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Quality in Sport

The Evolution of Energy Deficiency Disorders in Female Athletes: Female Athlete Triad and Relative Energy Deficiency in Sport: Pathophysiology, Diagnosis, and Multidisciplinary Management - a literature review
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The Evolution of Energy Deficiency Disorders in Female Athletes: Female Athlete Triad and Relative Energy Deficiency in Sport: Pathophysiology, Diagnosis, and Multidisciplinary Management - a literature review

Authors

  • Katarzyna Bartnik https://orcid.org/0009-0005-9095-5875
  • Alicja Winkowska https://orcid.org/0009-0005-2050-0031
  • Jakub Jan Pokrzepa https://orcid.org/0009-0000-7907-1511
  • Gabriela Blecharz https://orcid.org/0009-0007-9275-3913
  • Julia Szwech https://orcid.org/0009-0006-3792-0101
  • Marlena Jankowska https://orcid.org/0009-0005-2240-8853
  • Klara Hosiawa https://orcid.org/0009-0008-8646-5963
  • Aleksandra Siewielec https://orcid.org/0009-0005-2281-734X
  • Karolina Mędrysa https://orcid.org/0009-0002-1557-0244
  • Anna Chlubek https://orcid.org/0009-0001-0807-3883

DOI:

https://doi.org/10.12775/QS.2025.42.60657

Keywords

Female Athlete Triad, Relative Energy Deficiency in Sport, Low Energy Availability, Menstrual Dysfunction, Stress Fractures, Energy Deficiency Syndromes, Female Athlete Health

Abstract

Introduction:

The growing participation of female athlethes in competitive and recreational sports has brought attention to sport-specific health concerns related to energy imbalance. The Female Athlete Triad (FAT), characterized by low energy availability (LEA), menstrual dysfunction and low bone mineral density (BMD), and the broader concept of Relative Energy Deficiency in Sport (RED-S) are critical syndromes affecting both health and performance.
Purpose:
The objective of this review is to examine the current literature on the etiology, pathophysiology, clinical presentation, diagnostic methods, management and prevention of FAT and RED-S in female athletes, with an emphasis on early recognition and interdisciplinary care.

Materials and methods:

This review is based on a comprehensive literature search conducted on articles sourced from PubMed and Cochrane. The listed keywords were used and analysed for topic relevance and knowledge currency.

Conclusion:

FAT and RED-S remain underdiagnosed despite significant health risks such as infertility, osteoporosis and reduced performance. Effective prevention and management depend on restoring energy balance that should be supported by a multidisciplinary care team. Continuation of research, education and monitoring are essential to minimize long-term consequences and promote a sport culture that prioritizes both performance and athlete well-being.

References

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[2] A. R. Coelho, G. Cardoso, M. E. Brito, I. N. Gomes, and M. J. Cascais, “The Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S),” Revista Brasileira de Ginecologia e Obstetricia, vol. 43, no. 5, pp. 395–402, May 2021, doi: 10.1055/s-0041-1730289.

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[4] J. Mehta, B. Thompson, and J. M. Kling, “The female athlete triad: It takes a team,” Apr. 01, 2018, Cleveland Clinic Educational Foundation. doi: 10.3949/ccjm.85a.16137.

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[8] Suryawati, F. F. Dieny, R. Purwanti, A. F. A. Tsani, and N. Widyastuti, “Risk factors of eating disorders in young female athletes,” Food Res, vol. 4, pp. 83–91, 2020, doi: 10.26656/fr.2017.4(S3).S23.

[9] M. Mountjoy et al., “The IOC consensus statement: Beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S),” Br J Sports Med, vol. 48, no. 7, pp. 491–497, 2014, doi: 10.1136/bjsports-2014-093502.

[10] A. Sim and S. F. Burns, “Review: questionnaires as measures for low energy availability (LEA) and relative energy deficiency in sport (RED-S) in athletes,” Dec. 01, 2021, BioMed Central Ltd. doi: 10.1186/s40337-021-00396-7.

[11] K. E. Ackerman et al., “Methodology for studying Relative Energy Deficiency in Sport (REDs): A narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs,” Sep. 01, 2023, BMJ Publishing Group. doi: 10.1136/bjsports-2023-107359.

[12] T. M. da R. lemos Costa, V. Z. C. Borba, R. G. P. Correa, and C. A. Moreira, “Stress fractures,” 2022, Sociedade Brasileira de Endocrinologia e Metabologia. doi: 10.20945/2359-3997000000562.

[13] N. N. Kale, C. X. Wang, V. J. Wu, C. Miskimin, and M. K. Mulcahey, “Age and Female Sex Are Important Risk Factors for Stress Fractures: A Nationwide Database Analysis,” Sports Health, vol. 14, no. 6, pp. 805–811, Nov. 2022, doi: 10.1177/19417381221080440.

[14] A. E. Jeukendrup et al., “Does Relative Energy Deficiency in Sport (REDs) Syndrome Exist?,” Sports Medicine, vol. 54, no. 11, pp. 2793–2816, Nov. 2024, doi: 10.1007/s40279-024-02108-y.

[15] H. E. Cabre, S. R. Moore, A. E. Smith-Ryan, and A. C. Hackney, “Relative Energy Deficiency in Sport (RED-S): Scientific, Clinical, and Practical Implications for the Female Athlete,” 2022, Dynamic Media Sales Verlag. doi: 10.5960/dzsm.2022.546.

[16] A. E. Warrick, B. Hassid, B. Coleman, C. Cansino, and M. Faustin, “Multidisciplinary physician survey assessing knowledge of the female athlete triad and relative energy deficiency in sport,” J Eat Disord, vol. 11, no. 1, Dec. 2023, doi: 10.1186/s40337-023-00800-4.

[17] M. Grabia, J. Perkowski, K. Socha, and R. Markiewicz-Żukowska, “Female Athlete Triad and Relative Energy Deficiency in Sport (REDs): Nutritional Management,” 2024. doi: 10.3390/nu16030359.

[18] J. L. Areta, H. L. Taylor, and K. Koehler, “Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males,” Jan. 01, 2021, Springer Science and Business Media Deutschland GmbH. doi: 10.1007/s00421-020-04516-0.

[19] F. F. Lu et al., “Investigating the metabolomic pathways in female reproductive endocrine disorders: a Mendelian randomization study,” Front Endocrinol (Lausanne), vol. 15, 2024, doi: 10.3389/fendo.2024.1438079.

[20] E. Matzkin, E. J. Curry, and K. Whitlock, “Female Athlete Triad: Past, Present, and Future,” 2015. doi: 10.5435/JAAOS-D-14-00168.

[21] J. K. Ihalainen et al., “Beyond Menstrual Dysfunction: Does Altered Endocrine Function Caused by Problematic Low Energy Availability Impair Health and Sports Performance in Female Athletes?,” Sep. 01, 2024, Springer Science and Business Media Deutschland GmbH. doi: 10.1007/s40279-024-02065-6.

Quality in Sport

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Published

2025-06-17

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1.
BARTNIK, Katarzyna, WINKOWSKA, Alicja, POKRZEPA, Jakub Jan, BLECHARZ, Gabriela, SZWECH, Julia, JANKOWSKA, Marlena, HOSIAWA, Klara, SIEWIELEC, Aleksandra, MĘDRYSA, Karolina and CHLUBEK, Anna. The Evolution of Energy Deficiency Disorders in Female Athletes: Female Athlete Triad and Relative Energy Deficiency in Sport: Pathophysiology, Diagnosis, and Multidisciplinary Management - a literature review. Quality in Sport. Online. 17 June 2025. Vol. 42, p. 60657. [Accessed 29 June 2025]. DOI 10.12775/QS.2025.42.60657.
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Vol. 42 (2025)

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Medical Sciences

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Copyright (c) 2025 Katarzyna Bartnik, Alicja Winkowska, Jakub Jan Pokrzepa, Gabriela Blecharz, Julia Szwech, Marlena Jankowska, Klara Hosiawa, Aleksandra Siewielec, Karolina Mędrysa, Anna Chlubek

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