Iron Deficiency and Beyond: Implications for Cognitive Function and Recovery in Female Endurance Athletes

Abstract

Purpose  

This narrative review evaluates the systemic impact of iron deficiency (ID) in female endurance athletes, focusing on cognitive function, mitochondrial bioenergetics, and tissue recovery processes beyond traditional erythropoiesis. 

Materials and methods 

A comprehensive literature search was conducted across PubMed, Scopus, and Google Scholar databases, covering peer-reviewed publications from 2003 to 2025. A total of 31 key sources were analyzed, focusing on non-anemic iron deficiency (IDNA) and the regulatory role of hepcidin. 

Results 

Evidence demonstrates that iron is a critical cofactor for neurotransmitter synthesis (dopamine, serotonin) and the mitochondrial electron transport chain. Subclinical iron depletion impairs executive planning, attentional focus, and metabolic efficiency, often manifesting as "brain fog" and prolonged recovery times. Furthermore, exercise-induced interleukin-6 (IL-6) triggers a hepcidin surge 3–6 hours post-training, which degrades ferroportin channels and reduces fractional iron absorption by approximately 36%. 

Conclusions 

Effective iron management requires a "timing-first" approach, including monitoring serum ferritin (target 30–50 ng/mL) and utilizing alternate-day oral dosing (60–200 mg) in a fasted, early-morning state. Transitioning from reactive anemia treatment to proactive iron optimization, incorporating cognitive health markers into routine screening, is essential to safeguard the performance potential and long-term well-being of female endurance athletes.