Female athlete health, well-being focus of updated report

UNIVERSITY PARK, Pa. - When active and athletic girls and women don't eat enough food to meet their body's energy needs, it can disrupt key systems in the body and lead to irregular or absent menstrual cycles and impaired bone health, including osteoporosis and bone stress injuries.

These interrelated disruptions of energy status, reproductive function and bone health are known as the Female Athlete Triad (Triad). The condition can increase the risk of injury and impact long-term health and performance. It affects not only elite athletes but girls and women at all levels of sport. And its prevalence is rising, given the increasing number of girls and women participating in sport and the greater emphasis on sport specialization.

A panel of experts - including the researchers from Penn State - reviewed and synthesized existing scientific studies and data to advance understanding on the Triad and issued an updated consensus statement, the first issued since 2014. The consensus statement is a critical bridge between research and clinical practice, translating the scientific theory and studies into practical guidance, according to the researchers. This update includes two papers, both published in the journal Sports Medicine: a scientific paper that provides a detailed update on the scientific underpinnings of the condition and clinical guidelines for screening, diagnosis, treatment and return to play. It also introduces a first-of-its-kind adolescent model of the Triad.

"This work is crucial to advancing the health, well-being and participation of female athletes," said Mary Jane De Souza, distinguished professor of kinesiology at Penn State and lead author of the scientific paper. "We are delighted to have led this update, which draws on global expertise to provide evidence-based guidance that supports female athletes, coaches and clinicians."

-Mary Jane De Souza , distinguished professor of kinesiology at Penn State

The previous consensus statement on the Triad was released in 2014. Since then, there have been several key research advances in the field of female athlete health, prompting the need for an updated consensus statement, the researchers explained.

Here, an independent panel of 16 experts - including physicians, sports medicine practitioners, other health care providers and researchers and led by De Souza and Nancy Williams, professor of kinesiology and physiology at Penn State and lead author of the clinical guidelines - reviewed the existing scientific literature and data to provide an updated understanding of the Triad and to develop evidence-based recommendations for screening, diagnosis, treatment and return-to-play protocols, including a risk assessment tool.

Key updates in the new consensus statement

The new consensus statement introduces several updates aimed at improving diagnosis accuracy and clinical care of active and athletic girls and women.

1. New model for adolescent athletes

The Triad can affect up to 70% of adolescent athletes, particularly those in endurance or aesthetic sports like gymnastics, diving and figure skating, the researchers said. Energy deficiency during these years can disrupt growth, delay or alter the menstrual cycle and compromise bone health, which can have long-lasting impacts on a young person's health such as early onset osteoporosis. Yet there is little guidance for clinicians, coaches, parents and athletes for addressing Triad issues during adolescence.

"It's important to detail specific recommendations for this age group because the physiology in growing adolescents is distinct from adults," De Souza said. The consensus statement introduces a distinct model and clinical guidance specific to adolescent athletes, the first-of-its-kind to address this key population.

2. Redefining energy status

A significant shift in the 2025 update centers on how energy status is described and defined. Energy status is one of the three key pillars of the Triad - the balance between energy intake and energy the body uses for normal physiological functions and exercise. Previously, the term "low energy availability" was used to describe energy status that falls below healthy parameters. However, it's a confusing metric that's difficult to measure reliably outside of a laboratory setting and that can fluctuate widely day-to-day, Williams explained.

"While there is no gold standard for how to measure energy deficiency, our new consensus statement reflects the latest advances to address this complicated question of how to know when someone is not eating enough to support all their training and vital bodily processes," Williams said. "Body weight alone doesn't provide a full picture of one's metabolic status."

-Nancy Williams , professor of kinesiology and physiology at Penn State

The updated model uses the broader term "energy deficiency" to describe the lower end of the energy status spectrum. Low energy availability is now one of several indicators of energy deficiency, alongside low body weight, weight loss, and low body mass index. Researchers also introduce the term "metabolic compensation" to describe the body's adaptive - and protective - strategies to conserve energy when fuel is scarce, which can be reflected in measures like a low resting metabolic rate or suppressed levels of metabolic hormones.

"Being able to more precisely describe energy status lets coaches, clinicians and athletes know if an athlete is at risk for developing the Triad and, if they already have one or more Triad conditions, help them know how severe their energy deficiency is and whether interventions are working," Williams said.

3. Measures of recovery

The consensus statement raises the bar for what constitutes healthy menstrual status, reflecting strong evidence including randomized controlled trials led by De Souza and Williams. Previously, recovery from the Triad was assumed in someone with menstrual dysfunction if they had a single menstrual cycle after no menstruation or if they had more frequent menstrual cycles.

However, menstruation itself isn't necessarily a sign that levels of the hormone estrogen have reached healthy levels, the researchers explained. Studies show that it takes at least two consecutive cycles of less than 36 days for estrogen exposure to significantly increase in people with irregular or absent menstrual cycles. The papers also provide baseline calorie consumption recommendations needed to restore menstrual function in athletes who aren't menstruating.

Other Penn State authors on the papers include Ana Carla Salamunes, postdoctoral scholar in kinesiology and exercise physiology, and Rebecca Mallinson, assistant teaching professor at Penn State Harrisburg. Emily Ricker, scientist at Henry M. Jackson Foundation for the Advancement of Military Medicine, and Kristen Koltun, assistant professor in the department of sports science and nutrition at the University of Pittsburgh, both earned their doctorates at Penn State and contributed to the paper.

Other authors include Madhusmita Misra, Benjamin Armistead Shepherd Professor and Chair of the Pediatrics at the University of Virginia; Aurelia Nattiv, professor of family medicine and orthopedic surgery at University of California Los Angeles; Elizabeth Joy, Chief Medical Officer at Lore Health; Michelle Barrack, professor of nutrition and dietetics at California State University, Long Beach; Emma O'Donnell, senior lecturer in exercise physiology at Loughborough University; Kary Woodruff, associate professor of nutrition and integrative physiology at the University of Utah; Michael Fredericson, professor at Stanford University School of Medicine; and Sasha Gorrell, assistant professor of psychiatry, and Franziska Plessow, associate professor of psychiatry, at the University of California, San Francisco.