This study examined real-world CBD use among recreationally active women under 40, a population historically underrepresented in cannabinoid research. Consistent with the study aim, we evaluated both behavioral and physiologic health correlates associated with self-directed CBD use rather than testing an intervention under controlled dosing conditions. Overall, findings suggest that CBD use in this population is associated with distinct lifestyle behavioral patterns, while physiologic differences were modest and largely within clinical reference ranges.

In the survey only (SO) cohort, CBD users reported lower physical activity levels, shorter sleep scores, and lower mental health and quality of life scores compared to non-users. Importantly, both groups demonstrated poor sleep quality according to PSQI criteria (scores >5) (31), indicating that sleep disturbance may be common in this population regardless of CBD use. CBD use was not associated with differences in post-exercise pain (VAP), suggesting no clear behavioral correlates related to perceived recovery in this cohort.

The survey plus biomarkers (SB) cohort demonstrated higher physical activity levels among CBD users, similar dietary trends, and no significant differences in mental health or pain. The divergence in physical activity findings between cohorts is most likely attributable to systematic self-selection rather than a true biological difference. Every SB participant reported the highest level of physical activity at screening (> 2.5 h per week), compared to only 27% of the SO cohort, effectively creating a ceiling effect that eliminated the between-group variation observed in the larger sample. The SB subcohort was also more educated, older, reported no tobacco use, and consumed less alcohol than the SO sample, collectively suggesting that individuals who volunteered for phlebotomy represent a health-motivated subgroup that does not reflect the behavioral heterogeneity of the broader cohort. Together, these findings reinforce that observed behavioral correlates of CBD use may vary across samples and underscore the importance of adequately powered studies to clarify these relationships.

With respect to physiologic outcomes, biomarker analysis in the SB cohort showed that non-CBD users had higher basophils, SHBG, and testosterone levels, and lower TSH. However, basophils, TSH, and testosterone values remained within laboratory norms. To date, no studies have examined basophils or TSH specifically in the context of CBD use. Endocannabinoids have been identified in immune cells and are believed to be enzymatically produced (35) and capable of enhancing natural killer cell function (36). CBD has also been shown to modulate thyroid hormones via the cannabinoid receptor (37). Although CBD may influence testosterone concentrations in males, self-dosed supplementation has not been associated with decreases in females (38). Three non-CBD users had SHBG values above normative ranges; however, there is no existing research directly linking CBD use to SHBG levels. Taken together, these physiologic differences should be interpreted as exploratory, rather than evidence of clinically meaningful endocrine or immune modulation.

Existing literature on CBD and muscle recovery remains limited and inconsistent. Studies examining topical CBD following muscle fatigue (12, 39) found no improvement in soreness or performance, whereas Isenmann and colleagues (13, 14, 24) reported minor reductions in muscle damage markers with 60 mg oral CBD but no improvement in strength or functional performance. In the present study, self-reported post-exercise muscle pain did not differ between CBD users and non-users in either cohort. Reported CBD doses were generally low (< 25 mg), which may fall below thresholds used in prior experimental work (28). As such, our findings do not support a clear association between typical real-world CBD dosing patterns and improved recovery outcomes in active young women.

Although biomarker data represented the primary physiologic outcome in the SB cohort, sleep and mental health outcomes are also relevant to overall recovery and performance. Prior research has shown CBD to be safe for sleep, with some improvements observed at doses ranging from 50 mg (36) to 300–600 mg (40). In the present study, CBD users reported poorer sleep scores in both cohorts, although all groups met criteria for poor sleep per PSQI thresholds (31). Whether CBD use preceded sleep disturbances or was initiated in response to them cannot be determined. Given the generally low doses reported, it is plausible that participants were not using quantities consistent with those associated with sleep improvements in prior trials (36, 40, 41). However, the cross-sectional design precludes causal interpretation.

Given that tobacco and alcohol use were both elevated among CBD users in the SO group, and are independently associated with poorer sleep quality, we examined whether these behaviors may have contributed to the shorter sleep duration and lower sleep quality scores observed in this group. However, correlation analysis revealed only a weak, non-significant relationship between tobacco use and PSQI scores. Alcohol use, which was also higher among CBD users, showed a modest but statistically significant correlation with poorer sleep, suggesting it may contribute more to the observed sleep differences than tobacco. Nonetheless, because this study was cross-sectional and did not include multivariate adjustment, the independent contributions of tobacco and alcohol to sleep quality and quality of life cannot be formally separated from those of CBD use itself. Future studies should incorporate approaches to account for these co-occurring lifestyle behaviors as potential confounders.

Similarly, mental health findings were mixed. In the SO cohort, CBD users reported lower Short Form Mental Health Continuum and Quality of Life scores, whereas no such differences were observed in the SB cohort. Previous literature demonstrates variable mental health outcomes with CBD use, with higher doses (300–600 mg) over extended periods associated with reductions in mild to moderate anxiety (28, 40), and lower doses (50 mg) over eight weeks showing no significant changes (36). In the present study, it remains unclear whether CBD users experienced symptom improvement after initiating use or whether poorer mental health status motivated supplementation. Longitudinal data are necessary to determine real world directionality.

Given that sleep disturbance, anxiety, pain, and reduced quality of life are common motivators for supplementation, it is plausible that some women initiate CBD use in response to pre-existing symptoms. Prior research has documented CBD use among women managing chronic pain associated with inflammatory bowel disease (42) and anxiety during breast cancer treatment (43), supporting a symptom-management framework. Thus, the observed associations in this study may reflect self-selection rather than adverse behavioral effects of CBD.

This study contributes to the limited literature examining real world cannabinoid use specifically in young, physically active women. A major strength is the inclusion of a real-world cohort reflecting typical self-dosing behaviors rather than laboratory-controlled administration. The SB subcohort provides preliminary physiologic data in a population for whom biomarker evidence is scarce. Given the well-documented age and sex bias in sports medicine research (25), inclusion of women in this context is essential. These data provide foundational evidence needed to determine whether findings derived largely from male cohorts generalize to female populations.

Several limitations should be considered. The cross-sectional design prevents causal inference and limits conclusions to associations. The SB cohort was small and not powered to detect subtle physiologic effects. Multiple comparisons were not adjusted for, increasing the possibility of type I error. Additionally, CBD dose, formulation, frequency, and duration were self-reported and variable, reflecting real-world use but introducing heterogeneity. Future longitudinal and interventional studies are needed to determine whether CBD meaningfully influences behavioral or physiologic health outcomes in active young women.