How Strength Training Can Help Those Who Struggle with Painful Sex

By Julia Rosenthal, PT, DPT, OCS, PRPC

For too long, the standard advice for people experiencing pain with sex—also known as dyspareunia—has centered around rest, avoidance or at best, passive care. While techniques like breathwork, manual therapy, and desensitization have value, these approaches are often incomplete on their own. They miss a critical element: progressive, well-coached strength training.

As a pelvic and orthopedic physical therapist, I’ve worked with many clients who were told that loading their system—especially their pelvic floor—was too risky while they were in pain. But this overly cautious approach not only stalls recovery—it reinforces fear, fragility, and disconnection. In reality, strength is not the enemy of pelvic pain. It’s often the way out.

Reframing Dyspareunia and Movement

Dyspareunia is complex. It may be rooted in muscular tension, coordination issues, hormonal shifts, trauma, postural adaptations or scar tissue. But regardless of origin, what I see over and over is this: tissues that are sensitive, nervous systems that are on high alert, and bodies that have been underloaded and overprotected.

Avoidance feels safe at first—but over time, it can create more pain, more fear, and more disconnection from movement and intimacy.

Loading the body thoughtfully and progressively can help reverse this cycle. It builds capacity, rewires threat perception and restores confidence—not just in sex, but in movement, strength and daily life.

Why Strength Training Helps

Thoughtful strength training does three powerful things for people with dyspareunia:

Improves tissue capacity
- Loading builds resilience. It increases blood flow, elasticity and tolerance to movement in muscles that have often been guarded or underused
Retrains movement coordination
- Dyspareunia is often linked to poor pelvic floor timing—not just overactivity. Strength-based movements help recalibrate how and when muscles activate, especially in relation to breath and load
Reduces threat perception
- Pain is not just about tissue—it’s about interpretation. When someone starts to succeed at movements they were once afraid of, it changes how their brain and body experience threat

Movement Matters: A Progression-Based Approach

In my practice, we don’t throw people into a barbell deadlift on day one. We move thoughtfully—from foundation to progression, based on how the individual responds. The goal isn’t just to “strengthen muscles,” but to rebuild coordination, expand movement options, and restore trust in the body.

Phase 1: Foundation and Awareness

These are often where we start— we focus on breath, neuromuscular re-education, and gentle tissue loading.

1. Glute Bridges or Hip Thrusts

Help re-establish gluteal engagement and hip extension in a supported position
When the posterior chain is weak or under-recruited, clients often compensate with excessive pelvic floor or lumbar paraspinal tension. These movements promote eccentric pelvic floor loading in a safe and controlled way

2. Split Squats or Step Downs

Target single-leg strength and pelvic control, particularly in the glutes and lateral hip stabilizers
Asymmetrical strength deficits—especially at the hips and feet —are frequently linked to compensatory pelvic floor gripping
These exercises allow us to correct imbalances without imposing high load on the system

3. Adductor Slides or Ball Squeezes

Provide a low-load opportunity to retrain co-contraction patterns between the adductors, pelvic floor and breath
Overactivity in the adductors can contribute to pelvic floor hypertonicity; these movements help normalize tone and reduce protective guarding patterns

4. Deadbugs or Pallof Presses

Promote coordination between the trunk, breath, and pelvic floor in a way that minimizes pressure or strain on the pelvic floor itself

5. Loaded Carries

Reinforce global trunk and pelvic control in a dynamic, upright setting
Especially effective for training pressure regulation and postural endurance without cueing conscious pelvic floor engagement
A great way to “zoom out” from the pelvis while still addressing core stabilization patterns that influence pelvic tone

Phase 2: Progressive Load and Functional Strength

As symptoms ease and foundational coordination improves, we introduce compound, higher-load movements. These build real-world strength, reinforce pressure regulation, and help rewire the body’s relationship to intensity. The goal remains the same: load target tissues without defaulting to pelvic floor over-recruitment, bracing or substitution. Each movement here is chosen for its ability to challenge the system while supporting pelvic control and breath coordination.

1. Deadlift

Trains posterior chain strength and reinforces the hip hinge pattern introduced in earlier phases
Eccentrically loads the pelvic floor in a way that supports both capacity and control
Focus: Slow down the eccentric portion to maximize the eccentric loading benefits of the movement, and monitor for breath holding or bearing down at submaximal loads

2. Single-Leg Squat

Addresses side to side strength asymmetries at the hip and improves pelvic-on-femur control
Great carryover to dynamic tasks and sexual positions requiring single-leg loading or shifting
Use box or TRX support to start
Cue relaxed jaw, controlled descent and steady breath
Monitor for inner thigh compensation or foot collapse

3. Short-Lever Copenhagen Plank (or Side-Lying Adductor Work)

Why it helps:

Targets adductor and deep pelvic stabilizer coordination
Especially useful for those with adductor dominance or tension contributing to pelvic floor overactivity

Focus:

Start with bent knee or side-lying holds
Cue low-level isometric effort, steady breathing and watch for glute or core substitution patterns

4. Half-Kneeling Overhead Press (Kettlebell, Dumbbell or Landmine)

Why it helps:

This movement supports upper body strength while reinforcing trunk and pelvic stability, scapular control and thoracic mobility—all of which are key for pressure regulation and pelvic floor responsiveness
The half-kneeling setup adds a built-in stability challenge that helps integrate core and pelvic control into the movement

Focus:

Use a slow, controlled tempo to emphasize coordinated movement from the trunk through the arm
Prioritize smooth scapular upward rotation and thoracic extension, while maintaining alignment through the rib cage and pelvis
Cue steady, relaxed breathing to support pressure modulation throughout the press

5. Supported Single-Arm Rotational Dumbbell Row

Why it helps:

Builds scapular strength while integrating thoracic mobility and controlled trunk rotation
Reinforces dissociation between the ribcage and pelvis, which is often limited in people with pain-related guarding patterns

Focus:

Use a hand-supported hinge position
Allow the ribs to rotate gently with the pull while keeping the pelvis quiet
Think about initiating the movement from the mid-back and scapula, not the shoulder alone
Maintain steady breath throughout

Progression Isn’t Just About Load—It’s About Rebuilding Trust

As clients grow stronger, our goal isn’t simply to add weight. It’s to add options, coordination and confidence. Every movement we choose is an opportunity to reinforce better patterns, challenge old protective strategies and help the body learn that it can engage, move and perform without pain or fear.

In dyspareunia rehab, we’re not just training isolated muscles. We’re restoring the relationship between the pelvic floor and the rest of the system—the hips, the core, the breath, the nervous system and ultimately, the person’s sense of safety and connection in their own body.

Progress looks different for everyone; but when approached with care, clarity and a long-term lens, strength training becomes so much more than exercise. It becomes a way to reclaim intimacy, embodiment and resilience.

A Holistic, Empowering Approach to Pelvic Pain

If you’re a provider: Don’t underestimate your clients’ capacity to load, move and get stronger. With the right support, strength work can be a safe, trauma-informed and transformative part of dyspareunia care.

If you’re someone experiencing pain with intimacy: Your body isn’t broken. You don’t have to keep shrinking away from movement. There’s a way forward that includes strength, curiosity and joy—and you don’t have to walk that path alone.

Strength is not the enemy. It’s part of the path to freedom.

To learn more, follow me on Instagram or visit my web site to explore care options.

Dr. Julia Rosenthal, DPT, OCS, PRPC treats patients with all pelvic health and orthopedic conditions, and sees these elements of her practice as inextricably linked. Her approach integrates hands-on techniques with movement, exercise, and loading. Whether you’re living with chronic pain or experiencing pelvic floor dysfunction, no symptom or question is off-limits. She believes that physical therapy is about helping patients identify their values and goals, and providing individualized care that helps them take charge of their lives.