Female athlete representation in exercise-induced cardiac adaptation research: a systematic review and audit of the literature

Abstract

“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 ¼ 416), whereas female-only studies represented just 5% (n ¼ 38). Only 7% (n ¼ 56) of studies included a male-female subanalysis, whereas 3% of studies (n ¼ 21) used direct sex-comparative design. Notably, 6% of studies (n ¼ 44) did not report participant sex at all. Females accounted for less than one quarter of the total sample (24%, n ¼ 23,061 participants). Football (soccer) was the most represented sport overall (n ¼ 13,582 participants) and in male-only studies (n ¼ 5,242 participants). Basketball was the most common in female-only studies (n ¼ 314 participants). Ethnicity was reported in 17% of studies (n ¼ 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.