Getting walloped with repeat urinary tract infections, or UTIs, might be something you associate with having lots of sex. (Or, perhaps, it brings back memories of an adventurous string of hookups with a handful of new partners.) While it’s true that sex can make it easier for UTI-causing bacteria to scooch into your urethra (or pee tube), it’s far from the only risk factor. In fact, the peeing-flames infection can often surface in midlife, starting around perimenopause (a.k.a. the on-ramp to menopause), for a reason that has nothing to do with sex: hormone changes and their effect on the vagina and urinary tract.

UTIs are among the most common infections to hit women, with 50% to 60% of women getting one in their lifetime, and outside of a surge among folks ages 14 to 24, they become more prevalent with age. As does the rate of recurrence, or how often a UTI crops up again after treatment, which is around 19% to 36% in premenopausal people and jumps to 55% postmenopause. That spike is largely the result of genitourinary syndrome of menopause, or GSM, which describes a set of symptoms in your nether regions (like vaginal dryness, pain with sex, and urinary frequency and urgency) that can occur with dropping estrogen levels in perimenopause, too. As many as 70% of people will deal with GSM by the time they hit menopause, but because of the stigma shrouding its symptoms, it often goes underdiagnosed and undertreated—which leaves plenty of perimenopausal folks playing whack-a-mole with recurrent UTIs.

Below, experts break down why UTIs can be so prevalent and persistent in perimenopause and beyond, and share the solutions that get to the root of the problem.

The hormone fluctuations of perimenopause can increase your risk for UTIs in more ways than one.

A single UTI turning into an onslaught of them is not a problem unique to perimenopause—certain people have a stickier bladder lining that lets UTI-causing bacteria (like E.coli) hang around, while others have an immune system or gut microbiome that makes it easier for the bad microbes to proliferate. (All the while, some of the bacteria behind UTIs is becoming resistant to the antibiotics we use to treat them, which can keep ’em coming back.)

But even if you’re a person who hasn’t historically dealt with UTIs, you can run up against them in perimenopause because of changes to the vulva, vagina, and urinary tract that unfold with GSM, as estrogen levels first go haywire and then plummet.

Here’s why: Estrogen keeps your vulva and vagina in their optimal states—thick, bouncy, and moist. A decline in this hormone can cause the oft-cited vaginal dryness of menopause, alongside thinning and shrinking of the vulva, which can be irritating and itchy. What you might not know is that there are also estrogen receptors throughout the urinary tract, so “with loss of estrogen, the tissues in parts of the bladder and around the urethra tend to thin too,” Mindy Goldman, MD, an ob-gyn in San Francisco and chief clinical officer at Midi, a Telehealth platform for midlife, tells SELF. These changes can, in and of themselves, trigger pain with peeing or spark a need to pee more often or urgently—GSM symptoms that can mimic a UTI, says Sameena Rahman, MD, an ob-gyn in Chicago and perimenopause expert at women’s health app Flo. But at the same time, all the tissue-shriveling can increase your susceptibility to an actual UTI: It deflates the protective barrier surrounding your urethra, making it easier for bacteria in your vagina and anus to crawl on over.

There’s another reason losing estrogen can up your UTI risk—the hormone also helps your vagina make fuel that keeps its healthy bacteria, lactobacilli, alive. With lower estrogen levels, some of these beneficial bugs die. Less lactobacilli throws off your vagina’s pH and opens the door for harmful bacteria to take hold and overgrow, Karen E. Adams, MD, an ob-gyn and menopause specialist at the Stanford Health Care Gynecology Clinic and director of the Stanford Program in Menopause & Healthy Aging, tells SELF. More of these bad bugs just increases the chance that some make their way into your urethra.

And finally, dipping estrogen can reduce blood flow to your pelvic floor muscles, contributing to the weakening of this zone that can naturally happen with age and childbirth, Dr. Adams adds. When these muscles can’t contract and relax as usual, pee can stick around for too long in your bladder or dribble out randomly, both of which can increase your UTI risk.

Some good news: Hormonal treatments that counteract the changes of perimenopause can seriously help keep UTIs at bay.

The first-line treatment for UTIs is an antibiotic to squash the bad bacteria, and it’s important to see your doctor for a prescription if you suspect you’re dealing with one. But of course, that can get cumbersome if you’re constantly getting them. Not to mention, antibiotics aren’t always effective at killing drug-resistant bugs, and each UTI leaves you more susceptible to future infections, creating a vicious cycle. Hence why doctors advocate strongly for UTI prevention—and in the case of perimenopause, there’s a simple way to go about that: correcting the estrogen deficit at the core of the problem.

It’s the reason the American Urological Society (AUA) explicitly recommends vaginal estrogen therapy to reduce the risk of UTIs in peri- and postmenopausal folks with recurrent infections. This looks like a vaginal cream or suppository (which melts inside your vagina) or a vaginal ring (which you replace every 90 days) designed to bump up the level of estrogen right in the area of concern, Dr. Goldman says.

Vaginal estrogen therapy works by undoing some of the hormonal effects of perimenopause: It restores blood flow to your vulva and vagina, boosting their thickness, elasticity, and lubrication. “As these tissues become healthier and more similar to what they were like before you had dropping estrogen levels, you have more of a barrier to keep bacteria from entering your urethra,” Dr. Goldman explains. At the same time, she adds, estrogen-izing the vagina allows for good bacteria to thrive again, which ensures a healthy pH and keeps nefarious bugs in check. And it could improve the functioning of your pelvic floor. It’s no wonder research has shown vaginal estrogen can lower the frequency of UTIs by more than 50% in women lacking in this hormone. But the key to seeing results here is consistent use, Dr. Rahman says, at the cadence prescribed by your doctor (which is typically nightly to start and then tapers down to a couple times a week). “GSM is chronic and progressive, so if you stop using estrogen, your vagina can regress.”

Thankfully, vaginal estrogen is safe to use indefinitely because it consists of a low dose of the hormone and doesn’t absorb into your bloodstream, Dr. Adams says. That even applies to people whose doctors might advise them against systemic hormone replacement therapy (HRT), like a pill or patch, often prescribed for other symptoms of (peri)menopause like hot flashes and night sweats. (That mostly includes folks with a history of blood clots, breast or endometrial cancer, or heart attack or stroke.) Worth noting: If you’re safely taking systemic HRT for other reasons, you could also get relief from the vaginal dryness and urinary woes of GSM and ward off UTIs, but generally, vaginal estrogen is necessary to target these issues, so plenty of people end up on both versions, Dr. Goldman notes.

Along with vaginal estrogen, Dr. Adams and Dr. Rahman point to the benefits of pelvic floor physical therapy for warding off UTIs in perimenopause. The more supple and toned these muscles are, the less you’ll leak and the more effectively you’ll empty your bladder.

Ultimately, cutting down on UTIs in perimenopause isn’t just about sparing yourself the annoying symptoms, Dr. Adams notes. As you age, you also become more vulnerable to the complications of UTIs—like bacteria seeping into your blood and causing sepsis, she says. Strategies that tackle the unique risk factors of this phase can be true lifesavers.

Related:

• Why 30 Isn’t Too Young to Start Thinking About—And Preparing for—Menopause
• Is It a UTI or Is It Actually Interstitial Cystitis, a.k.a. Bladder Pain Syndrome?
• How to Soothe UTI Pain as You Wait for Your Prescription to Kick In

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