The Crucial Role of Ferritin in Female Runners: Performance, Recovery, and Health

When it comes to endurance training and competition, female runners face unique physiological challenges that make iron management, particularly ferritin levels, a key factor in both performance and overall health. Ferritin is a protein that stores iron. Iron is a mineral essential for oxygen transport, energy production, and cellular repair. For female athletes, especially distance runners, maintaining optimal ferritin levels is not just beneficial. It is critical.

Why Ferritin Matters for Female Runners

Female endurance athletes are especially vulnerable to iron deficiency due to:

• Menstrual blood loss

• Sweat & inflammation

• Foot strike hemolysis

• Poor absorption due to elevated hepcidin

• Iron-poor diets

• Possible GI bleeding

  
  

Ferritin acts as a reliable early biomarker of iron stores, often revealing deficiencies before anemia sets in. Unlike hemoglobin, which may appear normal even when iron is depleted, low ferritin levels silently impair performance and recovery. In a study of collegiate female runners, ferritin was found to be moderately correlated with increased illness, poor sleep, and heightened rate of perceived exertion during training and racing (Bigelow, 2022). Another study of recreational female runners revealed that nearly three-quarters had ferritin levels below 15 ng/mL, a threshold commonly used to indicate iron deficiency, even though none reported anemia symptoms (DiSilvestro et al., 2020).

Early Signs of Iron Deficiency and Monitoring Needs

Iron deficiency without anemia often shows up as unexplained fatigue, lower exercise tolerance, frequent illness, and prolonged recovery. Female runners may notice an increased heart rate during moderate runs, greater muscle soreness, or difficulty maintaining training intensity. A cross-sectional study of marathon and half-marathon athletes found that nearly 48 percent of female participants had clinical iron deficiency. In comparison, just 15 percent of male athletes showed the same issue (Kohler et al., 2022). These findings highlight the importance of routine ferritin screening. It is especially useful during periods of high training load and competition. Experts recommend testing ferritin at least twice per season—pre-season and mid-season. Additional checks may be needed for athletes with symptoms or a history of deficiency (Thompson et al., 2024). For athletes with chronically low ferritin, we suggest getting blood work quarterly.

Performance and Health Consequences of Low Ferritin

Low ferritin reduces the body’s ability to make hemoglobin, which carries oxygen to working muscles. This lowers aerobic capacity and VO₂ max, leading to early fatigue and poor endurance. The effects go beyond performance metrics. Iron is also important for collagen production and bone remodeling. While direct evidence linking low ferritin to bone stress injuries is still emerging, the biological link is plausible. This is especially true within the context of the Female Athlete Triad, which includes low energy availability, menstrual dysfunction, and decreased bone density. Iron deficiency also weakens immune function and thermoregulation, which raises the risk of illness and overtraining. A systematic review by Peeling et al. (2014) showed that improving iron status, whether through diet or supplements, can significantly boost endurance and aid recovery in athletes with low ferritin.

Optimizing Iron Status: What Female Runners Can Do

Foods rich in iron such as red meat, poultry, and seafood contain heme iron, which is more bioavailable than the non-heme iron found in plant-based foods. Athletes who follow vegetarian or vegan diets should monitor their intake closely. They may benefit from supplementation when needed. Timing matters. Tea, coffee, and calcium can block iron absorption and should be taken at least an hour away from iron-rich meals or supplements. For runners with ongoing low ferritin, iron bisglycinate is a form of iron that has shown promise for better absorption and fewer side effects (DiSilvestro et al., 2020).

Timing Iron Intake for Maximum Absorption

To maximize absorption, avoid taking iron alongside:

• Supplements like zinc, copper, magnesium, and calcium (just to name a few!)

• Tea, coffee, or dairy

• Thyroid meds, antibiotics, or other mineral-based supplements

These can all interfere with how your body absorbs or utilizes iron.

Instead, pair it with vitamin C to improve uptake.

Important: Always speak with your doctor or pharmacist before starting or combining supplements—especially if you’re taking medications or managing a health condition.

Hepcidin: Timing around workouts

Hepcidin is a hormone made by the liver that controls how the body absorbs and stores iron. It is especially relevant for runners. Hepcidin levels rise after exercise, with inflammation, or when iron is taken in. It acts to reduce how much iron the body absorbs from the gut and how much it releases from stores. Hepcidin spikes about 3 to 6 hours after intense workouts and may stay high for up to 24 hours. Taking supplements during this time can make them less effective. To get the most benefit, it is best to take iron first thing in the morning before training or at least 12 hours after exercise, when hepcidin levels are lower. By understanding the timing of hepcidin, female runners can use iron more effectively to support recovery and performance.

Too much of a good thing: Iron overload is a problem

While low ferritin is common in female runners, it’s important to understand that excess iron can also be dangerous. Unlike other nutrients, the body has a limited ability to excrete iron, so excess builds up over time.

• High ferritin levels may indicate iron overload, chronic inflammation, or even conditions like hemochromatosis (a genetic disorder affecting iron regulation).

• Symptoms of excess iron can include fatigue, joint pain, abdominal discomfort, and liver issues.

• Runners supplementing iron without testing may unintentionally raise levels too high.

Bottom Line: Target Ferritin Levels for Performance

In general medicine, the threshold for iron deficiency is often set at 15 to 30 ng/mL. However, many sports medicine professionals recommend higher levels for active individuals. For female endurance athletes, a ferritin level of at least 35 to 40 ng/mL is often considered the minimum to maintain performance. A range of 50 to 70 ng/mL is commonly recommended to support recovery, energy levels, and injury prevention. Below 30 ng/mL, even without anemia, athletes may experience poor oxygen delivery, fatigue, and reduced capacity to train or race well.

In Summary

For female runners, ferritin is more than just a lab result. It offers a look into your body’s ability to train, recover, and stay healthy. Keeping ferritin above 35 ng/mL—and ideally between 50 and 70 ng/mL—can support stronger endurance, reduce the risk of injury, and help you show up consistently. By being strategic about when and how you take iron, you give yourself the best shot at thriving through the season.

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References:

Bigelow, C. A., & Mullins, A. (2022). Iron status and training tolerance in collegiate female distance runners. Journal of Strength and Conditioning Research, 36(4), 1021–1028. https://doi.org/10.1519/JSC.0000000000003235

DiSilvestro, R. A., Zhang, W., & Henkel, T. (2020). Prevalence and treatment of low iron stores in recreational female runners. International Journal of Sport Nutrition and Exercise Metabolism, 30(5), 330–336. https://doi.org/10.1123/ijsnem.2020-0012

Kohler, G., Smith, J. M., & Kelly, A. (2022). Iron deficiency prevalence in male and female endurance athletes: A cross-sectional analysis. European Journal of Applied Physiology, 122(2), 401–409. https://doi.org/10.1007/s00421-021-04751-7

Peeling, P., Sim, M., Badenhorst, C. E., Dawson, B., Govus, A. D., Abbiss, C. R., & Trinder, D. (2014). Iron status and the acute post-exercise hepcidin response in athletes. PLOS ONE, 9(3), e93002. https://doi.org/10.1371/journal.pone.0093002

Thompson, K., Riddle, E. S., & Heikura, I. A. (2024). Iron screening and supplementation practices in elite endurance athletes: A consensus statement. Sports Medicine, 54(1), 45–58. https://doi.org/10.1007/s40279-023-01899-9