Iron Deficiency in Female Endurance Athletes: The Role of Hepcidin Regulation, Training Load, and Dietary Strategies in Optimizing Performance and Health
DOI:
https://doi.org/10.12775/QS.2025.42.60804Keywords
iron-deficiency, hepcidin, athletes, endurance, menstruation, inflammation, performance, ferritinAbstract
Purpose: Examine iron deficiency (ID) mechanisms in female endurance athletes, focusing on hepcidin dysregulation, training impacts, and dietary strategies.
Materials and Methods: Systematic review of 30 years of research on IL-6/hepcidin pathways, menstrual iron loss, supplementation (oral/IV), and dietary iron bioavailability. Data included hormonal studies, biomarker tracking (ferritin, CRP), and trials.
Basic Results: Post-exercise hepcidin surges (peaking 6h) cut absorption 30-50%. Menstrual losses (0.5–2 mg/day) worsen depletion. Tapering cut hepcidin 35%; follicular-phase iron intake improved absorption. Oral iron (100mg/d) raised ferritin 20-30µg/L; IV iron boosted performance 8-12% in severe deficiency. Borderline cases (ferritin 30-50) had variable outcomes.
Conclusions: Integrated strategies: hepcidin-aware training, cycle-aligned nutrition (heme iron + vitamin C), ferritin monitoring (>30µg/L). Future research on progesterone’s hepcidin effects and improved iron formulations. Holistic ID management boosts performance/health.
References
1. Kuwabara AM, Tenforde AS, Finnoff JT, Fredericson M. Iron deficiency in athletes: a narrative review.PM R. 2022 May;14(5):620-642. doi: 10.1002/pmrj.12779
2. Roy R, Kück M, Radziwolek L, Kerling A. Iron deficiency in adolescent and young adult German athletes—a retrospective study. Nutrients. 2022 Oct 27;14(21):4511. doi: 10.3390/nu14214511
3. Pasricha SR, Flecknoe-Brown SC, Allen KJ, et al. Iron deficiency. Lancet. 2021 Jan 16;397(10270):233-248. doi: 10.1016/S0140-6736(20)32594-0
4. Pedlar CR, Brugnara C, Bruinvels G, Burden R. Iron balance and iron supplementation for the female athlete: a practical approach. Eur J Sport Sci. 2018 Mar;18(2):295-305. doi: 10.1080/17461391.2017.1416178.
5. Beard J, Dawson H, Piñero DJ. Iron biology in immune function, muscle metabolism, and neuronal functioning. J Nutr. 2001;131(2):568S-580S. doi: 10.1093/jn/131.2.568S
6. Hinton PS, Giordano C, Brownlie T, Haas JD. Iron supplementation improves endurance after training in iron-depleted, nonanemic women. J Appl Physiol (1985). 2000 Mar;88(3):1103-11. doi: 10.1152/jappl.2000.88.3.1103
7. Clénin G, Cordes M, Huber A, et al. Iron deficiency in sports – definition, influence on performance and therapy. Swiss Med Wkly. 2015 Oct 29;145:w14196. doi: 10.4414/smw.2015.14196.
8. Nemeth E, Tuttle MS, Powelson J, et al. Hepcidin regulates cellular iron efflux by binding to ferroportin and inducing its internalization. Science. 2004 Dec 17;306(5704):2090-3. doi: 10.1126/science.1104742.
9. Camaschella C, Nai A, Silvestri L. Iron metabolism and iron disorders revisited in the hepcidin era. Haematologica. 2020 Jan 31;105(2):260-272. doi:
10.3324/haematol.2019.232124
10. Peeling P, Dawson B, Goodman C, Landers G, Trinder D. Exercise as a mediator of hepcidin activity in athletes. Eur J Appl Physiol. 2010 Nov;
110(5):877-83.doi:10.1007/s00421-010-1594-4
11. Peeling P, Dawson B, Goodman C, et al. Athletic induced iron deficiency: new insights into the role of inflammation, cytokines, and hormones. Eur J Appl Physiol. 2008 Jul;103(4):381-91. doi: 10.1007/s00421-008-0726-6.
12. Percy L, Mansour D, Fraser I. Iron deficiency and iron deficiency anaemia in women. Best Pract Res Clin Obstet Gynaecol. 2017 Apr;40:55-67. doi:
10.1016/j.bpobgyn.2016.09.007
13. Sim M, Dawson B, Landers G, Trinder D, Peeling P. Iron regulation in athletes: exploring the menstrual cycle and effects of different exercise modalities on hepcidin production. Int J Sport Nutr Exerc Metab. 2014 Apr;24(2):177-87. doi: 10.1123/ijsnem.2013-0067.
14. DellaValle DM, Haas JD. Iron supplementation improves energetic efficiency in iron-depleted female rowers. Med Sci Sports Exerc. 2014 Jun;46(6):1204-15. doi: 10.1249/MSS.0000000000000208.
15. Peeling P, Sim M, Badenhorst CE, et al. Effect of iron injections on aerobic exercise performance in iron-depleted female athletes. Int J Sport Nutr Exerc Metab. 2007 Jun;17(3):221-31. doi: 10.1123/ijsnem.17.3.221
16. DellaValle DM. Iron supplementation for female athletes: effects on iron status and performance outcomes. Curr Sports Med Rep. 2013 Jul-Aug;12(4):234-9. doi: 10.1249/JSR.0b013e31829a6f6b.
17. Saneela S, Iqbal R, Raza A, Qamar MF. Hepcidin: a key regulator of iron. J Pak Med Assoc. 2019;69(8):1170-1175.
18. Kumar A, Sharma E, Marley A, Samaan MA, Brookes MJ. Iron deficiency anaemia: pathophysiology, assessment, practical management. BMJ Open Gastroenterol. 2022 Jan;9(1):e000759. doi: 10.1136/bmjgast-2021-000759.
19. Elliott-Sale KJ, Tenforde AS, Parziale AL, Holtzman B, Ackerman KE. Endocrine effects of relative energy deficiency in sport. Int J Sport Nutr Exerc Metab. 2018 Jul 1;28(4):335-349. doi: 10.1123/ijsnem.2018-0127
20. Ganz T. Systemic iron homeostasis.Physiol Rev. 2013 Oct;93(4):1721-41. doi: 10.1152/physrev.00008.2013.
21. Maughan RJ, Burke LM, Dvorak J, et al. IOC Consensus Statement: dietary supplements and the high-performance athlete. Br J Sports Med. 2018 Apr;52(7):439-455. doi: 10.1136/bjsports-2018-099027.
22. Suedekum NA, Dimeff RJ. Iron and the athlete. Curr Sports Med Rep. 2005;4(4):199-202. doi: 10.1097/01.csmr.0000306207.79809.7f.
23. McClung JP. Iron status and the female athlete. J Trace Elem Med Biol. 2012 Jun;26(2-3):124-6. doi: 10.1016/j.jtemb.2012.03.006
24. Rana S, Prabhakar N. Iron disorders and hepcidin.Clin Chim Acta. 2021 Dec;523:454-468. doi: 10.1016/j.cca.2021.10.032
25. .Moisidis-Tesch CM, Shulman LP. Iron deficiency in women’s health: new insights into diagnosis and treatment. Adv Ther. 2022 Jun;39(6):2438-2451. doi: 10.1007/s12325-022-02157-7
26. Pilis K, Stec K, Pilis A, Mroczek A, Michalski C, Pilis W. Body composition and nutrition of female athletes. Rocz Panstw Zakl Hig. 2019;70(3):243-251. doi: 10.32394/rpzh.2019.0074.
27. Benson CS, Shah A, Stanworth SJ, et al. The effect of iron deficiency and anemia on women’s health. Anaesthesia.2021 Apr;76 Suppl 4:84-95. doi: 10.1111/anae.15405.
28. Nemeth E, Ganz T. Hepcidin-ferroportin interaction controls systemic iron homeostasis. Int J Mol Sci. 2021 Jun 17;22(12):6493.doi:10.3390/ijms22126493
29. Holtzman B, Ackerman KE. Recommendations and nutritional considerations for female athletes: health and performance. Sports Med. 2021 Sep;51(Suppl 1):43-57. doi: 10.1007/s40279-021-01508-8.
30. Cappellini MD, Musallam KM, Taher AT. Iron deficiency anaemia revisited. J Intern Med. 2020;287(2):153-170. doi: 10.1111/joim.13004
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Małgorzata Wasilewska, Krzysztof Pietrzak, Sebastian Polok, Łukasz Bialic
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Stats
Number of views and downloads: 412
Number of citations: 0
