Angela L. Spence

Objective: Conduct a comprehensive scoping review of sport science and medicine (SSM) research in highly trained, elite and world-class female athletes. Design: Scoping review. Data sources: PubMed (MEDLINE, EBSCOhost), Scopus, SPORTDiscus (EBSCOhost), Web of Science and base-search (grey literature). Eligibility: Peer-reviewed and grey literature informing the health and performance of highly trained, elite and/or world-class female athletes (>16 years of age), with mixed-group studies retained when data were reported separately. Sports that require physical exertion or highly skilled movements were included. The search was restricted to English with no date limits. Results: 3,867 (1970–2025) records including 3,250 (84%) original studies reporting 4,374,571 participants [31% female (n=1,368,170)] were reviewed. 3,221 (99%) studies included athletes [world class, n=433 (13%); elite, n=1,873 (58%); highly trained, n=1,302 (40%)] across 102 different sport disciplines from 74 different countries. 135 (4%) studies included athletes with disabilities, 58 (2%) retired and 37 (1%) masters athletes. Physiology (n=1,059 studies, 33%), performance analysis (n=947, 29%) and injury (n=820, 25%) were the most common SSM general themes; equipment (n=84, 3%), law (n=17, 1%) and business (n=8, 0%) were least common. Health-related SSM themes included musculoskeletal (n=364, 22%), mental (n=243, 15%) and cardiovascular (n=183, 11%) health; pelvic floor (n=26, 2%), breast health (n=11, 1%) and (peri-)menopause (n=2, 0%) were least common. Conclusion: Research in high-performing female athletes is increasing, however persistent gaps remain in participant representation, geographical coverage and health-related themes. Targeted, co-created and multidisciplinary research approaches are needed to improve equity, relevance and impact in female athlete health and performance.

“Athlete’s heart” is well-documented in males, but female-specific data remain limited despite increasing participation in women’s sport. This systematic review examined studies investigating exercise-induced cardiac adaptation, auditing female athlete representation and methodological quality using a standardized framework. A total of 767 articles met inclusion, comprising 94,744 participants. Male-only cohorts made up 54% of studies ( n = 416), whereas female-only studies represented just 5% ( n = 38). Only 7% ( n = 56) of studies included a male-female subanalysis, whereas 3% of studies ( n = 21) used direct sex-comparative design. Notably, 6% of studies ( n = 44) did not report participant sex at all. Females accounted for less than one quarter of the total sample (24%, n = 23,061 participants). Football (soccer) was the most represented sport overall ( n = 13,582 participants) and in male-only studies ( n = 5,242 participants). Basketball was the most common in female-only studies ( n = 314 participants). Ethnicity was reported in 17% of studies ( n = 127; 43,683 participants), with 80% of participants identified as White and 16% as African/Afro-Caribbean. Para-athletes comprised 0.4% of the total cohort. Echocardiography was the predominant imaging modality (88%), with 97% of studies reporting left ventricular parameters. Only 10 studies (3% of those including females) provided sufficient information to classify menstrual status, and none met best-practice recommendations. These findings highlight the need to prioritize diverse female athlete cohorts, including para-athletes, broader ethnic representation, and wider range of sport domains, to enable accurate clinical interpretation and equitable cardiovascular assessment in women.

This study examined the longitudinal patterns of concurrent aerobic and resistance training in young elite rowers to address the limited understanding of how training volume, modality, and periodisation interact across a season, and to introduce a novel rowing-specific resistance training classification. A retrospective design was used to analyse group training data over 36 weeks (n = 9; 20.6 ± 0.5 years), and individual case studies over 55 weeks (n = 4; 21.6 ± 0.4 years). Aerobic loads, resistance training tonnage, and ergometer performance (power output) were tracked, with resistance exercises categorised as rowing-specific, upper accessory, lower accessory, or core. Weekly aerobic volume averaged 14.0 ± 5.0 h, and rowing-specific resistance accounted for 48–57% of total tonnage (14.13 × 10³ ± 7.41 × 10³ kg). Exploratory analyses suggested an inverse relationship between aerobic, and resistance loads across training phases and trends toward improved ergometer power in three of four case athletes. High concurrent loads also appeared to coincide with occasional missed or modified sessions in several cases. These findings highlight the importance of managing concurrent loads to support consistent training while offering a practical resistance training classification that may enhance monitoring and decision-making for developing rowers.

Purpose: Exercise-induced cardiac adaptation is well-studied in male athletes. However, evidence for longitudinal adaptation, particularly in females, is limited. This study compared cardiac adaptation between elite female and male rowers across a competitive season. Methods: Ten females (19 ± 0.9 years) and 11 males (20 ± 1.7 years) were assessed across 21 weeks at early (ES), mid- (MS), and late season (LS). Echocardiography (2D, 3D, strain), peak oxygen consumption (V̇O ₂ peak), weekly training volume (sessions) and intensity (minutes in heart rate zones) were documented. Bayesian two-way repeated measures ANOVA assessed sex and training effects. Results: Training volume was comparable between sexes; however, females spent less time at maximal heart rate intensity. An interaction effect for V̇O ₂ peak demonstrated the highest value at LS in females (55.8 ± 1.6 mL kg min ⁻¹ ) and MS in males (64.1 ± 1.6 mL kg min ⁻¹ ). Females had smaller left ventricular (LV) 2D mass and volume with no training-induced response in either sex. A sex-specific interaction was observed for 3D LV mass: females peaked at MS (221.2 ± 20.6 g) compared to males at LS (301.9 ± 20.9 g). Females also had smaller LV diameter, wall thickness and right heart dimensions. Across the season, most females (67%) exhibited eccentric hypertrophy, whilst males (89%) showed concentric hypertrophy. However, classifications varied throughout the season. No sex or training effects were observed for strain. Conclusion: Whilst sex strongly influences cardiac morphology in elite rowers, sex-specific adaptation in 3D LV mass and LV geometry changes emphasise cardiac plasticity with training in athletes.

Manipulating the amount of muscle mass engaged during exercise can noninvasively inform the contribution of central cardiovascular and peripheral vascular-oxidative functions to endurance performance. To better understand the factors contributing to exercise limitation in older and younger individuals, exercise performance was assessed during single-leg and double-leg cycling. 16 older (67 ± 5 years) and 14 younger (35 ± 5 years) individuals performed a maximal exercise using single-leg and double-leg cycling. The ratio of single-leg to double-leg cycling power (RatioPower SL/DL) was compared between age groups. The association between fitness (peak oxygen consumption, peak power output, and physical activity levels) and RatioPower SL/DL was explored. The RatioPower SL/DL was greater in older compared with younger individuals (1.14 ± 0.11 vs. 1.06 ± 0.08, p = .041). The RatioPower SL/DL was correlated with peak oxygen consumption (r = .886, p < .001), peak power output relative to body mass (r = .854, p < .001), and levels of physical activity (r = .728, p = .003) in the younger but not older subgroup. Reducing the amount of muscle mass engaged during exercise improved exercise capacity to a greater extent in older versus younger population and may reflect a greater reduction in central cardiovascular function compared with peripheral vascular-oxidative function with aging.

Biological sex is a salient factor in exercise-induced vascular adaptation. Although a male bias is apparent in the literature, the methodological quality of available studies in females is not yet known. This systematic review with narrative synthesis aimed to assess available evidence of exercise interventions on endothelial function, measured using flow-mediated dilation, in otherwise healthy individuals and athletes. A standardized audit framework was applied to quantify the representation of female participants. Using a tiered grading system, studies that met best-practice recommendations for conducting physiological research in females were identified. A total of 210 studies in 5,997 participants were included, with 18% classified as athletes. The primary exercise mode and duration were aerobic (49%) and acute (61%), respectively. Despite 53% of studies ( n = 111) including at least one female, female participants accounted for only 39% of the total study population but 49% of the athlete population. Majority (49%) of studies in females were conducted in premenopausal participants. No studies in naturally menstruating, hormonal contraceptive-users or in participants experiencing menstrual irregularities met all best-practice recommendations. Very few studies (∼5%) achieved best-practice methodological guidelines for studying females and those that did were limited to menopause and pregnant cohorts. In addition to the underrepresentation of female participants in exercise-induced vascular adaptation research, there remains insufficient high-quality evidence with acceptable methodological control of ovarian hormones. To improve the overall methodological quality of evidence, adequate detail regarding menstrual status should be prioritized when including females in vascular and exercise research contexts.

The Improvement in Exercise Performance during Reduced Muscle Mass Exercise is Associated with an Increase in Femoral Blood Flow in Older and Younger Endurance-Trained Athletes