There’s a lot going on as we age, and not all of it is welcome. “A lot of women are blindsided by the changes that occur from menopause,” says Lauren Streicher, MD, a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine in Chicago.

During menopause, women experience a drop in estrogen levels and physical changes to the vagina, vulva, and vaginal opening, which can cause symptoms like dryness and urinary tract infections. These changes, which used to be called vaginal atrophy, are now known as genitourinary syndrome of menopause (GSM), a condition that affects more than half of postmenopausal women, according to a research review.

The good news is that these changes can be treated — and reversed, says Dr. Streicher. Here’s what’s up down there.

1. Sex Can Be Uncomfortable — or Even Painful

Premenopause, the vagina has a thick wall that’s comprised of rugal folds, which are “accordion-like wrinkles that allow the vagina to expand to accommodate a baby or penis,” says Streicher. During menopause, she says, many women experience a thinning-out of that layer; what’s more, those rugal folds flatten, preventing the vagina from expanding.

5. You May Leak a Bit When You Cough

If that “gotta go” feeling hits so strong that you struggle to make it to the bathroom, your pelvic floor may be weak. “A lot of the urinary symptoms of incontinence [are] from the pelvic floor,” says Streicher. A physical therapist who specializes in pelvic floor exercises can be helpful, she says.