The study of sex differences in Alzheimer’s disease is increasingly recognized as a key priority in research and clinical development. People with Down syndrome represent the largest population with a genetic link to Alzheimer’s disease (>90% in the 7th decade). Yet, sex differences in Alzheimer’s disease manifestations have not been fully investigated in these individuals, who are key candidates for preventive clinical trials. In this double-center, cross-sectional study of 628 adults with Down syndrome (46% female, 44.4 [34.6; 50.7] years) we compared Alzheimer’s disease prevalence, as well as cognitive outcomes and AT(N) biomarkers across age and sex. Participants were recruited from a population-based health plan in Barcelona, Spain, and from a convenience sample recruited via services for people with intellectual disabilities in England and Scotland. They underwent assessment with the Cambridge Cognitive Examination for Older Adults with Down Syndrome (CAMCOG-DS), modified cued recall test (mCRT), and determinations of brain amyloidosis (CSF amyloid-β (Aβ)42/40, amyloid-PET), tau pathology (CSF and plasma phosphorylated-tau181) and neurodegeneration biomarkers (CSF and plasma neurofilament-light (NfL), total-tau, fluorodeoxyglucose(FDG)-PET, MRI). We used within-group locally estimated scatterplot smoothing (LOESS) models to compare the trajectory of biomarker changes with age in women versus men, as well as by apolipoprotein (APOE) ε4 carriership. Our work revealed similar prevalence, age at diagnosis, and CAMCOG-DS scores by sex, but men showed lower mCRT scores from age 45 compared with women. AT(N) biomarkers were comparable in men and women. When considering APOE ε4, women ε4 carriers showed a 3-year earlier age at diagnosis compared with women non-carriers (50.5 versus 53.2 years, p=0.01). This difference was not seen in men (52.2 vs 52.5 years, p=0.76). Our exploratory analyses considering sex, APOE ε4, and biomarkers showed that women ε4 carriers tended to exhibit lower CSF Aβ42/Aβ40 ratio and lower hippocampal volume compared with women without this allele, in line with the clinical difference. This work showed that biological sex did not influence clinical and biomarker profiles of Alzheimer’s disease in adults with Down syndrome. Consideration of APOE ε4 haplotype, particularly in women, may be important for clinical research and clinical trials that consider this population. Accounting for, reporting, and publishing sex-stratified data, even when no sex differences are found, is central to helping advance precision medicine.