Pelvic health and strength training: what active women need to know

The Guardian recently published research that shows that elite female athletes are more likely to experience urinary incontinence than sedentary women. Most never seek help. The ones who do are often told it is to be expected — a reasonable cost of training hard, of having had children, of getting older. The message, delivered in various forms across GP surgeries and changing rooms and online comment sections, is essentially: this is just how it is now.

It is not.

Pelvic health dysfunction — which covers anything from urinary incontinence and pelvic organ prolapse to pelvic pain and a pelvic floor that is chronically braced rather than weak — is addressable in the vast majority of cases. What it requires is assessment, the right support, and the willingness to stop managing around it.

I spoke with Vicki Causer, a women's health coach specialising in pelvic health and movement, about what this actually looks like for active women, and why it so often goes unaddressed for so long.

What pelvic health actually means

The pelvic floor is a group of muscles and connective tissue that forms the base of the pelvis — running from the pubic bone at the front to the coccyx at the back and the sit bones at the sides. All major orifices pass through it. It works in constant relationship with the diaphragm, the deep abdominals, and the respiratory system. When it functions well, most people have no idea it is there.

Dysfunction shows up in movement. The classic markers — leaking during a box jump, during a sprint, during a heavy deadlift — are the ones women most often mention. But pelvic health encompasses a much broader range: pain, heaviness, prolapse, a floor that has become so chronically tight that it cannot respond correctly under load. Some women have a weak pelvic floor. Others have one that is working too hard, all the time, and has lost its ability to coordinate properly.

You do not need to have given birth to experience pelvic floor dysfunction. Young female athletes develop it. Women who have never been pregnant develop it. Men have pelvic floors and develop dysfunction too. Childbirth is a significant risk factor, but it is not the only one.

Why active women often struggle most

There is a particular pattern in women who are highly trained, highly functional, and used to pushing through discomfort. They have learned that effort and output are linked, that consistency is a virtue, and that the body can be managed by willpower if the willpower is strong enough.

Pelvic health issues tend to sit outside this framework. They are not resolved by training harder. They are often made worse by it. And the combination of physical dysfunction and psychological investment in a certain identity as an active woman can make the whole thing feel catastrophic in a way that is difficult to articulate.

Vicki described what happens when women receive a diagnosis and immediately Google it. The information they find is often outdated, worst-case, and not specific to their situation. The result is frequently a decision to stop moving entirely — which removes the community, the mental health benefit, and the sense of capability that training was providing. The dysfunction was hard enough. The loss of movement makes it much worse.

The irony is that movement, done correctly and with proper support, is part of the solution. You do not need to stop. You need guidance on how to continue.

The breath, the connection, and where the work actually starts

Both Vicki and I start in the same place with every client: the breath. Not chest breathing — but a full, deep breath that moves into the lower torso, into the pelvic bowl, into the centre of the body that many women have spent years not inhabiting.

Vicki describes it as a no man's land. Women say outright that they do not want to think about it, look at it, or touch it. There is often a history underneath that statement — births that were difficult, years of being told what that region should look like, the accumulated weight of shame and disconnection that is very common and rarely spoken about. It is, she says, very hard to strengthen something you cannot connect to.

From a biomechanical standpoint, the diaphragm and the pelvic floor work as a team. If the breath is shallow and held high in the chest — which is the default state for most stressed, high-functioning women — the pelvic floor cannot respond properly. Before any loading, any exercise, any prescription, there needs to be breath. Real breath. The kind that lands somewhere.

The stress connection

Vicki's first recommendation to every client is to look honestly at stress levels. This is also her most resisted suggestion. High-capacity women tend to interpret the instruction to reduce stress as an implication that they are not coping — which is not how they see themselves and not how they want to be seen.

But the physiology is not interested in capacity or identity. When cortisol is chronically elevated, it competes with the resources available for sex hormone production. Oestrogen, progesterone, testosterone — all of which are distributed throughout the body via oestrogen receptors, including in the pelvic tissue — become depleted. The pelvic floor, like every other muscle in the body, is affected by the overall hormonal and nervous system environment it exists in.

Sleep, hydration, and nutrition follow from this. Women who are leaking often stop drinking water, which creates a concentrated urine that is more irritating to the bladder, which increases urgency, which makes the original problem worse. The chicken-and-egg situation Vicki describes is real, and it is a direct result of treating the symptom rather than the system.

What assessment actually involves and why it matters

Vicki's consistent advice for any woman who suspects a pelvic health issue is to get assessed before making any assumptions. Self-diagnosis based on Google is almost always either an underestimate or an overestimate of the situation. Having a qualified women's health physiotherapist or coach assess what is actually happening provides a picture that is specific and actionable — rather than the generic worst-case presented by outdated online resources.

The assessment also provides something that is not often discussed: validation. Having someone acknowledge what you are experiencing, take it seriously, and tell you what is actually going on is, for many women, the first moment the emotional weight of the situation begins to lift.

From there, it is a question of building back. Slowly, in most cases. With attention to breath, to connection, to the signals the body is already sending when it is given space to be heard. And with a clear risk-and-reward framework for the activities that matter most — because the goal is not to stop doing the things that are important to you. The goal is to find a way to do them that your whole body can sustain.

Vicki Causer works with women on pelvic health and movement and can be found on Instagram at @realstrongwomen.

If you are an active woman in your thirties or forties who trains consistently but feels like something is off — energy, recovery, focus, or all three — you might benefit from working with a coach who understands the full picture. I work with women in person in South East London and online. More details can be found here.

Seema Chopra works with high-performing women to train intelligently, recover well, and sustain performance without burnout