Why does it feel like a UTI when my tests keep coming back negative?"

We all know the telltale signs of a urinary tract infection (UTI). Burning, stinging, frequency and urgency are often the top words to describe this common infection. But what if those classic UTI sensations arise and your urine sample comes back normal? 

Let’s get one thing clear—you are not imagining things. Those symptoms are very real, but they’re signaling something else going on in your body. Urinary symptoms become more common and confusing for  women in perimenopause and menopause. Sometimes, it actually is a UTI. But just as often, those symptoms point towards declining hormone levels in those tissues, which require a totally different approach—something antibiotics can’t fix. 

“Up to 77% of women in perimenopause or menopause suffer with GSM symptoms. The good news is that locally applied hormonal treatments, such as vaginal estradiol cream can help and is safe for most women.” - Dr. Gandhi

Why do UTI-like symptoms occur in menopause?

Menopause changes your body from head to toe, and your urinary tract is no exception. One of the biggest shifts is hormonal: as estrogen levels decline, the tissues in and around the vagina and urinary tract become thinner, drier, and ultra-sensitive.

That matters because estrogen helps keep your bladder and urethra (the tube that carries urine out of your body from your bladder) healthy. It also keeps your vaginal tissues lubricated, elastic, and resilient. When estrogen levels become erratic and inconsistent during perimenopause (and much lower  in menopause), those tissues can become irritated more easily—especially after anything that applies friction to that area, like having sex, wearing tight clothing, or even sitting for long periods of time.

These symptoms that mimic a UTI can include:

• Burning with urination

• Urgency (the sudden need to go)

• Frequency (peeing more often than usual)

• Feeling like you can’t fully empty your bladder

• Pelvic discomfort

Even though these symptoms can mirror those of a UTI, they aren’t always caused by a bacterial infection.

A major culprit of the above sensations is the genitourinary syndrome of menopause (GSM), which encompasses the menopausal changes that affect the vulva, vagina, pelvic floor, and lower urinary tract. GSM is extremely common, affecting 50% of menopausal women, but it’s also frequently misdiagnosed, which leads to a frustrating cycle: symptoms show up, a UTI is suspected, antibiotics are prescribed—but they bring no relief. One large 2026 study found that over 1 in 4 postmenopausal women with a negative urine culture still got antibiotics—even though there was no confirmed infection.

Getting to the bottom of your UTI-like symptoms is key to getting the right treatment(s).

How menopause changes the urinary tract and vaginal health

Estrogen has many roles beyond periods— it supports the health of your entire pelvic region. During your reproductive years, estrogen helps maintain:

• Thickness and elasticity of vaginal tissues

• Moisture and lubrication

• Healthy blood flow to the area which supports arousal and ability to orgasm

• Normal vaginal pH and microbiome balance

• Your bladder and urethra’s protective lining

As mentioned above, vaginal and vulvar tissues can become more sensitive and inflamed as estrogen declines in perimenopause and menopause. Specifically, your vaginal lining may become thinner and drier, and your urethra can become irritated more easily.

Your pH can also rise, which may throw off the balance of your vagina’s microbiome. That shift can make you more prone to irritation and inflammation, and increase your UTI risk.

Menopause can also affect bladder function. Some women notice:

• Having to pee more often

• Increased nighttime urination

• More sensitivity to caffeine, alcohol, or acidic foods

• Leaking with coughing, laughing, or exercise (urinary incontinence)

• A stronger “gotta go” feeling, even with a small amount of urine

These changes are common—but that doesn’t mean you have to accept them as “the new normal.”

UTI or not? Conditions that can mimic infection in menopause

When symptoms flare, it’s always smart to seek medical attention and get a urine analysis and culture to rule out a bacterial infection. But if these symptoms keep coming back, your tests are negative, or antibiotics don’t bring relief, it may be worth exploring other menopause-related triggers. Apart from GSM, other conditions common in menopause that can lead to UTI-like symptoms include:

1) Overactive bladder

An overactive bladder is exactly what it sounds like. Think of it as an over-sensitive smoke detector: it signals “time to go” more urgently and more often than it needs to. Hormonal shifts and pelvic floor changes during menopause can contribute to this.

2) Interstitial cystitis

This is a chronic condition that causes bladder pain, pressure, and urinary frequency without infection. It can be tricky to diagnose, but it’s important to consider when symptoms are persistent, and urine cultures are routinely negative.

3) Irritation from everyday products or clothing

Fragrances can irritate anyone’s vulvar area, but your tissues are even more sensitive during menopause. Something as simple as a fragranced body wash, bubble bath, scented laundry detergent or tight clothing such as leggings can worsen a burning sensation or itchiness.

When to see a healthcare provider for urinary symptoms

You don’t need to suffer with urinary discomfort—it’s always a good idea to schedule an appointment with your healthcare provider from the get-go. That way, you can get to the bottom of your symptoms much earlier. 

“The urinary symptoms of GSM can have a profound impact on well-being, functioning, and quality of life in menopausal women. Without treatment, these symptoms typically get worse with time. That’s why it is so important to seek out care from a menopause-trained clinician. Women do not need to suffer.” - Dr. Gandhi

Consider chatting with your doctor if you have persistent burning, worsening urgency or leakage, and recurrent symptoms despite getting care. If you have fever or chills, nausea or vomiting, blood in your urine, or feel weak, seek out medical care ASAP to check for a more serious infection or other causes.

Let’s be honest, recurring urinary symptoms can be painful and impact your quality of life. You deserve a clear plan, rather than another round of antibiotics. In fact, taking antibiotics when you don’t have an infection won’t fix GSM or bladder irritation. It can actually disrupt your vaginal and gut microbiome and cause vaginal yeast infections.

Treatment options: hormonal and non-hormonal relief

The right treatment depends on what’s actually causing your symptoms. If the root issue is GSM or hormone-related tissue changes, treating that with menopausal hormone therapy can be a game-changer.

Vaginal Estradiol Cream

Using locally applied vaginal estrogen medication is one of the most effective treatments for urinary and vulvovaginal symptoms in menopause. It helps with vaginal lubrication, improves blood flow and sensation, and improves bladder and urinary, and sexual symptoms. Vaginal estrogen can reduce uti infections by 50%. It is non-systemic – meaning It works locally. It can be used alongside systemic menopausal hormonal therapy.

Systemic hormone therapy

If you’re also dealing with other menopause symptoms, including hot flashes, night sweats, mood changes, or sleep changes, systemic menopause hormone therapy could help your whole body. But, it is important to note that systemic menopause therapy typically does not help with urinary and GSM symptoms. 

Non-hormonal options that can help

If hormones aren’t the right fit for you and your unique health needs—or you want to combine hormonal and non-hormonal strategies—these can offer real relief:

• Vaginal moisturizers (think: hyaluronic acid) can be used in conjunction to reduce dryness and irritation

• Pelvic floor physical therapy, which can improve bladder control, ease pelvic floor tension, and reduce urgency/leakage

• Bladder training techniques for urgency and frequency

• Avoiding irritants like fragranced soaps or harsh cleansers

• CO2 laser therapy, which involves stimulating collagen and elastin in vaginal tissues 

Antibiotics 

Antibiotics are absolutely the right treatment for a UTI or other bacterial infections. But if your tests are negative, or symptoms keep returning, another round likely isn’t the answer.

Lifestyle strategies to support urinary and vaginal health

Making small changes can make a big difference, especially when tissues in your pelvic area are more sensitive. Try these approaches to prevent irritation and infection: 

• Stay hydrated, as concentrated urine can burn more

• Pee after sex to flush out any bacteria

• Wipe front to back

• Avoid douching and fragranced products

• Choose breathable cotton underwear

• Limit bladder triggers, including caffeine, alcohol, carbonated drinks, and acidic foods

• Consider cranberry products, including supplements or juice 

• Do pelvic floor exercises, such as Kegels, to support bladder control

Keep in mind, making holistic lifestyle changes like these won’t treat GSM on their own, but they can ease discomfort and lower symptom flare-ups.

Advocating for yourself when symptoms persist

If you keep getting UTI-like symptoms, but the urine cultures don’t match the discomfort, it can feel isolating, and honestly, exhausting. But just know you’re allowed to advocate for yourself—you deserve better answers and a comprehensive treatment plan.

Here are a few ways to speak up:

• “If this isn’t a UTI, what else could be causing the symptoms?”

• “Could my symptoms be related to GSM?”

• “Can we consider vaginal estrogen or other GSM-appropriate treatments?”

• “Can I be referred to a specialist?”

Tracking your symptoms (which includes when they happen, what makes them worse, and what helps) can also give your provider clearer clues, and help you feel more in control.

The bottom line is this: burning, urgency, and frequency are common in menopause, but they aren’t something you have to live with. Once you know the real cause, relief isn’t just possible, it’s the expectation.

Frequently Asked Questions

Why do I have UTI symptoms like burning and urgency if my urine test is normal?

It is common for menopausal women to experience sensations that mimic a urinary tract infection, such as burning, frequency, and urgency, even when no bacteria are present. These symptoms are often caused by declining estrogen levels, which lead to the thinning and drying of the tissues in the urinary tract and vagina—a condition known as Genitourinary Syndrome of Menopause (GSM). Because the root cause is hormonal rather than bacterial, these symptoms will not respond to antibiotics but can often be relieved with localized hormone therapy.

How does the loss of estrogen during menopause affect my bladder and urethra?

Estrogen plays a vital role in maintaining the health, elasticity, and moisture of the entire pelvic region. When estrogen levels drop during perimenopause and menopause, the protective lining of the bladder and urethra becomes thinner and more sensitive to irritation from friction, certain foods, or even sitting for long periods. Additionally, a rise in vaginal pH can disrupt the healthy microbiome balance, making the area more prone to inflammation and increasing the actual risk of recurrent infections.

What is Genitourinary Syndrome of Menopause (GSM) and how is it treated?

GSM is a term that encompasses the various changes menopause causes in the vulva, vagina, and lower urinary tract, affecting up to 77% of women in perimenopause or menopause. One of the most effective treatments is low-dose vaginal estradiol cream, which works locally to restore tissue thickness, improve blood flow, and provide lubrication without being absorbed systemically. Other options include non-hormonal vaginal moisturizers, pelvic floor physical therapy, and lifestyle adjustments to avoid irritants like fragranced soaps.

What are the risks of taking antibiotics for UTI symptoms when an infection isn't present?

Taking antibiotics when a urine culture is negative does not treat the underlying hormonal causes of bladder irritation or GSM and can lead to several complications. Overusing antibiotics can disrupt the delicate balance of both the gut and vaginal microbiomes, potentially leading to vaginal yeast infections. It also contributes to the broader issue of antibiotic resistance, making it harder to treat actual bacterial infections when they do occur.