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Bone 2019 Feb 5;121:267-276. Epub 2019 Feb 5.

Army Personnel Research Capability, Army Headquarters, Andover, UK. Electronic address:

Purpose: To investigate the skeletal effects of the first all-female trans-Antarctic traverse.

Methods: Six women (mean ± SD, age 32 ± 3 years, height 1.72 ± 0. Read More

Contemp Clin Trials Commun 2019 Jun 18;14:100325. Epub 2019 Jan 18.

Pennsylvania State University, Department of Kinesiology, Noll Laboratory, Women's Health and Exercise Laboratory, University Park, PA, 16802, USA.

Purpose: Exercising women who consume inadequate energy relative to expenditure are at risk for downstream health consequences, such as menstrual cycle disturbances and poor bone health. Collectively, these conditions are known as the Female Athlete Triad (Triad). Clinicians often prescribe hormonal contraceptives to address this issue; however, the recommended treatment is reversal of the energy deficit. Read More

Scand J Med Sci Sports 2019 Jan 15. Epub 2019 Jan 15.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Introduction: The Female Athlete Triad (Triad) is a syndrome describing three interrelated conditions: low energy availability (LEA), menstrual dysfunction, and low bone mineral density (BMD). Relative Energy Deficiency in Sport (RED-S) expands the Triad to include multiple physiologic consequences of LEA in both sexes. The purpose of this study is to determine the prevalence of factors associated with the Triad/RED-S in an elite para athlete population. Read More

Am Fam Physician 2019 Jan;99(2):76-77

Fort Belvoir, VA, USA.

Br J Sports Med 2019 Feb 3;53(4):205-206. Epub 2019 Jan 3.

Br J Sports Med 2019 Feb 22;53(4):237-242. Epub 2018 Dec 22.

Stanford University, Stanford, California, USA.

Objectives: Bone stress injuries (BSI) are common in runners of both sexes. The purpose of this study was to determine if a modified Female Athlete Triad Cumulative Risk Assessment tool would predict BSI in male distance runners.

Methods: 156 male runners at two collegiate programmes were studied using mixed retrospective and prospective design for a total of 7 years. Read More

J Trace Elem Med Biol 2019 Jan 19;51:169-175. Epub 2018 Oct 19.

The Women's Health and Exercise Laboratory, The Pennsylvania State University, 104 Noll Laboratory, University Park, PA 16802, United States. Electronic address:

Objectives: Although exercising women are at high risk of poor iron status, it is unknown how non-pathological, physiological menstrual function affects iron status. As such, this study investigates the association between menstrual function and iron status in exercising women with amenorrhea and exercising women with ovulatory, eumenorrheic menstrual cycles.

Design: Cross-sectional analysis of iron depletion prevalence, iron status indices, exercise parameters, and diet composition. Read More

Int J Womens Health 2018 30;10:671-687. Epub 2018 Oct 30.

Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan,

Introduction: Menstrual dysfunction, musculoskeletal injury, and poor nutrition combine to form the female athlete triad (FAT), which results in serious health consequences for affected athletes. To this point, the risk factors of this phenomenon have not been fully explored in Japanese female college athletes. Additionally, the effect of competitive level on FAT risk factors has also not been reported. Read More

Prim Care 2018 Dec 4;45(4):615-624. Epub 2018 Oct 4.

KentuckyOne Health, University of Louisville, Louisville, KY, USA; Department of Family and Geriatric Medicine, Centers for Primary Care, University of Louisville, 215 Central Avenue, Suite 205, Louisville, KY 40208, USA.

The female athlete triad is a condition seen in physically active female athletes, consisting of low energy availability, menstrual dysfunction, and low bone mineral density. The condition should be viewed as a metabolic injury. It can have an impact on female athletes at any age or level. Read More

J Pediatr Adolesc Gynecol 2018 Nov 2. Epub 2018 Nov 2.

Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York. Electronic address:

Study Objective: The female athlete triad is often found in sports that value leanness and aesthetics and can lead to adverse health effects. We aimed to compare knowledge and risk of the triad among adolescent figure skaters, dancers, and runners.

Design, Setting, Participants, And Main Outcome Measures: We advertised our survey on social media platforms: sports-specific forums; Facebook; and Instagram. Read More

Br J Sports Med 2019 Feb 9;53(4):229-236. Epub 2018 Oct 9.

Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Objective: Normal-weight oligo-amenorrhoeic athletes (OAA) are at risk for low bone mineral density (BMD). Data are lacking regarding the impact of oestrogen administration on bone outcomes in OAA. Our objective was to determine the effects of transdermal versus oral oestrogen administration on bone in OAA engaged in weight-bearing activity. Read More

Curr Opin Pediatr 2018 Dec;30(6):874-882

Division of Adolescent Medicine, Department of Pediatrics, Cohen Children's Medical Center, New York, New York, USA.

Purpose Of Review: The purpose of this review is to provide an updated summary on the unique aspects of caring for female youth and adolescent athletes.

Recent Findings: Recent research on female athletes has led to a better understanding of injuries and conditions that are more likely to occur in female youth and adolescent athletes, including the frequency and severity of concussions, musculoskeletal injury such as involving the anterior cruciate ligament, and the female athlete triad. Social factors, such as the growing pressure to specialize in a sport particularly at an early age, also put young female athletes at risk for issues such as overuse injuries. Read More

Eur J Clin Nutr 2019 Feb 4;73(2):215-224. Epub 2018 Oct 4.

Exercise and Health Laboratory, CIPER, Faculdade Motricidade Humana, Universidade Lisboa, Estrada da Costa, 1499-002, Cruz-Quebrada, Portugal.

Advances in body composition assessment enable a detailed body composition analyses and the respective organization at different levels. Sports-related professionals are interested in understanding how and which body components are relevant for improving performance, prevent injury risk, and monitor athletic health. The aim of this review is to propose an integrative model that links performance, injury risk, and athletic health with body components, and to report their cross-sectional and longitudinal associations. Read More

Sports (Basel) 2018 Aug 19;6(3). Epub 2018 Aug 19.

Departments of Health, Human Performance, and Recreation, Southeast Missouri State University, Cape Girardeau, MO 63701, USA.

Low caloric intake or excessive energy expenditure can lead to a negative energy balance, which, in female athletes, may result in a condition called the female athlete triad. While several guidelines identified proper nutrition as a first line of treatment, little research has been reported to show the effect of a professional nutrition program (PNP) on the female athlete triad. The purpose of this case report was to measure the short- and long-term effects of a PNP on a female athlete presenting triad characteristics. Read More

Skeletal Radiol 2019 Jan 20;48(1):77-88. Epub 2018 Aug 20.

Department of Radiology, University of Michigan, 1500 E Medical Center Drive, B1 D502, Ann Arbor, MI, 48109, USA.

With the rising participation of girls in sports at both the recreational and elite levels, there has also been increased awareness of injuries common in this athlete population. Anatomic differences between boys and girls cause girl athletes to be predisposed to certain injuries. Certain behavioral patterns, such as eating disorders, also cause problems specific to girl athletes that may result in injury. Read More

Nutrients 2018 Aug 13;10(8). Epub 2018 Aug 13.

United States Olympic Committee, Chula Vista, CA 91915, USA.

Low energy availability (LEA) and nutrient intake have been well studied in able-bodied athletes, but there is a lack of research examining these issues amongst athletes with spinal cord injury (SCI). To date, there have been no studies that have examined energy availability (EA) amongst this population. Furthermore, athletes with SCI may experience unique challenges around nutrition that may increase their risk of LEA. Read More

Int J Sport Nutr Exerc Metab 2018 Jul 24;28(4):364-374. Epub 2018 Jul 24.

5 Harvard Medical School.

Low energy availability (LEA) is a key element of the Female Athlete Triad. Causes of LEA include failure to match high exercise energy expenditure (unintentional) or pathological behaviors of disordered eating (compulsive) and overzealous weight control programs (misguided but intentional). Recognition of such scenarios in male athletes contributed to the pronouncement of the more inclusive Relative Energy Deficiency in Sport (RED-S) syndrome. Read More

Int J Sport Nutr Exerc Metab 2018 Jul 14;28(4):335-349. Epub 2018 Jul 14.

4 Harvard Medical School.

The term Relative Energy Deficiency in Sport was introduced by the International Olympic Committee in 2014. It refers to the potential health and performance consequences of inadequate energy for sport, emphasizing that there are consequences of low energy availability (EA; typically defined as <30 kcal·kg fat-free mass·day) beyond the important and well-established female athlete triad, and that low EA affects populations other than women. As the prevalence and consequences of Relative Energy Deficiency in Sport become more apparent, it is important to understand the current knowledge of the hormonal changes that occur with decreased EA. Read More

Med Sci Sports Exerc 2018 Dec;50(12):2536-2543

Department of Orthopaedic Surgery, Boswell Human Performance Laboratory, Stanford, CA.

Purpose: Athletes in weight-bearing sports may benefit from higher bone mineral density (BMD). However, some athletes are at risk for impaired BMD with female athlete triad (Triad). The purpose of this study is to understand the influence of sports participation and Triad on BMD. Read More

Br J Sports Med 2018 Jun 2. Epub 2018 Jun 2.

Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.

Low energy availability (EA) is suspected to be the underlying cause of both the Female Athlete Triad and the more recently defined syndrome, Relative Energy Deficiency in Sport (RED-S). The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit. While the importance of adequate EA is generally accepted, few studies have attempted to understand whether low EA is associated with the health and performance consequences posited by the IOC. Read More

J Am Acad Orthop Surg 2018 Jul;26(13):447-454

From the Department of Orthopaedic Surgery, Yale University, New Haven, CT (Dr. Carter), the Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY (Dr. Ireland), the Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX (Dr. Johnson), the Department of Orthopaedic Surgery, Columbia University, New York, NY (Dr. Levine), the Department of Orthopaedic Surgery, the Brigham & Women's Hospital, Boston, MA (Dr. Martin), the Department of Orthopaedic Surgery, the University of Michigan, Ann Arbor, MI (Dr. Bedi), and the Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA (Dr. Matzkin).

The patient's sex plays an important role in mediating the risk for, and experience of, disease. Injuries of the musculoskeletal system are no exception to this phenomenon. Increasing evidence shows that the incidence, clinical presentation, and treatment outcomes for male and female patients with common sports injuries may vary widely. Read More

Br J Sports Med 2018 Jun;52(11):687-697

IOC Medical and Scientific Department, Lausanne, Switzerland.

Int J Sport Nutr Exerc Metab 2018 Jul 17;28(4):316-331. Epub 2018 May 17.

17 IOC Medical and Scientific Department.

Curr Sports Med Rep 2018 May;17(5):163-171

Int J Sport Nutr Exerc Metab 2018 Jul 3;28(4):375-384. Epub 2018 Jul 3.

2 McMaster University and FINA Sports Medicine Committee.

The syndrome of relative energy deficiency in sport (RED-S) is a clinical entity characterized by low energy availability, which can negatively affect the health and performance of both male and female athletes. The underlying mechanism of RED-S is an inadequacy of dietary energy to support optimal health and performance. This syndrome refers to impaired physiological function, including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health, with psychological consequences that can either precede (through restrictive dietary habits) or result from RED-S. Read More

Am Fam Physician 2018 Apr;97(8):499-502

University of Texas Southwestern Medical Center, Dallas, TX, USA.

Cleve Clin J Med 2018 Apr;85(4):313-320

Division of Women's Health, Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA.

The female athlete triad is a syndrome consisting of low energy availability (ie, burning more calories than one is taking in), menstrual dysfunction, and low bone mineral density, although all 3 components need not be present. Many providers, physical therapists, and coaches are unaware of it and thus do not screen for it. Early intervention using a team approach is essential in patients with any component of the female athlete triad to prevent long-term adverse health effects. Read More

Cleve Clin J Med 2018 04;85(4):321-322

Assistant Professor, Harvard Medical School, Boston, MA, USA.

J Obstet Gynaecol Res 2018 Jun 2;44(6):1007-1014. Epub 2018 Apr 2.

Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan.

The female athlete triad (FAT) is defined by the American College of Sports Medicine (ACSM) as low energy availability (low EA), functional hypothalamic amenorrhoea and osteoporosis. In low EA, lutein dysfunction first develops, followed by anovulation and, subsequently, oligomenorrhea, leading to amenorrhea. Moreover, low estradiol concentrations due to amenorrhea decrease bone mineral density (BMD). Read More

Eur J Pediatr 2018 Jun 3;177(6):815-825. Epub 2018 Mar 3.

CENC, Sleep Medicine Center, Lisbon, Portugal.

Sleep, body composition and dietary intake are crucial for athletes' health and performance but have never been investigated in acrobatic gymnasts. Thus, this study aimed to evaluate sleep, body composition, dietary intake and eating behaviours of acrobatic gymnasts. Using a cross-sectional study, 82 Portuguese acrobatic gymnasts (12. Read More

Int J Sport Nutr Exerc Metab 2018 Jul 7;28(4):332-334. Epub 2018 Jun 7.

1 Rocky Vista University.

Barbara Drinkwater has been a lifelong champion of equality for women in many areas of life well before it was widely accepted. Her "walking the walk" of women breaking barriers in traditional male roles in administration and leadership is exemplified by her election as the first woman president of the American College of Sports Medicine in 1988. Some of the controversial areas in which Barbara was vocal in the arena of women in sport, besides triad/relative energy deficiency in sport, include increased opportunity and participation, total equality, acceptance of diversity, intolerance of harassment and abuse, and fairness with transgender athletes. Read More

Br J Sports Med 2017 Feb;51(3):200-205

University of California Los Angeles, Los Angeles, California, USA.

Background: Limited research has evaluated risk factors for low bone mineral density (BMD) in male adolescent athletes.

Aims/objectives: To evaluate predictors of low BMD (defined as BMD Z-score <-1.0) in a sample of male adolescent distance runner and non-runner athletes. Read More

Int J Sport Nutr Exerc Metab 2018 Jul 12;28(4):403-411. Epub 2018 Jun 12.

1 Australian Catholic University.

We aimed to (a) report energy availability (EA), metabolic/reproductive function, bone mineral density, and injury/illness rates in national/world-class female and male distance athletes and (b) investigate the robustness of various diagnostic criteria from the Female Athlete Triad (Triad), Low Energy Availability in Females Questionnaire, and relative energy deficiency in sport (RED-S) tools to identify risks associated with low EA. Athletes were distinguished according to benchmarks of reproductive function (amenorrheic [n = 13] vs. eumenorrheic [n = 22], low [lowest quartile of reference range; n = 10] versus normal testosterone [n = 14]), and EA calculated from 7-day food and training diaries (< or >30 kcal·kg fat-free mass·day). Read More

J Athl Train 2018 Jan 18;53(1):51-59. Epub 2017 Dec 18.

Department of Exercise and Sport Science, University of North Carolina at Chapel Hill.

Context:   The female athlete triad (Triad) and relative energy deficiency in sport (RED-S) specify the consequences of energy imbalance. Athletic trainers (ATs) are positioned to identify athletes who are fueling themselves inadequately and experiencing related health and performance consequences.

Objective:   To assess the knowledge of collegiate ATs about the Triad and RED-S and to examine variability in related screening and referral behaviors among National Collegiate Athletic Association divisions. Read More

Int J Adolesc Med Health 2017 Nov 23. Epub 2017 Nov 23.

.

Objective Female adolescent athletes seem to use oral contraceptives (OCs) in the same proportion as the general population. In athletes not using OCs, menstrual irregularity (MI) is reported to be common but there are few studies of MI in adolescent athletes. The aim of the study was to survey menarche, menstrual irregularity and use of OCs in adolescent athletes in the National Sports High Schools in Sweden. Read More

Curr Sports Med Rep 2017 Nov/Dec;16(6):428-434

Division of Pediatric Sports Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Solon, OH.

Youth sports participation numbers continue to grow in the United States. A shift toward sport specialization has caused an increase in sport training frequency and intensity that places the growing athlete at risk for overtraining, nutritional deficits, and injuries. Individuals who participate in endurance sports are at especially high risk. Read More

Curr Sports Med Rep 2017 Nov/Dec;16(6):382-385

1Community Health and Food & Nutrition, Intermountain Healthcare, Salt Lake City, UT; and 2Division of Sports Medicine and Non-Operative Orthopaedics, Departments of Family Medicine and Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Department of Athletics, University of California, Los Angeles, CA.

JBJS Rev 2017 10;5(10):e4

1Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado 2Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.

Curr Osteoporos Rep 2017 12;15(6):577-587

Department of Kinesiology Women's Health and Exercise Lab, College of Health and Human Development, The Pennsylvania State University, University Park, USA.

Purpose Of Review: This review provides an update on the primary clinical sequelae of the Female Athlete Triad.

Recent Findings: Scientific advancements have contributed to improve understanding of Triad-related conditions, including leptin's role as a potential neuroendocrine link between energy status and reproductive function. Use of finite element analysis of HRpQCT imaging has provided a more accurate assessment of bone geometry and bone strength and may be clinically relevant. Read More

Am J Sports Med 2018 01 6;46(1):30-36. Epub 2017 Oct 6.

Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.

Background: While sports participation is often associated with health benefits, a subset of athletes may develop impaired bone health. Bone stress injuries (BSIs) are a common overuse injury in athletes; site of injury has been shown to relate to underlying bone health in female athletes. Hypothesis/Purpose: This case series characterizes the association of type of sports participation and anatomic site of BSIs with low bone mineral density (BMD), defined as BMD Z-score <-1. Read More

Clin Sports Med 2017 Oct 10;36(4):671-686. Epub 2017 Jul 10.

Department of Family Medicine, University of Virginia Health System, PO Box 800729, Charlottesville, VA 22908, USA.

Despite more than 3 decades of research on the Female Athlete Triad, research gaps remain. Although low energy availability (EA) is the key etiologic factor in the Triad and the pathways to low EA are varied, its effects can be modified by several factors. Accurate screening, diagnosis, and treatment of disordered eating are a challenge; however, recent techniques combined with novel educational and behavior interventions prove promising. Read More

Bone 2017 Dec 25;105:191-199. Epub 2017 Aug 25.

Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement Research Centre, School of Science and Technology, Nottingham Trent University, UK. Electronic address:

Background: The short-term effects of low energy availability (EA) on bone metabolism in physically active women and men are currently unknown.

Purpose: We evaluated the effects of low EA on bone turnover markers (BTMs) in a cohort of women and a cohort of men, and compared effects between sexes.

Methods: These studies were performed using a randomised, counterbalanced, crossover design. Read More

Curr Osteoporos Rep 2017 10;15(5):459-472

Women's Health and Exercise Laboratory, 104 Noll Laboratory, Department of Kinesiology and Physiology, College of Health and Human Development, The Pennsylvania State University, University Park, PA, 16802, USA.

Purpose Of Review: The review aims to summarize our current knowledge surrounding treatment strategies aimed at recovery of bone mass in energy-deficient women suffering from the Female Athlete Triad.

Recent Findings: The independent and interactive contributions of energy status versus estrogen status on bone density, geometry, and strength have recently been reported, highlighting the importance of addressing both energy and estrogen in treatment strategies for bone health. This is supported by reports that have identified energy-related features (low body weight and BMI) and estrogen-related features (late age of menarche, oligo/amenorrhea) to be significant risk factors for low bone mineral density and bone stress injury in female athletes and exercising women. Read More

Transl Pediatr 2017 Jul;6(3):144-149

Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA.

The number of adolescent girls participating in sports has dramatically increased throughout the last few decades. In the early 1990's, an association between amenorrhea, osteoporosis, and disordered eating was recognized and eventually labeled the 'Female Athlete Triad'. In 1997, the Task Force on Women's Issues of American College of Sports Medicine (ACSM) published a position statement on this triad of conditions that were becoming increasingly more prevalent amongst female athletes. Read More

Curr Opin Obstet Gynecol 2017 Oct;29(5):301-305

Departments Ob/Gyn and Pediatrics, Norton Children's Hospital Louisville, Clinical Faculty University of Louisville, Louisville, Kentucky, USA.

Purpose Of Review: The obstetrician/gynecologist (ob/gyn) may be the first provider to have the opportunity to recognize and diagnose female athlete triad. This review will help the ob/gyn to understand the female athlete triad and what is new on this topic, how to screen and diagnose the condition and the ob/gyn's role in treatment.

Recent Findings: Female athlete triad, also known as relative energy deficiency in sports, involves an interrelationship among energy availability, menstrual function and low bone density. Read More

Eur J Nutr 2018 Apr 18;57(3):847-859. Epub 2017 Jul 18.

Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, UK.

Purpose: The present review critically evaluates existing literature on the effects of short- and long-term low energy availability (EA) on bone metabolism and health in physically active individuals.

Methods: We reviewed the literature on the short-term effects of low EA on markers of bone metabolism and the long-term effects of low EA on outcomes relating to bone health (bone mass, microarchitecture and strength, bone metabolic markers and stress fracture injury risk) in physically active individuals.

Results: Available evidence indicates that short-term low EA may increase markers of bone resorption and decrease markers of bone formation in physically active women. Read More

Br J Sports Med 2017 Nov 6;51(21):1570-1571. Epub 2017 Jul 6.

Family Medicine, University of Washington, Seattle, Washington, USA.

Rev Med Suisse 2016 Jul;12(525):1262-1265

Unité de médecine physique et rééducation orthopédique, Département de chirurgie, HUG, 1211 Genève 14.

The Relative Energy Deficiency in Sport has been suggested as the new and wider denomination of the Female athlete triad. This new terminology enables a wider approach to the different consequences of an insufficient energy intake amongst regular athletes. In fact, this energy dysbalance leads to a wider pathological phenomenon touching many systems (e. Read More

Obstet Gynecol 2017 06;129(6):e160-e167

The female athlete triad is a medical condition observed in physically active females involving three components: 1) low energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone density. An individual does not need to show clinical manifestations of all three components of the female athlete triad simultaneously to be affected by the condition. Consequences of these clinical conditions may not be completely reversible, so prevention, early diagnosis, and intervention are critical. Read More