Introduction
Creatine monohydrate is one of the most extensively researched and scientifically supported ergogenic aids in sport and exercise science. Contemporary consensus statements confirm that creatine is effective for improving high-intensity exercise performance, increasing lean mass and enhancing training adaptations across a wide range of populations (Kreider et al., 2022; Antonio et al., 2021). Unlike many supplements in sport, creatine has a consistently strong evidence base supported by systematic reviews and meta-analyses, particularly when combined with resistance training (Chilibeck et al., 2017; Candow et al., 2019; Forbes et al., 2021). Although the physiological mechanisms are similar between males and females, emerging evidence suggests sex-specific differences in creatine metabolism, baseline muscle creatine stores and hormonal regulation may influence responsiveness and practical application (Smith-Ryan et al., 2021; Delpino et al., 2022).
Physiological Role and Mechanisms of Action
Creatine functions primarily within the phosphagen energy system, supporting rapid ATP regeneration during high-intensity exercise. During maximal effort, ATP is rapidly depleted and resynthesised via phosphocreatine (PCr), catalysed by creatine kinase. Contemporary evidence confirms that creatine supplementation increases intramuscular total creatine and phosphocreatine stores, enhancing ATP resynthesis during repeated high-intensity efforts (Kreider et al., 2022; Forbes et al., 2021). Key physiological effects include increased phosphocreatine availability, enhanced sprint and resistance performance, improved training volume tolerance, intracellular hydration and upregulation of anabolic signalling pathways associated with hypertrophy (Kreider et al., 2022; Antonio et al., 2021). Cell swelling is considered an anabolic stimulus contributing to protein synthesis and reduced protein breakdown (Forbes et al., 2021).
Creatine and Performance in Males
Meta-analytical evidence consistently demonstrates creatine improves maximal strength, lean body mass, training volume and muscular hypertrophy when combined with resistance training (Chilibeck et al., 2017; Candow et al., 2019). A meta-analysis reported significantly greater increases in lean mass with creatine supplementation alongside resistance training compared with training alone (Chilibeck et al., 2017). More recent evidence confirms increases in lean body mass of approximately ~1 kg in trained and untrained populations (Delpino et al., 2022). Creatine also improves repeated sprint ability, peak power output and anaerobic performance capacity, making it highly relevant to team sports such as football, rugby and hockey (Kreider et al., 2022; Antonio et al., 2021).
Creatine and Performance in Females
Although historically underrepresented in research, recent systematic reviews demonstrate that females benefit from creatine supplementation in strength, high-intensity performance and lean mass adaptations (Smith-Ryan et al., 2021; Delpino et al., 2022). Females typically have lower baseline intramuscular creatine stores and dietary intake, which may influence responsiveness (Smith-Ryan et al., 2021). While absolute gains in lean mass are often smaller than in males, relative improvements are comparable when adjusted for baseline differences (Delpino et al., 2022). Evidence suggests creatine may be particularly relevant in female athletes due to hormonal influences on energy metabolism and creatine kinase activity across the menstrual cycle (Smith-Ryan et al., 2021).
Creatine and the Menstrual Cycle
Oestrogen and progesterone fluctuations influence substrate utilisation, neuromuscular performance, thermoregulation and fatigue perception. These hormonal changes may also influence creatine kinase activity and energy metabolism (Smith-Ryan et al., 2021). Although phase-specific intervention studies remain limited, creatine’s role in ATP resynthesis suggests potential benefits during phases of increased fatigue or reduced energy availability.
Creatine, Recovery and Training Adaptation
Creatine supplementation may enhance recovery between training sessions and improve tolerance to high training loads. Evidence suggests improvements in training volume capacity, reductions in muscle damage markers in some contexts and enhanced glycogen resynthesis when combined with carbohydrate intake (Antonio et al., 2021; Kreider et al., 2022). These effects are most pronounced when creatine is combined with structured resistance or high-intensity training programmes (Candow et al., 2019).
Creatine and Cognitive Function
Creatine plays a role in brain energy metabolism, and supplementation may improve working memory, processing speed and cognitive resilience under stress or sleep deprivation (Antonio et al., 2021; Kreider et al., 2022). These effects are most evident in conditions of metabolic stress, making creatine relevant for athletes experiencing travel, congestion, sleep disruption or high cognitive load. This may also be relevant for female athletes experiencing cyclical fatigue or hormonal fluctuations (Smith-Ryan et al., 2021).
Creatine Across the Female Lifespan
In adolescence, creatine supports strength and power development alongside training. During reproductive years, it supports high-intensity performance and recovery. In perimenopause and menopause, creatine combined with resistance training improves lean mass, strength and functional performance (Candow et al., 2019; Delpino et al., 2022). Bone health outcomes remain inconclusive, but functional improvements are consistently reported.
Safety and Long-Term Use
Consensus statements confirm creatine monohydrate is safe when used at recommended doses in healthy individuals (Kreider et al., 2022). Evidence does not support adverse effects on kidney function, liver function, hydration status or cramping risk (Antonio et al., 2021; Kreider et al., 2022). Long-term studies support its safety in both male and female populations.
Practical Application
Loading phase (optional): 20 g/day split into 4 doses for 5–7 days. Maintenance: 3–5 g/day. Alternatively, 3–5 g/day without loading achieves full saturation over ~3–4 weeks. Timing is not critical; total daily intake is the key factor (Antonio et al., 2021). Creatine monohydrate remains the gold standard due to its efficacy, safety, cost-effectiveness and evidence base (Kreider et al., 2022).
Conclusion
Creatine monohydrate is one of the most effective and well-supported supplements in sport science. Evidence demonstrates consistent benefits for strength, lean mass, high-intensity performance, recovery and cognition in both males and females. While males show greater absolute gains in lean mass, this is largely due to baseline physiological differences rather than differences in responsiveness. In females, creatine may have additional relevance due to hormonal fluctuations and lower baseline creatine stores. Overall, creatine should be considered a foundational evidence-based supplement for athletes across sexes and performance levels.
References
Antonio, J. et al. (2021) Journal of the International Society of Sports Nutrition, 18, pp.1–17.
Candow, D.G. et al. (2019) Journal of Clinical Medicine, 8, 488.
Chilibeck, P.D. et al. (2017) Open Access Journal of Sports Medicine, 8, pp.213–226.
Delpino, F.M. et al. (2022) Nutrition, 103–104, 111791.
Forbes, S.C. et al. (2021) Nutrients, 13(6), 1915.
Kreider, R.B. et al. (2022) Journal of the International Society of Sports Nutrition, 19(1), pp.1–46.
Smith-Ryan, A.E. et al. (2021) Nutrients, 13(3), 877.
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