The female athlete triad syndrome is a serious condition that can occur among female athletes who do not meet their caloric needs. It is estimated that one-third of college-level athletes develop this condition, leading to detrimental effects on growth, development, and athletic performance.¹ Because of its severity and commonality, it’s important to understand how the triad develops and the risks associated once diagnosed.

By: Sunny Streep

Updated Terminology: RED-S

Historically, the term “female athlete triad” has been used to distinguish the trifecta-nature of this disorder. However, it is clear that inadequate energy can cause a broad range of physiological and psychological impairments outside of this triad. In turn, this disorder has been replaced by a new classification called RED-S, or, “relative energy deficiency in sport”. This allows for treatment for athletes who do not fall solely within the confines of inadequate energy availability, menstrual irregularities, and low bone mineral density.

RED-S is typically characterized by three components: low energy availability, menstrual irregularities, and low bone density. These health challenges can vary in severity, with the most extreme being disordered eating, amenorrhea, and osteoporosis.¹

We will dive into each of these health challenges below.

An important aspect of the disorder is that its health challenges develop in response to one another. For example, low energy availability is the leading cause of menstrual irregularities, and menstrual irregularities can have detrimental effects on bone. To understand this domino effect more clearly, let’s break down each health challenge.

Energy Availability

Energy availability is the amount of fuel that the body needs in order to function correctly.¹ This is determined by a multitude of factors, including how much food you eat and your level of physical activity. RED-S is caused by low energy availability, typically as a result of disordered eating. In fact, up to 67% of female athletes have engaged in disordered eating behaviors such as food restriction and bingeing/purging.² There are so many pressures in sports that can play an influential role here: the pressure to win, to be a star athlete, to earn a scholarship, to meet specific physical standards (i.e. in ballet, gymnastics, running)...no matter the cause, disordered eating can develop and potentially spark RED-S.

Menstrual Irregularities

Once food restriction is present, the body undergoes a multitude of changes in order to adapt and survive. One of the first things that is affected is the menstrual system, with irregularities ranging from oligomenorrhea (menstrual cycle every 35+ days) to amenorrhea (no menstrual cycle for 3+ months).¹ Unfortunately, menstrual irregularities can be normalized by coaches and athletic peers, causing female athletes to go months, even years, without having adequate menstrual function. But many don’t realize this crucial fact: menstrual function is directly correlated with bone health, therefore any irregularities can significantly increase the risk for injury.¹⁻³

Bone Mineral Density

The majority of bone mass is formed during puberty, primarily around the time of a female’s first menstrual cycle. When a female has menstrual irregularities, less estrogen is produced.⁴ Estrogen is a vital hormone in the process of bone formation, whereby lower levels result in weaker bones.¹,⁴ In fact, athletes who have amenorrhea or other menstrual irregularities have up to 20% less bone mineral density than athletes with regular menstrual function.⁴ A lower bone mineral density creates a greater risk for injuries like stress fractures and broken bones. In addition, females may have stunted growth, hunched postures, scoliosis, or other disorders as a result of suboptimal bone health. If unaddressed, these detriments can be permanent - making it all the more imperative to seek medical attention at the first sign of disordered eating, menstrual dysfunction, or both.

Treatment

In regards to treatment options, an important issue to note is the role of oral contraceptives (birth control pills). Although they are often prescribed by medical professionals, oral contraceptives have no role in restoring bone density. Menstrual cycles may return, but this is not an indicator of restored bone health.³ In fact, complete weight restoration is the only way to aid in repairing bone density loss.

While food restriction and excessive exercise may seem beneficial in the short term, they can ultimately compromise athletic performance. If you or a loved one are experiencing disordered eating or RED-S, there are treatment options available.

At BALANCE eating disorder treatment center™, our compassionate, highly skilled team of clinicians is trained in diagnosing and treating the spectrum of eating disorders, including anorexia, bulimia, binge eating disorder, compulsive overeating, and other disordered eating and body image issues, including RED-S. In addition to our full-time Day Treatment Program and Weeknight Intensive Outpatient Program, we offer nutrition counseling with a licensed dietitian, meal support, and a variety of other groups and resources to assist those seeking help for food concerns. Click the button below to learn more about our programs and services.

Our admissions team would be happy to answer any questions you may have about our programs and services. Book a free consultation call with our admissions team below, or read more about our philosophy here.

This post was written by BALANCE Dietetic Intern, Sunny Streep (she/her).

Sunny is a graduate student at New York University receiving a Master's degree in Clinical Nutrition. After moving to NYC to pursue a career in professional dance, she became passionate about nutrition and mental health awareness. With her degree, Sunny hopes to educate on the connection between physical and emotional health, and is committed to supporting clients on their journey to recovery.

References

1. Zhaoping Li MD. Patient information: Intermittent fasting. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2784658. Published October 5, 2021. Accessed November 16, 2021.

2. Intermittent fasting with diabetes: A guide. Healthline Web site. https://www.healthline.com/health/type-2-diabetes/intermittent-fasting-and-diabetes-safe. Updated 2021. Accessed Nov 8, 2021.

3. Cuccolo K, Kramer R, Petros T, Thoennes M. Intermittent fasting implementation and association with eating disorder symptomatology. null. 2021:1-21. https://www-tandfonline-com.proxy.library.nyu.edu/doi/full/10.1080/10640266.2021.1922145. Accessed Nov 14, 2021. doi: 10.1080/10640266.2021.1922145.

4. Setnick J. The Eating Disorders Clinical Pocket Guide. Snack Time Press; 2013.

What is RED-S (Formerly, Female Athlete Triad Syndrome)?