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The impact of physiology on women's health, training and performance

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Article written by  Rob Hobson

Date published  06 September 2022

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Physiological differences exist between men and women. Research in the field is also more biased towards men and to help female athletes reach peak performance, they should not be viewed as smaller male athletes. Coaches need to be fully informed about female health and its impact on training and performance so they can offer a truly individualised approach. Rob Hobson explores the physiological differences between male and female athletes and how it could impact performance.

How do women differ from men physiologically?

Men and women are physiologically different, including muscle mass and strength,1 maximal aerobic capacity and performance,2 and anaerobic power and capacity.3 Research shows that a female's absolute whole-body strength is up to 63.5% of a man's,4 while upper body strength is 55%5 and lower limb strength is 72%.6

Interestingly, women's physiology may put them at an advantage in endurance sports. Sex differences in endurance performance are reflected in how they utilise energy from carbohydrates and fats and exercise intensity and duration.7 Carbohydrates provide the body with an immediate energy source, but this is limited. Hence, athletes need to refuel during events. In contrast, fatty acids provide a source of dense energy that fuels longer-duration exercises such as marathon running.

During aerobic-based exercise, women preferentially use fatty acids as the dominant fuel source compared with men, who demonstrate lower rates of fatty acid utilisation, relying more on carbohydrates as the dominant fuel source.8 The relatively 'unlimited' fat reserves and the enhanced fatty acid utilisation in women versus men are thought to contribute to favourable endurance performance in women, most notably during prolonged (ultra-endurance) versus less-prolonged (marathon) endurance events.

How can female health issues impact training and performance?

A significant amount of sports performance research is based on men. Often a reason for this is because women are physiologically too variable, one reason being the menstrual cycle.9 Many differences occur between sexes, and these include both physiology and psychology. Even amongst women, differences arise, which may involve the use of oral contraceptives or HRT in master’s athletes. A master’s athlete is generally considered to be someone over the age of 40 years.

Female-specific issues need to be considered so that coaches can offer an individualised strategy that compliments the athlete's needs. Such issues include the menstrual cycle, breast health, female psychology, and trends in female injuries. Women are also more prone to nutrient insufficiencies such as iron, resulting in fatigue and depression, impacting performance.

Woman and man lifting heavy weights on a barbell in gym setting

Coaches need to be fully informed about female health and its impact on training and performance so they can offer a truly individualised approach.

What about RED-S?

Women are also more prone to RED-S, which refers to relative energy deficiency in sport. This used to be called the "Female Athlete Triad" (disordered eating, menstrual disturbance, low bone density) but was renamed to reflect that it also occurs in men and impacts more than the three original areas described initially.

The condition occurs when an athlete does not have enough energy to meet the demands of the amount of exercise they perform. Athletes more prone to RED-S include endurance athletes who benefit from a high power-to-weight ratio, weight category sports such as boxing, and aesthetic sports such as gymnastics and diving.

Alongside insufficient energy to achieve peak sports performance, RED-S also impacts an athlete's ability to maintain overall optimal health and other bodily functions. This can result in irregular periods, recurrent illnesses, mood changes, delayed growth, and development, and nutrient deficiencies.10

What injuries are more prevalent in women?

Research shows that women incur more stress fractures, shoulder injuries, ankle sprains, and ACL injuries than men.11, 12, 13 Low bone mineral density can increase the risk of musculoskeletal injury. This is particularly relevant to athletes diagnosed or previously diagnosed with RED-S and older athletes during menopause.

Ligamentous laxity (very flexible joints) is more significant in women, explaining why they experience ankle sprains twice as often as men.12 Research has also shown that women are at greater risk of overuse injuries, including stress fractures, tendonitis, and medial tibial stress syndrome (damage to the shin area).14 It has also been shown that female athletes in jumping and cutting sports (football, basketball, lacrosse) are up to six times more likely to sustain a severe knee injury than males.15

1Ford, L. E., Detterline, A. J., Ho, K. K., & Cao, W. (2000). Gender- and height-related limits of muscle strength in world weightlifting champions, Journal of applied physiology (Bethesda, Md. : 1985) 89(3), 1061–1064
2Cheuvront, S. N., Carter, R., Deruisseau, K. C., & Moffatt, R. J. (2005). Running performance differences between men and women:an update, Sports medicine (Auckland, N.Z.) 5(12), 1017–1024
3Hill, D. W., & Smith, J. C. (1993). Gender difference in anaerobic capacity: role of aerobic contribution, British journal of sports medicine 27(1), 45–48
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5Sharp M. A. (1994). Physical fitness and occupational performance of women in the u.s. Army, Work (Reading, Mass.) 4(2), 80–92
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7Montero, D., Madsen, K., Meinild-Lundby, A. K., Edin, F., & Lundby, C. (2018). Sexual dimorphism of substrate utilization: Differences in skeletal muscle mitochondrial volume density and function, Experimental physiology 103(6), 851–859
8Venables, M. C., Achten, J., & Jeukendrup, A. E. (2005). Determinants of fat oxidation during exercise in healthy men and women: a cross-sectional study, Journal of applied physiology (Bethesda, Md. : 1985) 98(1), 160–167
9Bruinvels, G., Burden, R. J., McGregor, A. J., Ackerman, K. E., Dooley, M., Richards, T., & Pedlar, C. (2017). Sport, exercise and the menstrual cycle: where is the research?, British journal of sports medicine 51(6), 487–488
10Dipla, K., Kraemer, R. R., Constantini, N. W., & Hackney, A. C. (2021). Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females, Hormones (Athens, Greece) 20(1), 35–47
11Beasley, L., Faryniarz, D. A., & Hannafin, J. A. (2000). Multidirectional instability of the shoulder in the female athlete, Clinics in sports medicine 19(2), 331–x
12Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J., & Bleakley, C. (2014). The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies, Sports medicine (Auckland, N.Z.) 44(1), 123–140.
13Sigward, S. M., Pollard, C. D., & Powers, C. M. (2012). The influence of sex and maturation on landing biomechanics: implications for anterior cruciate ligament injury, Scandinavian journal of medicine & science in sports 22(4), 502–509
14Brunet, M. E., Cook, S. D., Brinker, M. R., & Dickinson, J. A. (1990). A survey of running injuries in 1505 competitive and recreational runners, The Journal of sports medicine and physical fitness 30(3), 307–315
15Hewett T. E. (2000). Neuromuscular and hormonal factors associated with knee injuries in female athletes. Strategies for intervention, Sports medicine (Auckland, N.Z.) 29(5), 313–327

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About Rob Hobson

Rob Hobson MSc RNutr is a Registered Nutritionist who has worked with some of the UK’s largest food and health companies and performs training in the public health sector (including government agencies and the NHS). Rob contributes regularly to press publications and has a monthly column in Women’s Health magazine.

robhobson.co.uk