Effects of creatine supplementation on exercise performance, physiological outcomes, and body composition in females engaged in exercise or training: a systematic review and multilevel meta-analysis

Background Female-specific creatine trials span different sports, training states and outcome types. The preceding systematic review included 27 studies and provided a narrative synthesis of performance outcomes; the average magnitude of effects across correlated outcomes remained unknown. Objective To estimate overall and domain-specific effects of creatine supplementation on exercise and sport performance, physiological outcomes and body composition in females engaged in exercise, sport or structured training. Methods PubMed, Scopus, Web of Science, SPORTDiscus and CINAHL were searched for experimental studies published from 1 January 1996 to 5 March 2026. Two reviewers independently screened records, extracted data and appraised risk of bias. Female-specific creatine-vs.-control contrasts were synthesized with multilevel random-effects models and CR2 small-sample robust inference. Sensitivity analyses addressed graph-digitized and reconstructed percentage-change data and plausible within-study sampling correlations. GRADE was applied to the overall estimate and each quantitative domain. The review was retrospectively registered on OSF ( https://doi.org/10.17605/OSF.IO/U8V7A ). Results The search identified 13,244 records; 160 reports were assessed in full text, and 34 studies with 692 female or female-eligible participants entered the systematic review. Twenty-one studies contributed 170 model-compatible effects from 424 analyzable participants. The overall model yielded a small positive estimate (Hedges g = 0.23, CR2 robust 95% CI 0.09 to 0.37). The performance model yielded g = 0.30 (95% CI 0.06 to 0.54), and the body-composition model yielded g = 0.24 (95% CI 0.06 to 0.43). The body-composition model combined outcomes without a uniform favorable direction. The physiological estimate was uncertain (g = 0.10, 95% CI −0.17 to 0.38). Risk-of-bias concerns and variation in protocols and outcomes reduced certainty, which was low for performance and body composition and very low for the overall and physiological evidence. Conclusion Available female-specific evidence suggests possible small effects on selected strength, power, high-intensity performance and lean-mass-related measures. Substantial heterogeneity, methodological limitations and low or very-low certainty prevent firm sport-specific or outcome-specific conclusions. Systematic review registration https://doi.org/10.17605/OSF.IO/U8V7A , identifier: OSF.IO/U8V7A.