By Dr. Liji Thomas, MD

A large-scale European study reveals that female bodybuilding athletes experience elevated rates of sudden cardiac death, urging tighter medical screening and regulation of performance-enhancing drug use in competitive sport.

Study: Mortality in female bodybuilding athletes

While many more women than before are participating in bodybuilding, the risks of sudden cardiac death (SCD) in particular, and of death overall, in this population, remain unknown. A recent study published in the European Heart Journal addresses this question, drawing on a large longitudinal study of female bodybuilders and comparing the results with those previously reported from male bodybuilders.

About the study

The study followed a previous analysis done using data on male bodybuilders, from the same study period (2005–2020). Women athletes were classified into three divisions, namely, Women’s Bodybuilding, Women’s Physique, and Figure categories. Master athletes is a term applied to those who are 35 years old or more.

Death rates were found for each category, per 100,000 athlete-years (AYs). Subgroups were assigned, such as junior, open, master, division type, amateur, and professional athletes, to find mortality and SCD incidences.

Study results

The 16-year study period included follow-up of 9,447 women bodybuilders participating in international events. There were 32 deaths in this cohort, the mean age of death being approximately 43 years. The largest share of deaths occurred among North American athletes (44%).

Of the 32, 24 were attributed to a specific cause of death. These comprised: • Non-sudden deaths – 5 • Sudden deaths – 19

Again, seven and twelve deaths were traumatic and non-traumatic, respectively. Notably, ten deaths were classified as sudden cardiac deaths (SCDs), making up about 31% of the total, with a mean age of 42 years. Approximately 13% of all deaths were due to suicide or homicide, over four times higher than among male bodybuilders. This difference may reflect greater psychosocial vulnerability and gender-specific stressors reported in female bodybuilding, as discussed in prior qualitative work, though causality cannot be established.

As with male bodybuilders, SCDs were the most common cause of death. SCD incidence was highest in the Women’s Bodybuilding division. Among professionals, rates were 53.98 (95% CI 23.31–106.36) per 100,000 AYs versus 2.48 (95% CI 0.30–8.95) per 100,000 AYs among amateurs. For the overall female cohort, all-cause mortality was 33.51 (95% CI 22.92–47.30) per 100,000 AYs, while SCD incidence was 10.47 (95% CI 5.02–19.26) per 100,000 AYs.

Among professional women athletes, only two deaths were followed by an autopsy. These showed a normal heart and myocarditis, respectively. In contrast, deaths in currently competing male bodybuilders are often associated with heart abnormalities such as an enlarged heart or left ventricular hypertrophy. This could suggest that structural cardiac adaptations may differ between sexes.

Conversely, many of the same risk determinants described in male cohorts, extreme strength training, acute weight-cutting strategies, and performance-enhancing drug (PED) abuse, are likely to be present in female athletes as well. However, the study could not quantify their relative contribution. Toxicological analyses confirmed PED use in four cases in total.

Only one death was reported in the junior athlete category, the cause being trauma. In contrast, there were nine deaths among master athletes, of which three were SCDs, the mean age of death being about 52 years.

Seven deaths among women bodybuilders occurred within a year of their latest competition. Both the SCDs in this group occurred around competitions. Currently competing athletes had incidence rates of 40.87 (95% CI 16.43–84.22) for all-cause mortality and 11.68 (95% CI 1.41–42.19) for SCD per 100,000 AYs.

When comparing these findings with those in male bodybuilders, similar trends were observed for both groups. SCD was the most common cause of death in both male and female athletes. However, the incidence of death from all causes in women was half that in men. The incidence rate ratio (IRR) for all-cause mortality was 0.53 (95% CI 0.35–0.78), while SCD incidence was 57% lower (IRR 0.43; 95% CI 0.19–0.87). Among professionals, the SCD IRR was 0.28 (95% CI 0.11–0.64).

Conclusions

This unique study quantitatively assessed SCD rates and overall mortality in female bodybuilders using a large cohort followed up over 16 years. As expected from corresponding studies in male bodybuilders, SCD was the most common cause of death. However, this interpretation should be cautious because the cause of death was undetermined in 25% of cases, and the study relied on publicly available data from competition registries without adjustment for potential confounders.

Overall, the observed SCD incidence exceeded that reported in other female athletic populations, although methodological differences limit cross-study comparisons.

“Given the increased mortality risk observed in female bodybuilding athletes, there is a pressing need for targeted preventive strategies, including structured medical evaluations, educational initiatives, and tighter monitoring of PED abuse, also to promote a cultural shift in this sport discipline.”