The wisdom and confidence that come with age are welcome. The physical changes, less so. Like most muscle groups, the pelvic floor tends to lose strength as women get older. Understanding why helps clarify what can actually be done about it.

Pregnancy is often the first challenge. The growing weight of the uterus adds new strain, and pelvic organs naturally shift lower during pregnancy, putting extra pressure on the muscles that support them. Constipation, common during pregnancy, may lead to straining during bowel movements and can negatively affect the pelvic floor. Occupational lifting or caring for small children requiring carrying provides additional strain on the pelvic floor.

Childbirth asks even more of these muscles. During vaginal delivery, the pelvic floor stretches to several times its resting length to allow a baby through the birth canal. That’s a normal part of childbirth, but it often leaves some degree of pelvic floor dysfunction behind — issues with bladder or bowel control being the most common. In some cases, there’s enough injury that focused rehabilitation is needed. Either way, pelvic floor exercises during pregnancy and postpartum help the muscles prepare and recover.

Women who never experience pregnancy or childbirth aren’t off the hook. Aging alone causes muscle loss throughout the body. Menopause adds another factor: falling estrogen levels cause pelvic tissue to thin and lose elasticity, making the muscles more prone to weakening. This is also a time when general physical activity declines and this can contribute to weakness throughout the entire body, including the pelvic floor.

None of this is just a minor inconvenience. Weak pelvic floor muscles can’t fully support the pelvic organs, which can contribute to bladder or bowel symptoms, and sometimes problems with sexual function. In some cases, inadequate support leads to prolapse, which can be painful and may need surgery. Most commonly, it leads to urinary incontinence (UI) — everything from occasional drops to a full loss of bladder control. Left alone, it tends to get worse with time.

UI affects a large share of women, tens of millions in the U.S. alone and many more worldwide. It’s common. It isn’t something anyone has to just accept, though many do. The unpredictability wears on people: mental health, relationships, willingness to be social or active. Women also tend to live longer than men but report more years of illness and disability, and conditions like UI are part of why. Studies link untreated UI to a greater risk of falls, hospitalization, and loss of independence in older women, along with faster physical decline than their continent peers. About one in five women with UI also deals with fecal incontinence.

There’s a lot working against the pelvic floor as women age. But pelvic floor muscle training, lifestyle changes and a range of clinical treatments can meaningfully change that picture, at almost any stage.