to be explored about PCOS; it is a complex condition! In fact, for a majority of cases it sits at the intersection of being a hormone imbalance and a metabolic disorder. Approximately 35-80% of PCOS cases fall into the ‘insulin resistant’ subtype. In these cases, insulin resistance plays a central role in driving symptoms, as the body becomes less responsive to insulin, and often leads to elevated blood sugar levels.

How is PCOS Diagnosed?

According to the Rotterdam criteria, to be diagnosed with PCOS you must fulfill at least 2 of the following 3 items:

1. Irregular or absent ovulation
2. High levels of androgens, or male hormones like testosterone and DHEA-S 
3. Polycystic ovaries

Unfortunately, PCOS and UTIs share a commonality when it comes to awareness and difficulty of diagnosis. An estimated 70% of PCOS cases go undiagnosed despite the relatively easy diagnostic process.

It is important to understand that PCOS is a “spectrum” disorder and not a disease with a single cure. That means its presentation and severity can shift  over time, and some people may even find that they can temporarily or permanently leave the PCOS ‘spectrum’ by no longer fulfilling the PCOS diagnostic criteria. 

There is also a distinction between PCO vs. PCOS. PCO, or polycystic ovaries, is even more common than PCOS, as 1 in 3 women fall into this category. PCO is a state of having an immature number of follicles, or immature eggs, surrounding one’s ovaries. 

Although polycystic ovaries are one of the three possible criteria for a PCOS diagnosis, having PCO does not guarantee PCOS. One can still qualify for PCO while having reproductive hormones that fall within normal ranges and a normal menstrual cycle. 

That is why it is important to assess other factors, such as menstrual cycle regularity and sex hormones, in making a PCOS diagnosis. 

PCOS Treatment Options

Conventional PCOS treatments include medications like hormonal birth control to help regulate menstrual cycles and lessen hormone imbalance symptoms, metformin to increase insulin sensitivity and reduce metabolic risks, and spironolactone to improve acne, hair loss, and hirsutism.  

However, there is also a wide range of lifestyle changes that can help manage PCOS. Research has shown that diet, exercise, stress management, sleep, and targeted supplements can all improve symptoms and reduce overall health risks. An interdisciplinary approach, or one that combines both conventional and lifestyle-based changes, has been shown to be very effective.

Vaginal health is an important component of UTI prevention. While the vagina is part of a different bodily system than the urinary tract, the vaginal and urinary microbiomes are interconnected, and the vagina is an important defence mechanism when it comes to UTIs.

But is there a relationship between PCOS, vaginal health and the risk of UTI? Let’s explore.

Vaginal Health and Hormones 

At its core, PCOS is a hormone imbalance that generally presents in an excess amount of male hormones, or androgens. But other hormones like estrogen have also been shown to be disrupted for people with PCOS, making estrogen a noteworthy hormone when it comes to both PCOS and UTI.  

As we age and approach menopause, our estrogen levels drop. This causes not only symptoms such as hot flashes and vaginal dryness, but also an increased risk for UTIs.

Part of the increased risk of UTI during peri and postmenopause is due to the vulnerability of epithelial cells as estrogen is lessened. Epithelial cells serve to both prevent infection and release antimicrobial peptides at the first sign of infection. 

As the epithelial cells that line the urinary tract become more fragile and prone to damage as we approach menopause, the risk of UTI increases. 

In addition, estrogen allows “good” Lactobacillus bacteria to thrive in the vaginal microbiome, which research has shown can be beneficial in preventing UTI.

Learn more about hormone therapy pre-menopause in this interview with Dr. Rachel Rubin:

It is for this reason that vaginal estrogen creams have been shown to be effective at preventing UTIs for perimenopausal and postmenopausal women. But what about people who are still of reproductive age? And is there any relationship between estrogen and PCOS?

PCOS and Estrogen 

While there is a relationship between PCOS and disrupted estrogen levels, research does not indicate that low estrogen is characteristic of PCOS. 

In fact, estrogen dominance is characteristic of many PCOS cases. This describes a dynamic in which the ratio of estrogen to progesterone is too high, which often occurs when a woman is not ovulating. Lack of ovulation and lack of a subsequent period result in continuous high levels of estrogen and not enough progesterone.

How PCOS May Impact Vaginal and Urinary Tract Health 

Despite low estrogen not being a problem for PCOS, there is still a link between vaginal health and PCOS that just may involve our hormones. 

In a 2020 study that included 39 participants with PCOS and a control group of 40 participants without PCOS. There was a significant difference found in the make-up of the vaginal microbiome between the two groups. The PCOS group had lower levels of Lactobacillus crispatus bacteria, which has been shown to be protective against urinary and vaginal infections. What’s more, the PCOS group showed a higher prevalence of disruptive bacteria like Mycoplasma and Prevotella.

Another 2022 study showed similar results with decreased levels of Lactobacillus and higher levels of Prevotella and Chlamydia found in the vaginal microbiomes of PCOS participants. 

While more research is needed on this link, early evidence suggests the possibility that even though PCOS does not cause low estrogen, irregular menstruation seen with the condition can negatively impact the composition of our vaginal and urinary microbiomes.

Regular menstruation, with standard monthly shifts in estrogen and progesterone, drives changes in our vaginal cells and thereby helps maintain a balanced bacterial environment. This process is disrupted by the irregular menses seen with PCOS.

While a majority of PCOS cases are driven by metabolic issues, as mentioned earlier, systemic inflammation is also a hallmark factor of this condition. In fact, it can catalyze it. 

This refers to ‘inflammatory’ PCOS, a subtype of the condition that occurs when inflammation due to food allergies or sensitivities, or even a hidden autoimmune issue, is putting the body into a state of imbalance. Chronic inflammation can catalyze excess androgen production and vice versa, triggering PCOS. 

Note: A person can fit into more than one subtype of PCOS. For example, symptoms may be catalyzed by both insulin resistance and inflammation. 

Inflammation has also been linked to recurrent UTIs. Let’s take a deeper look at how inflammation can impact both PCOS and UTI.

Mast Cells & PCOS

There is anecdotal evidence that shows a connection between PCOS and histamine. Histamines are chemicals that our mast cells, a type of immune cell, store and release. They can cause rashes, redness, general inflammation, itchy eyes, and a runny nose – think of seasonal allergies! 

In the case of PCOS (and all female bodies), our ovaries and other reproductive tissues are  common homes for mast cells that produce histamine. High levels of estrogen, a prevalent symptom of PCOS, can further trigger mast-cell activation and histamine release. This can create a vicious cycle – one in which inflammation worsens hormone imbalance, and hormone imbalance worsens inflammation.   

Newer research also suggests that PCOS is linked with ongoing low-grade inflammation throughout the body. This inflammation may involve mast cells, which release histamine and other inflammatory chemicals. Over time, this may contribute to insulin resistance, hormone imbalance, weight gain, and worsening PCOS symptoms. In other words, histamine may not just be a side effect of inflammation in PCOS – it may contribute to keeping inflammation going.

Mast Cells & UTI

Mast cells do not just play a role in PCOS. They have been linked to a variety of hormone, autoimmune, and other complex chronic issues, including bladder inflammation and cystitis symptoms. 

This is why, for some people, particularly those who experience unexplained UTI symptoms and lower urinary tract dysfunction, mast cell inhibitors such as antihistamines have been shown to improve pain.

Mast cells have also been shown to help bacteria adhere to the bladder wall, thus increasing the risk for UTI. A 2013 study showed that bladder mast cells in mice were a source of interleukin 10 (IL-10), an anti-inflammatory cytokine that functions as an immunosuppressant.

The study found that when infected with uropathogenic Escherichia coli (UPEC), the mice that had fewer mast cells actually had a more effective immune response. In a nutshell, the mice with fewer mast cells produced more antibodies, more effectively clearing the infection. 

On the other hand, mice with abundant mast cells that were producing higher levels of IL-10 had a suppressed immune response that allowed infection to linger in the bladder tissue, thus increasing the risk for recurrent infections.

Mast Cell and Inflammation takeaways 

Mast cells, histamine, and inflammation are a correlation seen with both PCOS and UTI. However, more research is needed to determine why mast cell dysfunction or Mast Cell Activation Syndrome happens for certain individuals.

Lastly, the connection between metabolic imbalances and how they can be a root cause of both PCOS and recurrent UTIs is worth exploring.

Insulin Resistance, Diabetes, and PCOS

Insulin is a hormone secreted by the pancreas, whose job is to convert glucose, or blood sugar, into energy for muscles to use. If we are insulin-resistant, our bodies do not do this conversion as efficiently as other bodies. 

This means that the pancreas must produce higher amounts of insulin relative to the blood glucose. Over time, this can exhaust the pancreas and lead to chronically high blood sugar, which in turn can lead to prediabetes, diabetes, and weight instability.

As previously discussed, insulin resistance is very common with PCOS. It is actually seen as a driver of the condition, and for many people, it is difficult to separate the two because high insulin levels can inhibit ovulation and increase androgen production, and in turn, high androgens can also worsen insulin resistance.

Blood Sugar and Bladder health 

Having diabetes increases the risk of UTIs and increases the risk of more severe infections. 

This is because high levels of glucose, or blood sugar, are ultimately excreted through our urine, and sugar helps bacteria thrive. 

While a common recommendation for all people navigating recurrent UTI is to limit consumption of sugar-filled drinks and food that can aggravate an existing infection, maintaining blood sugar balance is even more important for people with diabetes and struggling with recurrent UTI.

A confounding factor of diabetes increasing the risk for UTIs is dehydration. When the kidneys have to work extra hard to excrete excess glucose, more water is lost from urination. This can quickly lead to dehydration if the lost fluids are not being replaced, which can increase the likelihood of UTIs.

If you have PCOS and also struggle with recurrent UTIs, you are not alone. While PCOS does not directly cause infections, there are several underlying risk factors of both PCOS and UTI that can be addressed to improve your overall health. 

The most direct link between PCOS and recurrent UTI is likely the impact of hormone imbalance on vaginal health. However, underlying characteristics of both conditions may also be seen relating to mast cells and a disrupted inflammatory response, as well as metabolic issues. 

Just like struggling with symptoms of recurrent UTI can be demoralizing, so can PCOS. Fortunately, here are some resources that can help you in your journey:  

• Verity – a registered charity for those with PCOS 
• PCOS Relief – a charitable organisation established to support and advise on the four types of PCOS

Also, if you would like to get involved in PCOS research, the NIHR offers opportunities to join ongoing studies, and ClinicalTrials.gov provides a global directory of active clinical trials.