UTI

To step on a soapbox straight from the start, many people treat UTIs (urinary tract infections) as trivial, but when you’re dealing with UTI after UTI, then you know how life altering this seemingly small little infection is for your daily routine. Two weeks after stopping long-term use of hormonal birth control, I developed my first ever UTI and continued to struggle with recurrent UTIs and UTI symptoms for nearly a year and a half afterwards. Finally, when one healthcare practitioner prescribed a 28-day supply of a potent antibiotic at the maximum dose, a prescription I was certain would result in a case of C. diff, I walked away from the hamster wheel of treating the infection and decided to get serious about finding out why my bladder was now a safe harbor for pathogenic bacteria.

What changed within my body to allow for those bacteria to thrive unabated when I stopped hormonal birth control?

It turns out, long-term use of hormonal birth control impacted my ability to process glucose. When I stopped taking hormonal birth control cold turkey, this left my body in a lurch, unable to use glucose correctly and this inability to use glucose resulted in developing chronic UTIs. Ironically, the use of hormonal birth control itself may also precipitate frequent UTIs for some women. Similarly, it is common for women who undergo a major hormonal shift such as pregnancy, postpartum, perimenopause, starting or stopping hormonal birth control, to experience a problem with the way their body uses glucose. The symptoms vary, and include things like:

• Weight gain
• Fatigue
• Melasma
• Migraine
• UTI symptoms
• UTIs

In the rest of this article, we will:

• Briefly recap how natural estrogen (estradiol) and progesterone impact insulin sensitivity and glucose control
• Quickly revisit how synthetic estrogen (specifically ethinyl estradiol) and synthetic progesterone (progestins) impact insulin sensitivity

Then, we will take a close look at:

• How blood glucose control increases your vulnerability to UTIs
• Why standard urine cultures are negative and you still have symptoms
• How to repair insulin sensitivity after a major hormonal fluctuation

In case you didn’t catch the article on hormones and insulin resistance and want to know more about how reproductive hormones and hormonal birth control impact how your body uses insulin, you will find that article here.

How Estrogens, Progesterone, and Birth Control Impact Insulin Sensitivity

In the previous article, we discussed how natural hormones, estradiol and progesterone, and the artificial hormones in hormonal birth control impact  insulin regulation, specifically how well the cells respond to insulin (insulin resistance/insulin sensitivity). To briefly recap how estrogen and progesterone impact insulin sensitivity:

• Estradiol improves insulin sensitivity / reduces insulin resistance
• Progesterone reduces insulin sensitivity / increases insulin resistance

The synthetic form of estradiol, ethinyl estradiol, the most prevalent in combined hormonal contraceptives here in the US, works like estradiol by increasing insulin sensitivity. The synthetic varieties of progesterone, progestins, have various effects on insulin sensitivity based on the androgenicity of the progestin, along with other factors.

Insulin resistance is only one piece of how well the body is able to use glucose as a fuel source. Gluconeogenesis, the process of releasing glucose from stored reserves to meet energy needs in between meals, is another key piece to this conversation. The liver, kidneys, and skeletal muscles are the biggest storage sites for glucose. Briefly, here is how reproductive hormones impact the use of glucose reserves for energy.

• Estradiol and ethinyl estradiol reduce liver gluconeogenesis.
• Progesterone increases the storage of glucose for later use by the body (the reverse of gluconeogenesis) and increases the use of fats as a fuel source.

When the body is unable to release these stored glucose reserves to meet its energy needs, it must find an alternate fuel source for supplying energy. This alternate fuel source is fats. With this in mind, let’s explore the link between UTIs and glucose control.

Chronic UTIs After Stopping Hormonal Birth Control

When I stopped hormonal birth control cold turkey, my body no longer received the artificial hormones to encourage it to release extra insulin. I used hormonal birth control for the vast majority of 25 years, and for the last four and a half years of my own hormonal birth control journey, I took an oral contraceptive pill (OCP) continuously, every day without a break for a withdrawal bleed. This particular OCP contained 20 micrograms ethinyl estradiol (EE) plus 100 micrograms levonorgestrel (LNG).

Studies have found that a combination of ethinyl estradiol with levonorgestrel increases insulin production by about 60 to 90%, contributing to insulin resistance. So, when I stopped hormonal birth control, my cells were insulin resistant, unable to hear insulin’s call and thus unable to absorb the circulating levels of glucose in my bloodstream, and in turn, to use that glucose for energy.

On top of that insulin resistance, since my liver was also receiving the signal from the artificial estrogen, ethinyl estradiol, to decrease gluconeogenesis (creation of glucose from stored reserves), this created a further deficit in the supply of glucose as the long-term downregulation of gluconeogenesis was not automatically restored when I stopped taking synthetic hormones. The insulin resistance coupled with the impaired ability to generate glucose from reserves forced my body to switch to burning fatty acids for fuel, placing it in a ketogenic state.

UTI Symptoms, Negative Standard Urine Cultures, and Keto

Fueling the body with fatty acids rather than glucose results in breakdown products of ketone bodies. Under normal conditions, an insulin sensitive state, the body is capable of repurposing those ketone bodies through various energy production and energy storage processes. However, with insulin resistance, one is unable to use glucose as an energy source, and those excess ketones are expressed in the urine. They may even build up to levels that create a state of ketosis.

The presence of ketones in the bloodstream lowers the production of both urea and ammonia, both anti-microbial compounds made within your kidneys. This then results in lower concentrations of both urea and ammonia in your bladder making you more susceptible to UTIs (here, here, here, here, here, and here). The ketones themselves, acetoacetate and 3-betahydroxybutyrate, create similar symptoms to a UTI including:

• Cloudy urine
• Urinary urgency
• Burning when you pee

In the keto community, there is even a term for this… “keto crotch”. So, not only does a ketogenic state make someone more likely to develop a UTI because those ketones disrupt the balance of urea and ammonia in the urine, both of which provide antimicrobial resistance, those ketones also create symptoms that mimic UTIs. This makes it even more likely for a standard urine culture (SUC) to return a negative result even with active symptoms.

Side note, when my own standard urine cultures began coming back negative and I was still suffering with extreme UTI symptoms, I fell down a rabbit hole of chasing the infection and sought out healthcare practitioners that used polymerase chain reaction (PCR) testing to find infections that evaded detection by SUC. This resulted in about 6 months of lost time, and 4 additional rounds of antibiotics. It was not until later that I uncovered the root cause of the condition, dysregulated use of glucose caused by long-term use of hormonal contraceptives.

Increasing Insulin Sensitivity

It was December 2022, and for the first time since I started tracking my cycles, I had a cycle consistent with PCOS (polycystic ovarian syndrome). This turned out to be the turning point in my battle with recurrent UTIs. Upon seeing my cycle trend with PCOS, I began researching the causes of PCOS. In general, there are several potential root causes of this condition, and the one that stood out to me was insulin resistance. Suddenly, the puzzle was falling together. I now had solid evidence that supported my suspicion that my body was struggling with blood sugar control, and so I did what any good scientist would do… change lots of things at once. Here are the four things I changed immediately.

• Akkermansia muciniphila. Akkermansia muciniphila is a specific strain of probiotic with quite a bit of scientific literature behind it supporting it as a key strain to promote healthy blood sugar control. I started taking Akkermansia muciniphila daily for 3 months to get a handle on blood sugar regulation (here and here).
• Inositol. There is much science to unpack around the class of sugar alcohols known as inositols. Over the last 9 months, I still have not unpacked it all, but I am convinced that introducing the most commonly recommended inositol blend for women with PCOS, a 40 to 1 ratio of myo-inositol to D-chiro-inositol, helped my body recover from its insulin resistant state.
• B vitamins. Long story short, when I was struggling so much with recurrent UTIs, I had also stopped taking a B multivitamin. Since pretty much every single B vitamin is used in glucose metabolism within your body and because hormonal birth control is known to deplete several B vitamins within your body (and because B vitamins are necessary for healthy ovulation), I diligently reincorporated a B vitamin complex into my day. Unlike Akkermansia and inositol, I still make sure to get my B vitamin complex daily.
• Reduced sugar intake. I reduced the amount of sugar in my breakfast. Ideally, while you are training your body to be more insulin sensitive it is best to reduce sugar in every meal and snack. The most important is the first and last meal of the day. For me, my last meal of the day was already low in sugar, but breakfast had room for improvement. I still eat yogurt, granola, and fresh fruit for breakfast, but the yogurt is now plain and the granola now homemade so that I control how much sugar is in it.

These four changes profoundly impacted UTI symptoms for me within just one week. It took about 6 months to completely resolve symptoms. Still to this day, though, if I overdo it on alcohol, which suppresses gluconeogenesis, I can easily revert back to strange smelling urine the next day and ever so slight symptoms of UTI, but I haven’t had the need to be treated for a UTI or be seen for UTI like symptoms since recognizing this connection between insulin resistance and UTIs/UTI symptoms.

Long-term Support of Insulin Sensitivity and Gluconeogenesis

Since that early success, I have learned even more about supporting insulin sensitivity and gluconeogenesis, and these additional changes have supported my health beyond UTIs. Most notably, they have helped me to maintain a healthy weight and a decent appetite.

1. Build muscle mass. Skeletal muscle is more sensitive to insulin than other cell type in your body, so by building skeletal muscle, you’re restoring insulin sensitivity within your body. Weightlifting is the single best way to build skeletal muscle the fastest.
2. Avoid alcohol. Alcohol potently suppresses liver gluconeogenesis. For me, I wondered why symptoms (acetone-y smelling urine, cloudy urine, urinary urgency), were so much worse when I had a glass of wine. This was also perhaps the biggest reason why, when I stumbled across the connection between ketosis and UTIs, that I truly believed I was onto something. To this day, about 9 months after breaking the chronic UTI cycle, I have to watch how much I drink or risk return of mild symptoms (most notably urinary urgency and slightly cloudy urine).
3. Green tea. I am a green tea fiend, and there is nothing like tea (green, black, or white) to help support insulin sensitivity. Whether you sip on a cup before or after a meal, abundant research shows that tea supports healthy blood glucose regulation.
4. Herbs from your garden or your pantry. Mint, cinnamon, fenugreek, turmeric, and more support healthy blood sugar control (here and here). For me, mint especially has been a game changer in helping to boost appetite (a signal that insulin sensitivity is returning). I add a freshly picked crushed mint leaf to breakfast, and when I remember, also chew half a fresh picked mint leaf before lunch and dinner.

Summary

If you have chronic UTIs, then dysregulated blood sugar metabolism or currently being on a keto diet may be the root cause. As women, we are not told of the link between reproductive hormones and insulin sensitivity. This link is not given the attention it needs, especially when hormonal birth control is thrown into the mix.

If you have recently started hormonal birth control or recently stopped hormonal birth control and are experiencing UTI symptoms, I am willing to bet you are dealing with an underlying problem of insulin resistance. The same holds true for women experiencing UTIs and UTI-like symptoms for the first time during pregnancy, post-partum, and during the menopausal transition. If you are ready to free yourself from chronic UTIs, consider my own journey to restore insulin sensitivity and gluconeogenesis.

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A Word of Caution About UTIs

At the outset, I mentioned that urinary tract infections are often treated as trivial. Despite this misconception by the world at large, UTIs can kill when they progress into the upper urinary tract (ureters and kidneys) or when they become systemic. In fact, urinary tract infections account for nearly a quarter of sepsis cases in hospitals. Part of the reason for this is because during most surgeries, it is common to place a catheter in the urethra. This can lead to infection.

If you exhibit symptoms of an upper UTI, which include: flank pain, lower back pain, pain in the kidneys, possibly extreme pelvic pain, it is time to see a doctor or check into the emergency room. When a urinary tract infection becomes systemic and enters the bloodstream, symptoms like fever, chills, low blood pressure, or rapid heartbeat develop. In other words, when a UTI becomes anything other than an infection confined to the lower urinary tract (urethra and bladder), it is a medical emergency.

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