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Cited by 73Eating Disorders and BehaviorsHypothalamic control of reproductive hormonesLower Extremity Biomechanics and Pathologies

The Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S)

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Coelho, Alexandra Ruivo, Cardoso, Gonçalo, Brito, Marta Espanhol, Gomes, Inês Neves, Cascais, Maria João·2021·Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics
DOI 10.1055/s-0041-1730289PMC PMC10304901
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Abstract

In a healthy athlete, the caloric intake is sufficient for sports energy needs and body physiological functions, allowing a balance between energy availability, bone metabolism, and menstrual cycle. On the other hand, an imbalance caused by low energy availability due to a restrictive diet, eating disorders or long periods of energy expenditure leads to multisystemic deregulation favoring the essential functions of the body. This phenomenon, described as the female athlete triad, occurs in a considerable percentage of high-performance athletes, with harmful consequences for their future. The present review was carried out based on a critical analysis of the most recent publications available and aims to provide a global perception of the topic relative energy deficit in sport (RED-S). The objective is to promote the acquisition of more consolidated knowledge on an undervalued theme, enabling the acquisition of preventive strategies, early diagnosis and/or appropriate treatment.

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  • LEA and REDs lead to a decline in athletic performance in the long term because gradual reduction in body weight results in slower muscle glycogen synthesis, loss of muscle protein, and increased risk for stress fractures.

    “However, regardless of the potential for shortterm gains in athletic performance, LEA and REDs lead to a decline in athletic performance in the long term because gradual reduction in body weight results in slower muscle glycogen synthesis, loss of muscle protein, and increased risk for stress fractures [4,24].”

    From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [4]

    The “Other Consequences” section (page not provided) links low energy availability to impaired recovery, changes in muscle mass and function, and interference with glycogen reserves and protein synthesis, but says evidence for a measured performance decline is scarce. “Bone Metabolism” reports a higher fracture risk. The paper does not establish that gradual weight loss causes these effects or that athletic performance necessarily declines in the long term. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Changes in leptin, ghrelin, peptide YY, insulin, and increased cortisol negatively impact GnRH secretion, resulting in functional hypothalamic amenorrhea in females.

    “Changes in these four hormones, as well as increased cortisol levels in response to bodily stress, all negatively impact gonadotropin-releasing hormone (GnRH) secretion, resulting in functional hypothalamic amenorrhea in females [4,12].”

    From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [4]

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References 92 · Cited by 73

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Authors
Coelho, A. R., Cardoso, G., Brito, M. E., Gomes, I. N., & Cascais, M. J.
Affiliations
  • Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário, Lisboa, Portugal
  • Hospital Garcia de Orta (PT)
Corresponding author
Coelho, Alexandra Ruivo
ORCID
Venue
Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics
Publisher
Federação das Associações de Ginecologia e Obstetrícia
Published
2021-05
Volume
43
Issue
05
Pages
395-402
ISSN
  • 0100-7203 (ISSN-L)
  • 1806-9339
DOI
10.1055/s-0041-1730289
PMC
PMC10304901
OpenAlex
W3163999029
Cited by
73
References
92
Citations by year
2026: 20 · 2025: 18 · 2024: 22 · 2023: 6 · 2022: 7
FWCI
1.16
Type
journal article
Language
en
Open access
Licence
Locations
  • Revista Brasileira Ginecologia e Obstetrícia (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (publishedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
  • Health Sciences › Medicine › Reproductive Medicine › Hypothalamic control of reproductive hormones
  • Physical Sciences › Engineering › Biomedical Engineering › Lower Extremity Biomechanics and Pathologies
Keywords
female athlete triad, relative energy deficiency in sport, energy availability, bone metabolism, menstrual cycle, eating disorders, restrictive diets, energy expenditure, elite athletes, prevention, early diagnosis
MeSH terms
Relative Energy Deficiency in Sport, Amenorrhea, Feeding and Eating Disorders, Energy Intake, Energy Metabolism, Female, Humans, Menstruation Disturbances, Female Athlete Triad Syndrome, Athletic Performance, Athletes

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