Background: Sex-specific recovery responses following high-intensity intermittent exercise in aquatic sports remain poorly understood. Warm-up configuration may differentially influence performance and post-exercise autonomic and metabolic recovery. Aim: To compare performance and post-exercise physiological responses between male and female water polo players following dryland (DL), in-water (IN), and combined (integration of both protocols) warm-ups. Methods: Twenty international-level water polo players (10 males: 22.4 ± 3.5 years; 10 females: 21.0 ± 2.0 years) completed three randomized warm-up conditions, each lasting approximately 20 minutes. The warm-ups included phases of activation (e.g., shoulder and hip mobility; 200m mixed swimming), specific preparation (e.g., squats and lunges; eggbeater kicking, technical drills, and 1vs1 situations), and final preparation (e.g., burpees; passing and shooting exercises). Each condition was followed by a Water Polo Intermittent Shuttle Test (WIST). Performance (distance covered), tympanic temperature, heart rate (HR), blood lactate concentration ([La*]), and rating of perceived exertion (RPE) were assessed 5 min post-test. Results: In females, combined increased performance (315.0 ± 142.1m) compared to DL (241.5 ± 93.9m; p=0.02; d=0.90; *=73.5m) and IN (259.5 ± 111.4m; p=0.04; d=0.75; *=55.5m). HR was lower after combined (84.5 ± 8.4 bpm) vs. DL (92.0 ± 6.7bpm; p<0.001; d=1.52; *=*7.5 bpm). RPE showed a moderate reduction vs. IN (p=0.068; d=0.66; *=*0.9). In males, DL reduced performance vs IN (p<0.001; d=2.00; *=105m) and combined (p<0.001; d=1.53; *=132m), with no physiological differences across protocols. Conclusions: Combined enhances performance in both sexes, but only female athletes show lower HR and RPE with this warm-up strategy, suggesting that physiological, thermoregulatory, or anthropometric factors may contribute to cardiovascular efficiency and effort perception among female athletes. From a practical perspective, it is important to consider combined warm-up for elite female and male water polo athletes before competition. Future research should investigate the physiological mechanisms underlying these differences and the potential benefits of individualized warm-up strategies in elite water polo athletes.
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