From Biological Foundations to Optimizing Performance and Health in Elite Female Winter Olympians

The Milano Cortina 2026 Olympic Winter Games are projected to be the most gender-balanced Winter Games to date, with women comprising an estimated 47% of athletes. However, this numerical balance has outpaced the scientific evidence base informing the training and health support of elite female winter sport athletes. This expert-led narrative review synthesizes the biological foundations of sex-based performance differences, evaluates corresponding training and health considerations specific to female winter sport athletes. Biological divergence emerging at puberty, particularly in hemoglobin mass, cardiac dimensions, skeletal muscle mass, and body composition, underpins persistent sex differences in absolute performance. When normalized to body mass or lean mass, many physiological differences are attenuated, with hemoglobin concentration and body fat percentage remaining as primary determinants of the performance gap. Despite these differences, contemporary evidence indicates that when training is prescribed relative to individual capacity, women exhibit comparable physiological adaptations to men after puberty. Thus, the principles of effective training are largely shared across sexes, emphasizing the need for sport-specific and individualized training prescriptions. Health is a critical enabler of performance. Female athletes face elevated risks of iron deficiency, relative energy deficiency in sport (REDs), and menstrual dysfunction, conditions that can compromise adaptation, increase injury risk, and threaten career longevity. Addressing these challenges requires integrated, sex-specific monitoring and prevention strategies. By translating biological insights into individualized training and health practices, this review provides evidence-based support to enhance the performance and health of elite female winter Olympians at Milano Cortina 2026 and beyond.