Menopausal hormone therapy: route of administration and blood clot (VTE) risk

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  3. Weller SC, et al. Hormone exposure and venous thromboembolism in commercially insured women aged 50 to 64 years. Res Pract Thromb Haemost. 2023;7(3):100135. doi.org/10.1016/j.rpth.2023.100135

  4. Sundell M, et al. Pulmonary embolism in menopausal hormone therapy: a population-based register study. Climacteric. 2022;25(6):615–621. doi.org/10.1080/13697137.2022.2127352

  5. Hicks A, et al. Safety of menopause hormone therapy in postmenopausal women at higher risk of venous thromboembolism: a systematic review. Climacteric. 2025;28(5):497–509. doi.org/10.1080/13697137.2025.2503874

  6. Howells P, et al. The use of HRT containing transdermal estradiol in women with a personal history of venous or arterial thromboembolism: a consecutive series of 115 cases. Post Reprod Health. 2025;31(4):249–253. doi.org/10.1177/20533691251369205

  7. Neville A, et al. Incidence of venous thromboembolism in women receiving transdermal oestradiol/testosterone with micronised progesterone in accordance with NICE guidelines. Transl Androl Urol. 2026;15(3):85. doi.org/10.21037/tau-2025-662

  8. Switzer J, et al. Management of menopausal hormone therapy. Curr Opin Obstet Gynecol. 2026;38(5):331–338. doi.org/10.1097/GCO.0000000000001135

  9. Arnautu AM, et al. Menopausal hormone therapy: risks, benefits and emerging options. A narrative review. Int J Mol Sci. 2025;26(22). doi.org/10.3390/ijms262211098

Vaginal estrogen: preventing UTIs and treating urinary symptoms

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  2. Christmas MM, et al. Menopause hormone therapy and urinary symptoms: a systematic review. Menopause. 2023;30(6):672–685. doi.org/10.1097/GME.0000000000002187

  3. Porcari I, et al. Vulvovaginal estrogen therapy for urinary symptoms in postmenopausal women: a review and meta-analysis. Climacteric. 2025;29(1):13–22. doi.org/10.1080/13697137.2025.2517138

UTI hospitalizations and deaths in the United States

  1. Simmering JE, et al. The increase in hospitalizations for urinary tract infections and the associated costs in the United States, 1998–2011. Open Forum Infect Dis. 2017;4(1):ofw281. doi.org/10.1093/ofid/ofw281

  2. Rustia G, et al. Inpatient mortality among U.S. women treated for urinary tract infection 2016–2020. Urogynecology. 2026;32(7):887–894. doi.org/10.1097/SPV.0000000000001756

  3. Zilberberg MD, et al. Descriptive epidemiology and outcomes of hospitalizations with complicated urinary tract infections in the United States, 2018. Open Forum Infect Dis. 2022;9(1):ofab591. doi.org/10.1093/ofid/ofab591

  4. Zilberberg MD, et al. Descriptive epidemiology and outcomes of emergency department visits with complicated urinary tract infections in the United States, 2016–2018. J Am Coll Emerg Physicians Open. 2022;3(2):e12694. doi.org/10.1002/emp2.12694

  5. Meghwar S, et al. Trends and disparities in urinary tract infection-related mortality in the United States from 1999 to 2023: insights from CDC WONDER. Medicine (Baltimore). 2026;105(21):e49032. doi.org/10.1097/MD.0000000000049032

  6. Liu X, et al. Mortality trends in US women with concurrent sepsis and urinary tract infection. Int J Gynaecol Obstet. 2026. doi.org/10.1002/ijgo.71110

  7. Trends in urosepsis-related mortality among adults ≥25 years of age in the United States from 1999 to 2020 (abstract P-775). Open Forum Infect Dis. 2025;13(Suppl 1). academic.oup.com/ofid/article/13/Supplement_1/ofaf695.986/8421170

The cost of UTIs

  1. Lodise TP, et al. Longitudinal, nationwide, cohort study to assess incidence, outcomes, and costs associated with complicated urinary tract infection. Open Forum Infect Dis. 2019;6(11):ofz446. academic.oup.com/ofid/article/6/11/ofz446/5601270

  2. Thorpe K, et al. Factors associated with the costs of treating privately insured adults with complicated urinary tract infections. BMC Infect Dis. 2026;26(1). doi.org/10.1186/s12879-026-13595-x

  3. Broughton E, et al. Assessing the economic burden of complicated urinary tract infection: a systematic literature review. Eur J Health Econ. 2025;27(6):1149–1169. doi.org/10.1007/s10198-025-01846-8

  4. Chopra T, et al. The changing picture of community acquired urinary tract infections in the US: a daunting prospect. Expert Rev Anti Infect Ther. 2026;24(9):845–853. doi.org/10.1080/14787210.2026.2695445

Vaginal estrogen safety: breast cancer survivors

  1. McVicker L, et al. Vaginal estrogen therapy use and survival in females with breast cancer. JAMA Oncol. 2024. doi.org/10.1001/jamaoncol.2023.4508

  2. Agrawal P, et al. Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer. Obstet Gynecol. 2023. doi.org/10.1097/AOG.0000000000005294

  3. Cold S, et al. Systemic or vaginal hormone therapy after early breast cancer: a Danish observational cohort study. J Natl Cancer Inst. 2022. doi.org/10.1093/jnci/djac112

  4. Mitchel OR, et al. Survival outcomes in breast cancer patients with use of vaginal estrogen therapy: a SEER analysis. JCO Oncol Pract. 2026. doi.org/10.1200/OP-25-01142

  5. Beste ME, et al. Vaginal estrogen use in breast cancer survivors: a systematic review and meta-analysis of recurrence and mortality risks. Am J Obstet Gynecol. 2024;232(3):262–270.e1. doi.org/10.1016/j.ajog.2024.10.054

  6. Santos GML, et al. Vaginal estrogen therapy for treatment of menopausal genitourinary syndrome among breast cancer survivors: a systematic review and meta-analysis. Rev Bras Ginecol Obstet. 2025;47. doi.org/10.61622/rbgo/2025rbgo46

  7. Mainar LB, et al. Safety of vaginal estrogen in breast cancer survivors: current evidence on systemic absorption and oncologic outcomes. Maturitas. 2026;208:108914. doi.org/10.1016/j.maturitas.2026.108914

  8. Faltinová M, et al. Effects of vaginal estrogen on serum estradiol during aromatase inhibitor therapy in breast cancer patients with vulvovaginal atrophy: a prospective trial. Breast Cancer Res Treat. 2024;210(2):295–305. doi.org/10.1007/s10549-024-07564-8

  9. Sánchez-Rovira P, et al. A phase II randomized, double-blind, placebo-controlled trial to assess the safety of 0.005% estriol vaginal gel in hormone receptor-positive postmenopausal women with early-stage breast cancer on aromatase inhibitors. Oncologist. 2020;25(12):e1846–e1854. doi.org/10.1634/theoncologist.2020-0417

Vaginal estrogen safety: blood clots

  1. Eckert-Lind C, et al. Recurrent venous thromboembolism and vaginal estradiol in women with prior venous thromboembolism: a nested case-control study. Eur J Haematol. 2024;113(6):745–750. doi.org/10.1111/ejh.14287

  2. Juul SL, et al. Is vaginal estrogen treatment associated with risk of thrombosis in postmenopausal women? A scoping review. Semin Thromb Hemost. 2026. doi.org/10.1055/a-2882-1241

  3. Svendsen ALO, et al. Does administration of vaginal estrogens increase the risk of venous thromboembolism: a case-control study. Basic Clin Pharmacol Toxicol. 2021;129(5):385–388. doi.org/10.1111/bcpt.13644