In a surrogacy deal between a rich and poor woman, only one is acting as a free agent
Considering how quickly “too posh to push” once took off as a way of rebuking mothers who planned to cheat nature with a Csection, current reporting about affluent women who, for reasons seemingly unconnected to fertility, outsource entire pregnancies to poorer women is distinguished by a touching delicacy.
So much so that a whole new vocabulary – “welcomed”, “surrogacy journey”, “gestational carrier” – is now helping normalise these womb-saving conveniences. You would hardly know from the tributes to celebrity hirers of surrogates, customarily accompanied by zero interest in the labouring women’s journeys, that commercial surrogacy is banned in most of the world, and only occurs within the UK in its expenses-only form. And some will certainly take it as a sign of progress that, even as studies expose the longterm health problems associated with childbirth, no reason now seems too trivial to justify paying a less fortunate woman to risk these complications.
Who are strangers to comment on a would-be parent exercising what is increasingly claimed, even if it requires the bodies of others, to be a right? Or on the choices of a surrogate mother, also assumed to be a free agent? It remains a mystery why the choice to gestate a stranger’s child is almost never, if ever, taken by the richest 1%.
While the essential service is unchanged, give or take the egg provider, since the sensational arrival of baby Cotton in 1985, the impact of celebrity customers, commercial agencies and proselytisers for fertility equality means a buyer like, say, the heiress Paris Hilton, can now feel confident her various reasons for womb-rental, including teenage trauma, are unlikely to be seriously interrogated. For instance, recently: “My life has been so public.” With this explanation, even women’s magazines notionally alert to the physical and mental risks of reproductive labour appear fully satisfied. Two babies acquired within the last year have been displayed.
“The surrogacy process,” Hilton said, “was definitely a difficult decision to make.” If anything, you gather, it’s Hilton’s wellbeing, not that of her childbearers that should concern us. She would have loved, she said, “that experience of growing the baby in your tummy and feeling the kicks and all of those exciting moments”.
Spare a thought, too, for fellow customer Khloé Kardashian, who used a surrogate to avoid, it was reported, a second child putting her body “under more strain”. She has spoken about the “transactional” difficulties of the transaction, feelings of guilt and of struggling to bond with her son. “I wish someone was honest about surrogacy and the difference of it,” she said.
To be fair, there have been a few attempts, over the years. In fact, while principled objections relating to commodification, to coercion, to alienation from self (for the birth mother), to surrogacy’s shared characteristics with the sale of organs, may have escaped some clients, it would surely be quite difficult to remain ignorant about the entire, international horror story. And if not ignorant, untroubled. Along with occasional scandals, such as the leaving behind in Thailand by the buyers (the father a sex offender) of baby Gammy, a twin born with Down’s syndrome (the other was acceptable), researchers have exposed exploitation, trafficking, grim housing and dehumanising treatment of surrogate mothers leading, in one country after another, to the trade’s prohibition. The UN special rapporteur, Maud de Boer-Buquicchio, rejecting the idea of any right to a child, has identified most commercial surrogacy as the sale of children.
But some countries hold out. With the US so costly, Ukraine was particularly favoured until the collision of war with reproductive tourism separated surrogate mothers from their own children and families. To save foreign clients’ pregnancies, some host women were removed by agencies to neighbouring countries. Kenya is among the countries stepping up, although buyers have been warned about, among other things, maternal death rates and the use of hostels.
Closer to home, some parents via surrogacy have also helped clarify how shopping for the perfect eggs and gestators can differ not only from unassisted parenthood, but from anything formerly understood as human dignity. A couple of Made in Chelsea alumni recently treated themselves to something special: “There’s a company in LA and they have a company that basically is, supermodels who are like Ivy League educated,” one explained.
In the Guardian, a revelatory article about a Ukrainian arrangement, published last week, confirmed that surrogacy does not need to be similarly crass and distasteful to seem nonetheless, utterly unimaginable. The very nice-sounding Dorothy and Charlie, although they could not have foreseen a catastrophe that would end with them living on intimate terms with their baby’s Ukrainian surrogate mother and her son, would have presumably been aware, as buyers, the transaction was asymmetrical. They knew – Dorothy has a grown-up child – what they were asking for their initial £43,000 outlay, a sum that is, you might think, a fairly reasonable price for a human. You can hardly welcome a BMW for that. Even before new figures on the number of women – 40 million annually – who experience lasting health issues from childbirth, anyone interested would know the risks, increased in multiple births. Surrogate mothers have heightened levels of depression, with secrecy and the avoidance of stigma likely, in some cases, to stand in the way of treatment.
That endless evidence of exploitation and harm seems never to discourage pro-surrogacy campaigners was again demonstrated last week, when Irish ministers approved what is likely to become regulated international surrogacy. Fine Gael senator Mary Seery Kearney (whose child was born by surrogacy in India before it prohibited the trade) says the change would bring “much needed certainty and legal protection to intended parents and children”. If the past is any guide it would also increase the risk of gestational slavery in poorer parts of the world. You wonder what, other than deterrent costs, would ever strike the determined womb-renter as too high a price to pay.
• Catherine Bennett is an Observer columnist
The UN special rapporteur has identified most commercial surrogacy as the sale of children
had a house in the country, and loved being there with her family around her – but after the tragedy of losing Kate, her first child [in 2013], she didn’t work for two years. She was tempted back when the Symphony Orchestra of Montreal asked her to perform Serge’s songs for the 25th anniversary of his death and she then toured with different symphony orchestras around the world for two years. Serge was a classical musician at heart and in a way, Jane was able to honour this.
We had a wonderful 48 hours together in 2015 at a literary festival with William Blake’s poetry. We rehearsed in her home, she worked intensely at everything she did, never resting, always on the move as if she felt she never had enough time to make everything perfect.
Jane was a fine writer of diaries, songs, plays and films. Her last album, Oh! Pardon Tu Dormais (Sorry, You Were Sleeping, 2020), took the title of the play that she had written and performed in years before. In this album she wrote all her own lyrics, delving deep into the truth of the powerful emotions that still haunted her, saying in song what she needed to be heard before she went.
Jane had been unwell for a long time, but she never stopped wanting to find expression. She kept pushing herself to the limit, however she was feeling, always there performing for those who loved her.
She had an extraordinary sense of survival right up until the end.
We met by chance at the Paris Opera just before she died, bumping into each other in the big foyer of the Palais Garnier and we had our last friendly chat. Ours was the kind of friendship where you hold the person in your esteem and your heart, you’re going along the same road, parallel lives, you bump into each other now and again, you chat then move on but you are always watching out quietly for each other. Jane B and Charlotte R.
She was very open about her emotional state. She had no interest in saying or doing the cool thing either
says Carson, “but now that she’s gone, we realize how far over the line we are.”
‘He has to be legitimate’
“I started with no money,” Pina bragged in one of his Breakfast Club appearances, “and here I am, $50m later, in real estate.” Really, his main qualification for appearing on the show seems to be that he had Envy to vouch for him.
In general, Envy comes off on mic as a moral authority who defaults to respectability politics – about on par for the son of a New York City cop. He wags his finger at single fathers, brags about his Hampton University education, and supports stop-and-frisk (he has said he was shot at three times in 2016 carjacking). In his brief on-air apology following Pina’s federal indictment, Envy said, by way of explanation: “I’ve never stole anything from anybody.” But Acosta, the scammed Breakfast Club listener, calls bullshit.
He points to a clip from a podcast Envy co-hosts with his wife, in which the DJ harks back to college days spent shoplifting from Sam’s Club in his Sunday best. (“It worked,” Envy said. “I did this about three, four times.”) Acosta also harbors suspicions about the wealth displayed on Envy’s social media accounts – the cars, the chains, the glow-up. “There’s all this wealth that’s unaccounted for,” Acosta says, “and he’s saying he had nobenefit from that whole situation? Nobody with two eyes would believe that, right?” (Envy’s social media accounts suggest his apparent wealth predates Pina’s appearances on The Breakfast Club.)
His skepticism was hard-earned. Acosta was listeningto The Breakfast Club when Envy swore by this buddy of his, building him into a Trump-like mogul with thousands of properties and the keys to generational wealth. He was watching when, in one promotional video shot with Pina, Envy held a fan of envelopes that he said contained rent checks from his investment.
Also in the shot was DJ Prostyle, another Power 105.1 personality, who held up rent envelopes while touting the fourth real estate deal he was about to close with Pina. “This guy’s tryna get more houses than me! He’s gonna start speaking at the seminars!” Envy joked before turning serious: . “That’s what it’s about, teaching and learning how to do it.”
“This was my first real estate deal ever in life,” Acosta says. “I’m thinking to that point Cesar [Pina] is legitimate. He has to be legitimate. Envy has been backing him for at least two to three years. I saw over 20 videos of him promoting this business. It just didn’t strike me at all in any possible way that this could have been a scam. The Breakfast Club is too big of an organization. iHeartRadio was too big of an organization for that to go down, right?”
When Acosta met Pina in March 2022 at his New Jersey office to close his $150,000 real estate deal, he found Pina charismatic and authoritative. It helped him ignore his concerns about the way Pina conducted business – that he didn’t follow the proper steps for notarizing documents (“but the stamp looked legitimate,” Acosta says), that he demanded the $150,000 in cash and didn’t bother to count it (“he made a joke like, ‘If it’s not there, I’ll let you know’”), that he was pitching Acosta on crypto and NFTs before the ink was dry on their real estate deal. “He started telling me that he was going to become a private money lender himself, so that he wouldn’t need to come to people like us for loans – that he would be the one that actually providing the loans in the future,” says Acosta.
Pina kept asking Acosta if he had more money to invest besides the $150,000 – a nest egg Acosta had built from years of savings, cash gifts from his wedding and a side hustle reselling sneakers. “I told him, ‘I’m broke,’” Acosta says.
But after that meeting, Acosta had a hard time reaching Pina. He’d call or text to ask when he could expect to collect the promised return (30-45% in six months, he says). After a stretch of nonresponses, Acosta returned to Pina’s office hoping to catch him. “I would see notes from FedEx or UPS that would be on the door for like a week and a half, like no one was here,” he says. “That’s when I got fed up with everything and filed my lawsuit.”
The doomed investment with Pina cost Acosta his marriage and complicated the future for his four-year-old daughter and two-year-old son. He is suing Envy, Pina, Pina’s wife, Jennifer, and their related businesses in New Jersey state court for damages and losses totalling $329,500 (Schachtel is his lawyer).
Acosta has considered calling in to Slander the Breakfast Club “maybe once or twice”, he says. “But I never had luck in the past. I did think about trying to go on as a fan and then hit them with the hard question.” Ultimately, he went for a more diplomatic approach and slid into the Instagram DMs of Tom Poleman, iHeart’s chief programing director, calmly outlining his situation, Acosta says. He got silence in return.
Tamara Holder-DeMaio is a Chicago-based attorney who has represented former iHeart employees in workplace harassment lawsuits against the company. “There are rules about advertising your own business interests on air [without disclosure]. FCC rules. You literally can’t do that,” says Holder-DeMaio, raising the possibility that Pina’s relationship with Envy relative to the Breakfast Club could be construed as (at least) an indirect form of payola. For context, she cites Dave Ramsey, a Christian radio host who promoted a timeshare exit company that allegedly fleeced his listeners; he was recently hit with a $150m classaction lawsuit. (Ramsey, who has not responded to the allegations, has attempted to have the class action dismissed on grounds that it’s too broad.)
The rumblings about Pina’s Breakfast Club appearances reached a fever pitch in May of this year, when the real estate influencer Tony “the Closer” Robinson, an ex-NFL player with a reputation for uncovering scams, began posting interviews with upset Pina investors. “I’ve been working with the victims who have given me a laundry list of receipts, text messages, phone conversations, email exchanges,” Robinson saidon his YouTube show. “I passed an entire file to the federal government … Yes, I’m a proud rat for anybody that thinks they can come and steal hardearning people’s money.”
Envy confronted Robinson directlywith a full-fledged denial: “[Pina] does not owe me money,” he snarled in a tense Instagram Live exchange in May. “We don’t have any dealings with each other.” He also sued Robinson for defamation. (Robinson denies defaming Envy and plans to vigorously fight the motion.) Pina brushed the accusations off but made a point of distancing Envy from the allegations.
In mid-October, the feds arrested Pina and reportedly visited Envy at the iHeart studios in New York to inform him of Pina’s arrest. A month later, Pina filed his own $10m defamation lawsuit against Robinson. (Robinson stands by his statements.)
Schachtel, the victims’ attorney, reckons it shouldn’t be much longer before iHeart, which brags about reaching “90% of Americans each month”, finds itself the subject of a class-action litigation brought on behalf of the victims. “I think what we want to see at this point is a little bit more of that direct evidence of exactly what was being aired on the radio [about the alleged fraud] before we pull the trigger,” he says. “That’s really the missing piece.”
Sticking to the script
Suffice to say, if it weren’t their cohost in the middle of this messy drama, The Breakfast Club would be snickering about it louder than anyone. Instead, disinclined to address the elephant in the room, The Breakfast Club sticks faithfully to the script. One recent episode led off with the hosts discussing a story out of Jackson, Mississippi, about police burying Black homicide victims without notifying their families. Another episode featured an interview with Busta Rhymes. Throughout, there were the usual digressions into mating habits, celebrity foolishness and trending topics – with Envy steering the conversation, as ever.
That’s not to say the idea of a Breakfast Club without Envy hasn’t occurred internally. “I think the Breakfast Club is bigger than any of us as individuals,” Charlamagne said in a recent Rap Radar interview. “What I’ve always wanted for The Breakfast Club was new talent constantly comes in and is a part of this, is under this umbrella of the Club. So whether Angela Yee is there or I’m there or Envy’s there, the platform can still continue.”
Either way, Acosta’s too angry to listen any more. He trusted The Breakfast Club, and he feels the show betrayed him.
Meanwhile, alternatives abound. Ebro in the Morning is a more grounded, thoughtful rival. Just as star athletes dived into the content creation game to bypass the sporting press, hiphop needle-movers who might have relied on The Breakfast Club for relevance or record sales now have platforms of their own – like NORE’s Drink Champs podcast, which is broadcast on the P Diddy-founded Revolt TV network. ESPN’s Shannon Sharpe is one of a handful of upstarts with buzzier long-form interviews than The Breakfast Club. Roland S Martin, on YouTube too, is more robust on Black news. Budden is a sharper music critic. Tasha K, the internet gossip who lost a $4m defamation lawsuit to Cardi B, is more outrageous.
“The Breakfast Club created ripples that folks might not even trace back to that original plop in the water,” Carson says. If indeed the Breakfast Club loses listeners from a scandal brought home by Envy, its weakest link all along, it’s because the show itself became such an easy mark.
susceptible to both genital and urinary symptoms. So, yes, it’s about pain with sex, decreased orgasm, decreased arousal. As a sex doctor, those are important to me. However, as a urologist, the much more serious issues are discomfort, pain when sitting, irritation, burning and itching of the vulva, urinary frequency and urgency. And the thing that kills elderly people all the time is urinary tract infections, which can lead to sepsis, worsened dementia, and death.” The NHS says the death rate for hospital UTIs is 4 in 100, rising to 1 in 10 in those aged 95 and over.
Just as we have a gut microbiome, we have a vaginal microbiome. Lack of oestrogen means the lactobacilli and other good bacteria in the vaginal microbiome can be replaced by pathogenic ones. Oestrogen also helps collagen production, and collagen disappears from the vulva by up to 30% in the five years after menopause. We invest millions in collagen supplements and anti-ageing serums for our faces, but it never occurs to us that precisely the same process goes on down below.
More than half of women get UTIs and so many of us know the burning sensation on peeing, the rushing to the toilet every 10 minutes, the abdominal pain and fever, plus the time it takes to get the damned thing sorted, again and again. That’s one reason why the nasty bacteria are winning: one in four women have a UTI strain resistant to certain common antibiotics.
“Thinking about UTIs again brought to mind early-hour bouts of rolling around on the bathroom floor in agony. Middle-of-the-day baths in tears, and leaving dinners, parties, all kinds of fun things in an absolute panic as soon as I felt the familiar change”:@ageless.menopause.info
But guess what? We can prevent GSM for women in perimenopause and menopause by giving them a safe, incredibly low dose of vaginal oestrogen, which plumps the tissue back up again, feeds the vaginal microbiome and reduces UTIs by 50%, according to the American Journal of Obstetrics & Gynecology. It’s safe for most breast cancer patients, too, it’s a win-win on the sex front and you can take it alongside normal HRT. Vaginal hormones come as a cream, gel or pessary and are cheap, costing the NHS around £5 for the cream. Meanwhile hospital admissions for people with UTIs stand at around £400m a year.
Professor Chris Harding, a consultant urologist at Newcastle upon Tyne Hospitals NHS Foundation, said: “Vaginal oestrogen replacement has got good evidence in terms of trending UTI frequency downward and the absorption of oestrogen given vaginally is minimal so it’s pretty safe. And it’s great to have a non-antibiotic alternative to increase prevention. I sometimes use it in pre-menopausal women, too, to change the microbiological environment of the vagina.”
Although some GPs and urologists are getting the message and prescribing vaginal oestrogen, more work needs to be done. In one California study in 2003 of over 5,000 women (average age 70), more than half had reduced UTIs after a year on vaginal oestrogen and a third had none whatsoever. Dr Rubin said: “We have millions of people in nursing homes who are dying of UTIs [in the US] and we have lots of data since the 1990s to show that vaginal hormones massively decrease urinary tract infections. We have new data. We have old data. We have so much data. The problem is that nobody’s talking about it.”
The science is often ignored. A recent NHS England press release on UTI prevention advised women to stay hydrated and wash themselves more, but failed to mention vaginal oestrogen at all, despite aiming warnings at “older adults” and their carers. Is this due to gender bias in medicine, embedded disinterest in the post-fertile vagina or a complete misunderstanding of the low risk around local oestrogen?
Then to make matters worse, Food and Drug Administration “black box” warnings in the US, and patient leaflets for vaginal oestrogen products in the UK, have not been updated and still list risks like blood clots, stroke and even memory loss, which have now been proven incorrect. No wonder doctors are cautious. Dr Ashley Winter, a Los Angeles urologist colloquially known as “the Angel of Estrogen” on X, formerly Twitter, said: “In the US, vaginal oestrogen has been approved by the FDA for vaginal dryness and painful sex – but not for an overactive bladder and UTI prevention, although we know it overwhelmingly works. So there’s an education gap. I never learned it in medical school. That’s why you have to bootstrap the education through social media.”
Sometimes a simple UTI can be a turning point in life. It was for my mum, Ella Muir, who used to work as a personnel manager in a Glasgow department store. She was living at home independently with Alzheimer’s disease in her 80s, helped by a wonderful carer who went in twice a day to provide meals and even take her out for coffee to Dobbies Garden Centre. But when her carer and I were away for two days one August, the replacement carers failed to turn up and Ella became dehydrated, confused and delirious. She was taken to hospital, diagnosed with a UTI, and given intravenous antibiotics. By the time I flew in that evening, my mother was crashed out asleep.
She rallied a bit physically over the next few days, but not mentally. The UTI had taken its toll. For the first time, she didn’t recognise me and sometimes thought that I was her mum. She wasn’t eating properly, so her carer and I took turns to come in and feed her, something she had always managed by herself. She struggled to stand or go to the hospital bathroom. Although the delirium went and she recognised us again, something had shifted mentally. Ella never came home to her flat. She started using a wheelchair and moved to a nursing home where she died less than a year later, listening to music after lunch.
Now I know that dehydration was the cause of the UTI, and even if Ella had had decades of vaginal oestrogen, it might have made no difference. But I had no sense until then that UTIs could have greater consequences and permanent physical and mental losses. There is already emerging evidence that infections, including UTIs, are themselves associated with an increased risk for dementia, according to a 2021 Lancet study. Professor Harding explained: “UTIs can cause delirium, specifically in elderly patients, and that can make them disoriented and affect their cognition. A severe infection might just be sufficiently debilitating to cause it and then getting back to your baseline is quite difficult.”
How many UTIs like that could be avoided? Back in 2015 when Ella died, I had never heard of vaginal oestrogen or atrophy, but now when I think of the truckloads of incontinence pads arriving every week at care homes like hers and the other women sitting in constant genitourinary discomfort on those plastic-covered armchairs with the television blaring, I wonder if we couldn’t do more for them.
So I talked to Dr Charlotte Gooding, a British Menopause Society specialist and GP in the northeast of England. “UTIs are a large chunk of GP workload in primary care and it’s mostly women of menopausal age. The majority of my home visits are to older women, particularly in care homes. They ring up to say a patient is unwell and delirious and I’ve got to assess and try to keep her out of hospital and make sure she doesn’t get sepsis. Mortality from urosepsis is huge. When people get delirious and need to go to the bathroom, they might climb over the bed rails and fall and break their hip. I’ve seen that many times and it makes me incredibly sad walking round care homes, knowing we could do more to prevent UTIs in the first place.” Over half of hospital UTI admissions are for people over 65 and a quarter of all sepsis cases are related to UTIs – that’s more than 50,000 a year in the UK.
Dr Gooding believes that no one is looking at the bigger picture and takes direct action when she can. “Twice weekly oestrogen pessaries, such as Vagifem, are very effective, but can be tricky for older women who might have dexterity issues and their carers don’t always have time to help. But an Estring hormonal vaginal ring is great, like a floppy hairband with a jelly consistency and you can bend it to slip it in and leave it there for three months to oestrogenise the tissues.” She sees improvement “even for women in their 80s. Some people find the idea of consent to vaginal rings difficult and I understand that, but sometimes there is a medical ‘best interest’ argument for that kind of care. So much better than ending up catheterised or using incontinence pads or with urosepsis.”
But while Dr Gooding is doing good, many medical professionals are not up to speed on the efficacy of vaginal oestrogen. She explained: “I wasn’t taught about menopause in my medical training. I wasn’t taught about the role of oestrogen in bladder functioning. We were just taught to treat UTIs with antibiotics, and it can make your heart sink, watching people go round in circles, in and out of hospital and care homes with embedded UTIs that we can’t seem to help.” She completed her own menopause qualification after training, but amazingly menopause will only be a compulsory module in medical schools next year – although it affects half the planet.
Men suffer UTIs, too, making up about 20% of cases. I remember my dad, Douglas, had a UTI a couple of times after he had a catheter following a stroke, but there was no mental change or delirium. For men, a UTI can often mean something more serious and Dr Gooding says they tend to get seven days of antibiotics compared to the three offered to most women. “Men are just designed much better – everything is more spread out and they’re got a longer urethra. When they get a UTI it is often a sign of something else going on in the immune system – their prostate affecting the emptying, or cancer, or being catheterised.”
Those who suddenly see UTI prevention through menopause glasses are evangelical about getting the message out. In the UK, Dr Louise Newson, who runs the biggest private menopause clinic in the world and created the free menopause app, Balance, wants to encourage women to ask their GPs for vaginal oestrogen and says it is never too early or too late to take action. “Women in early menopause, breastfeeding or even some women using the contraceptive pill can benefit from using vaginal hormones, and so do older women who start having problems in their 60s, 70s or even 80s.”
Vaginal oestrogen is available overthe-counter in UK pharmacies, but only one brand, Gina, at £29.99 for 24 pessaries. That’s useful for emergencies, but most women need to continue taking it for life. In America, where getting full-body hormone replacement therapy on insurance is hard, at least vaginal oestrogen cream is available for $20. Dr Winter points out that the States could save billions if they made it free. “I say again and again that oestrogen prevents UTIs and prevents UTIlike symptoms. And until every single preventable UTI that can be addressed with oestrogen is done, I will not stop talking about this. Millions of people who are suffering don’t have to.”
Dr Winter needs to have a word with public health bosses in the UK, too, who seem to be on another planet. This autumn, “ahead of what is expected to be another busy winter”, NHS England and the UK Health Security Agency put out a “new awareness campaign to help reduce hospital admissions for urinary tract infections”. (Professor Harding pointed out that infections actually “peak in the summer due to dehydration”.) The NHS warned that UTIs, particularly for older women, “are one of the leading causes of life-threatening E coli bloodstream infections.”
Yet there was no mention whatsoever of the preventive effect of oestrogen.
“I had recurrent UTI’s from the age of 43-45 until I was finally diagnosed as perimenopausal and started HRT. The UTIs continued until I asked for Vagifemand then they finally stopped. During this period I took 20+ courses of antibiotics, I’m still paying for this now with gut issues. I was even referred to a urologist at age 43, but due to my age, no one thought low hormones could be the source of my problem”:Anon, Instagram
If only the press release reflected what’s on Instagram, or findings in the Journal of Obstetrics and Gynaecology way back in 2014, which looked at 44 studies and concluded: “All commercially available vaginal oestrogens… have additional utility in patients with urinary urgency and recurrent UTIs.” NHS England told me that although vaginal oestrogen was omitted in the press release, according to National Institute for Health and Care Excellence guidance elsewhere, “It seems vaginal oestrogen can be used as an option for recurring UTIs off-licence.” They directed me to the UK Health Security Agency for more information – who said the same thing. I spoke to the agency’s Dr Colin Brown, deputy director for antimicrobial resistance, who told me: “It is a valid point about the role of it [vaginal oestrogen] in the prevention of recurrent disease. That might be something we can take back to our colleagues.” I got the impression Dr Brown was doing his best, overseeing huge of amounts of work on antimicrobial resistance, checking out different strains and changing the type of antibiotics in certain resistant areas. Antibiotics for UTIs will be available over-the-counter from pharmacists in February 2024 and Dr Brown is hoping this will increase the number of trackable urine tests. But it all sounds more like firefighting than prevention.
Aside from vaginal oestrogen, Professor Harding pointed me to European Association of Urology 2023 guidelines, which looked at lots of promising non-antibiotic options, including certain probiotics taken orally to improve the vaginal microbiome and the sugar supplement D-Mannose, which helped in a few small trials. Cranberry products, however, seemed to be pretty ineffective. Another NHS-approved hormonal solution, perhaps the best, is Prasterone, containing DHEA, which converts to oestrogen and testosterone, and binds, with restorative powers, to the oestrogen and many testosterone receptors in the vulva.
We’re not just talking about UTIs here. We’re talking about a whole generation of women who have kept their miserable symptoms secret and have just carried on. Now, however, the omertà is over, thanks to the growing menopause conversation, and change could be instant, if doctors and women speak up and, perhaps, if the NHS put out a press release simply stating: “Vaginal oestrogen can half UTIs in older women and help prevent antibiotic resistance!”
The news is spreading fast: there’s even been a literary foray into the urinary tract. Novelist Nina Stibbe recently published Went to London, Took the Dog, a diary of leaving her family home in Truro at the age of 60 and running away to London for a year. “I’ve always been prone to laughing and weeing myself a little bit,” she told me, “but I was out with my dog, Peggy, in the city, and we got into a tussle over a chicken bone in the street and I weed myself and had to walk back with wet trousers. I realised I’d just been ignoring it for years.” In the book, Nina wees herself laughing while having spaghetti with the writer Nick Hornby. She begins to use Tena Lady pads for safety and tries pelvic-floor exercises, which don’t make much difference.
It was at that point I met Nina and her landlady, author Deborah Moggach, at the launch of my 89-year-old neighbour’s painting exhibition. We discussed the joys of general hormone replacement therapy and vaginal oestrogen, and Debby said: “Will that stop Nina peeing herself?” I suggested there was hope, posted my book through their door with the relevant page marked, and Nina went on HRT and vaginal oestrogen. The HRT took a while to settle down, but the Vagifem was instantly popular. “It made a difference within a week. I’m almost completely cured now, dry as a bone,” she said. Nina got her mum on vaginal hormones, too. “She’d been on and off antibiotics for UTIs for 10 years, and now she’s doing much better.” Nina had been worried about including the “UTI narrative arc” in her book, but it turned out to be an incredibly popular topic on her book tour. “The audience is loving it.” Spread the word.