Written by Sneha Kamat. Senior Physiotherapist APPI Clinics.
Female Athlete Triad is a syndrome in active females characterised by the interrelationship between 3 components:
- Low Energy Availability – Energy availability is the energy remaining for the body to use, leaving out the energy expended during exercise. Low energy availability is when the energy consumed is not sufficient to meet the demands of bodily functions and exercise. This can occur due to disordered eating, ranging from healthy dieting, fasting, binging and purging, using diet pills/laxatives or skipping meals.
- Menstrual Dysfunction – Poor nutrition, low fat percentage, physical or emotional stress can all cause hormonal changes (involving reduced estrogen production) which lead to irregular menstrual cycle. Since the energy available is limited, the body goes into energy saving mode, prioritising the essential processes over the non-essential ones. In severe cases, menstruation can be absent for over 3 months, also called amenorrhea.
- Altered Bone Mineral Density – Bone remodeling is done under the influence of certain hormones like the growth hormones, estrogen, etc. With a change in hormone levels, the bone remodelling is also affected leading to increased risk of stress fractures, especially in amennorheic athletes.
Signs and Symptoms
Physical signs –
- Chronic fatigue that doesn’t improve with rest.
- Stress fractures or repeated bone injuries.
- Recurring infections and illnesses.
- Absent or irregular menstrual cycles in females.
- Anaemia.
- Weight loss.
- Gastrointestinal problems.
- Decreased muscle strength.
- Always being hurt or injured.
Psychological signs –
- Depression.
- Irritability.
- Disordered-eating thoughts.
Performance related signs –
- Poor performance or a decline in athletic ability.
- Inability to gain or build muscle or strength.
- Training hard, but not improving performance.
How can it be identified?
RED-S can be a difficult condition to diagnose as there is no single test but more, a combination of symptoms, risk factors and training. Your healthcare professional may use one of more of the below:
- Detailed medical and training history
- Symptom questionnaire – detailing all the signs and symptoms of the condition
- Physical examination – strength testing, weight changes, performance testing
- Blood tests – hormonal profile, vitamin D levels and other nutritional deficiencies
- DEXA scans – to check the bone density if there is a history of stress fractures/bone injuries.
Treatment
The treatment of RED-S involves addressing the underlying cause which is usually through a combination of nutritional, psychological, and physical interventions.
Nutritional Management – This involves increasing the dietary intake under the guidance of a nutritionist to match the demands of the physical activity. Any disordered eating is also addressed through psychological support and nutritional counselling. Ensuring adequate Vitamin D and calcium intake is key in maintaining good bone health.
Psychological Management – Athletes with disordered eating or body image issues are referred on to psychologists or psychotherapists to address the same. Any other stressors that contribute to this syndrome are also addressed here.
Physical Management – Hormonal imbalances are first management through lifestyle changes and increased dietary intake. If further intervention is warranted, pharmacological treatment can be considered. Monitoring and adjusting training loads forms a big part of the treatment as it is important to balance between training and recovery. Strength training can be part of the recovery process but it is essential to first address the underlying cause.
Recovering from RED-S works best when you have the right people supporting you – this may include a physiotherapist, sports doctor, dietitian, and psychologist. By working together, they can address RED-S from all angles to restore health and performance.
References:
Raj MA, Creech JA, Rogol AD. Female Athlete Triad. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430787/
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De Souza MJ, Nattiv A, Joy E, et al2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013British Journal of Sports Medicine 2014;48:289.