Purpose Arteriovenous fistula (AVF) outcomes are consistently inferior in female patients at both upper arm and forearm sites. Although smaller vessel diameter contributes, higher failure rates persist even after adjusting for size. Women also undergo re-intervention for non-maturing fistulas at roughly twice the rate of men. This review summarises evidence on factors underlying reduced AVF success in females and considers how these insights may inform changes in fistula creation strategies. Methodology A focused literature review examined gender disparities in AVF maturation and complications. Anatomical, physiological, and haemodynamic contributors were assessed alongside strategies to improve durability and outcomes in women. Results Maturation rates are lower in women, who are more likely to require PTFE graft placement. Contributing factors include smaller vessel calibre and greater vessel depth. Women are about twice as likely to need salvage procedures, with a greater relative impact than in men. Emerging evidence suggests sex-specific differences in venous remodelling and haemodynamic responses may further impair maturation. Some studies question whether the traditional superiority of native AVFs over PTFE grafts applies to women. Despite these disparities, guidance on incorporating such findings into clinical decision-making remains limited. Conclusion Sex-based differences in AVF outcomes highlight the need for a more individualised approach to vascular access in women. This includes earlier consideration of alternative strategies, proactive surveillance, and timely assisted maturation. The “AVF-first” paradigm may require re-evaluation, with increased consideration of endovascular AVFs and techniques using deep perforating veins to improve outcomes.