Menstrual dysfunction in youth female athletes and their management in the context of models of energy deficiency


  • Danika A Quesnel University of British Columbia - Okanagan
  • Tristen Hefner
  • Maria Fernandez-del-Valle
  • Jacalyn McComb



Female Athlete Triad, RED-S, Menstrual Dysfunction, Youth Athletes, Athletic Management, Women


Today many young females consider themselves athletes, and participate in recreational, club, collegiate, or professional sport. Yet many of these girls and women, as well as their coaches, are not even aware of theoretical concepts in sport that relate to the reproductive health of females. Two such concepts are the Female Athlete Triad and the Relative Energy Deficiency in Sport (RED-S) Model.  Both the Female Athlete Triad and the RED-S Model conceptualize the negative sequala that can result from engaging in sport without adequate fueling. One symptom that can result from inadequate fueling can result in the onset of menstrual dysfunctions (MDs).  Early intervention and the prevention of MDs is crucial to mitigate long term health consequences.  Long term adverse health consequences may result, especially if MD persists throughout the developmental years necessary to achieve peak bone mass in the young female. Conclusion: Thus the following narrative review will outline how models of energy deficiency (The Female Athlete Triade and RED-S) interplay in the development of MDs as well as outline the current knowledge of the screening, treatment and education for MDs in young female athletes.


Abood, D. A., Black, D. R., & Birnbaum, R. D. (2004). Nutrition education intervention for college female athletes. J Nutr Educ Behav, 36(3), 135–139. doi:10.1016/S1499-4046(06)60150-4

Ackerman, K. E., Holtzman, B., Cooper, K. M., Flynn, E. F., Bruinvels, G., Tenforde, A. S., . . . Parziale, A. L. (2019). Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport. Br J Sports Med, 53(10), 628-633. doi:10.1136/bjsports-2017-098958

Beals, K. A. (2003). Eating disorder and menstrual dysfunction screening, education, and treatment programs. The Physician and Sportsmedicine, 31(7), 33–38. doi:10.3810/psm.2003.07.434

Beals, K. A., & Hill, A. K. (2006). The prevalence of disordered eating, menstrual dysfunction, and low bone mineral density among US collegiate athletes. Int J Sport Nutr Exerc Metab, 16(1), 1–23. doi:10.1123/ijsnem.16.1.1

Beals, K. A., & Manore, M. M. (2002). Disorders of the female athlete triad among collegiate athletes. Int J Sport Nutr Exerc Metab, 12(3), 281–293. doi:10.1123/ijsnem.12.3.281

Bernhardt., D., & Roberts, W. (2019). PPE Participation physical evaluation. 5thEd. American Academy of Pediatrics.

Bieber, E., Sanfilippo, J., Horowitz, I., & Shafi, M. (2015). Clinical gynecology (2nd ed.). Cambridge, United Kingdom: Cambridge University Press. Retrieved from,+E.+J.,+Sanfilippo,+J.+S.,+Horowitz,+I.+R.,+%26+Shafi,+M.+I.+(Eds.).+(2015).+Clinical+Gynecology.+Cambridge+University+Press.&ots=qMO24j-d05&sig=yvKEPY-TVHg58iHOca_4OhnIyCw

Black, D. R., Larkin, L. J., Coster, D. C., Leverenz, L. J., & Abood, D. A. (2003). Physiologic screening test for eating disorders/disordered eating among female collegiate athletes. J Athl Train, 38(4), 286-297. Retrieved from

Bonci, C. M., Bonci, L. J., Granger, L. R., Johnson, C. L., Malina, R. M., Milne, L. W., … Vanderbunt, E. M. (2008). National athletic trainers’ association position statement: preventing, detecting, and managing disordered eating in athletes. J Athl Train, 43(1), 80–108. doi:10.4085/1062-6050-43.1.80

Bonomi, A. G., Plasqui, G., Goris, A. H. C., & Westerterp, K. R. (2009). Improving assessment of daily energy expenditure by identifying types of physical activity with a single accelerometer. J Appl Physiol (1985), 107(3), 655–661. doi:10.1152/japplphysiol.00150.2009

Bratland-Sanda, S., & Sundgot-Borgen, J. (2013). Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. European Journal of Sport Science, 13(5), 499–508. doi:10.1080/17461391.2012.740504

Cialdella-Kam, L., Guebels, C. P., Maddalozzo, G. F., & Manore, M. M. (2014). Dietary intervention restored menses in female athletes with exercise-associated menstrual dysfunction with limited impact on bone and muscle health. Nutrients, 6(8), 3018–3039. doi:10.3390/nu6083018

Cleary, S., Chi, V., & Feinstein, R. (2018). Female athletes: Managing risk and maximizing benefit. Curr Opin Pediatr, 30(6), 874–882. doi:10.1097/MOP.0000000000000700

DePalma, M. T., Koszewski, W. M., Romani, W., Case, J. G., Zuiderhof, N. J., & McCoy, P. M. (2002). Identifying college athletes at risk for pathogenic eating. Br J Sports Med, 36(1), 45–50. doi:10.1136/bjsm.36.1.45

De Souza, M. J., Koltun, K. J., Etter, C. V., & Southmayd, E. A. (2017). Current status of the female athlete triad: update and future directions. Current osteoporosis reports, 15(6), 577-587. doi:10.1007/s11914-017-0412-x

Dueck, C. A., Matt, K. S., Manore, M. M., & Skinner, J. S. (1996). Treatment of athletic amenorrhea with a diet and training intervention program. Int J Sport Nutr, 6(1), 24–40. doi:10.1123/ijsn.6.1.24

Eime, R. M., Harvey, J. T., Sawyer, N. A., Craike, M. J., Symons, C. M., Polman, R. C. J., & Payne, W. R. (2013). Understanding the contexts of adolescent female participation in sport and physical activity. Res Q Exerc Sport, 84(2), 157–166. doi:10.1080/02701367.2013.784846

El Ghoch, M., Soave, F., Calugi, S., & Dalle Grave, R. (2013). Eating disorders, physical fitness and sport performance: A systematic review. Nutrients, 5(12), 5140–5160. doi:10.3390/nu5125140

Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24(4), 230-235. doi:10.1179/2047480615Z.000000000329

Fischer, A. N., Yang, J., Singichetti, B., & Young, J. A. (2017). Menstrual dysfunction in females presenting to a pediatric sports medicine practice. Translational Journal of the American College of Sports Medicine, 2(13), 79-84. doi:10.1249/TJX.0000000000000037

Georgopoulos, N. A., & Roupas, N. D. (2016). Impact of intense physical activity on puberty and reproductive potential of young athletes. In D. Vaamonde, S. S. du Plessis, & A. Agarwal (Eds.), Exercise and human reproduction: Induced fertility disorders and possible therapies (pp. 239–251). New York, NY: Springer New York. doi:10.1007/978-1-4939-3402-7_15

Gibbs, J. C., Williams, N. I., & De Souza, M. J. (2013). Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc, 45(5), 985–996. doi:10.1249/MSS.0b013e31827e1bdc

Glazer, J. L. (2008). Eating disorders among male athletes. Curr Sports Med Rep, 7(6), 332–337. doi:10.1249/JSR.0b013e31818f03c5

Gordon, C. M. (2010). Functional hypothalamic amenorrhea. N Engl J Med, 363(4), 365–371. doi:10.1056/NEJMcp0912024

Hinton, P. S., & Kubas, K. L. (2005). Psychosocial correlates of disordered eating in female collegiate athletes: Validation of the ATHLETE questionnaire. J Am Coll Health, 54(3), 149–156. doi:10.3200/JACH.54.3.149-156

Holtzman, B., Whitney, K. E., Parziale, A., & Ackerman, K. E. (2019). Relationship between age and red-s or female athlete triad risk level. Orthopaedic Journal of Sports Medicine, 7(3), doi:10.1177/2325967119S00011

Joy, E., Kussman, A., & Nattiv, A. (2016). 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. Br J Sports Med, 50(3), 154-162. doi:10.1136/bjsports-2015-095735

Joy, E., De Souza, M. J., Nattiv, A., Misra, M., Williams, N. I., Mallinson, R. J., … Borgen, J. S. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Current Sports Medicine Reports, 13(4), 219–232. doi:10.1249/JSR.0000000000000077

Kilpela, L. S., Blomquist, K., Verzijl, C., Wilfred, S., Beyl, R., & Becker, C. B. (2016). The body project 4 all: A pilot randomized controlled trial of a mixed-gender dissonance-based body image program. Int J Eat Disord, 49(6), 591–602. doi:10.1002/eat.22562

Klein, D. A., & Poth, M. A. (2013). Amenorrhea: an approach to diagnosis and management. Am Fam physician, 87(11), 781-788. Retrieved from

Łagowska, K., Kapczuk, K., Friebe, Z., & Bajerska, J. (2014). Effects of dietary intervention in young female athletes with menstrual disorders. J Int Soc Sports Nutr, 11(1), 21. doi:10.1186/1550-2783-11-21

Łagowska, K., Kapczuk, K., & Jeszka, J. (2014). Nine–month nutritional intervention improves restoration of menses in young female athletes and ballet dancers. Journal of the International Society of Sports Nutrition, 11, 21. doi:10.1186/s12970-014-0052-9

Ljungqvist, A., Jenoure, P., Engebretsen, L., Alonso, J. M., Bahr, R., Clough, A., … Thill, C. (2009). The International Olympic Committee (IOC) Consensus Statement on periodic health evaluation of elite athletes March 2009. Bri J Sports Med, 43(9), 631–643. doi:10.1136/bjsm.2009.064394

Ljungqvist, A., Jenoure, P. J., Engebretsen, L., Alonso, J. M., Bahr, R., Clough, A. F., … Dubi, C. (2009). The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes, March 2009. Clin J Sport Med, 19(5), 347–365. doi:10.1097/JSM.0b013e3181b7332c

Logue, D. M., Madigan, S. M., Heinen, M., McDonnell, S. J., Delahunt, E., & Corish, C. A. (2019). Screening for risk of low energy availability in athletic and recreationally active females in Ireland. Eur J Sport Sci, 19(1), 112–122. doi:10.1080/17461391.2018.1526973

Logue, D., Madigan, S. M., Delahunt, E., Heinen, M., Mc Donnell, S. J., & Corish, C. A. (2018). Low energy availability in athletes: A review of prevalence, dietary patterns, physiological health, and sports performance. Sports Med, 48(1), 73–96. doi:10.1007/s40279-017-0790-3

Loucks, A. B., & Thuma, J. R. (2003). Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women. J Clin Endocrinol Metab, 88(1), 297-311. doi:10.1210/jc.2002-020369

Loucks, A. B., & Callister, R. (1993). Induction and prevention of low-T3 syndrome in exercising women. Am J Physiol, 264(5 Pt 2), R924–R930. doi:10.1152/ajpregu.1993.264.5.R924

Loucks, A. B, & Heath, E. M. (1994). Induction of low-T3 syndrome in exercising women occurs at a threshold of energy availability. Am J Physiol, 266(3 Pt 2), R817-823. doi:10.1152/ajpregu.1994.266.3.R817

Loucks, A. B., Verdun, M., & Heath, E. M. (1998). Low energy availability, not stress of exercise, alters LH pulsatility in exercising women. J Appl Physiol, 84(1), 37–46. doi:10.1152/jappl.1998.84.1.37

Loucks, A. B., Laughlin, G. A., Mortola, J. F., Girton, L., Nelson, J. C., & Yen, S. S. (1992). Hypothalamic-pituitary-thyroidal function in eumenorrheic and amenorrheic athletes. J Clin Endocrinol Metab, 75(2), 514-518. doi:10.1210/jcem.75.2.1639953

Loucks, A. B., Kiens, B., & Wright, H. H. (2011). Energy availability in athletes. J Sports Sci, 29 Suppl 1, S7–S15. doi:10.1080/02640414.2011.588958

Loucks, A. B. (2006). The response of luteinizing hormone pulsatility to 5 days of low energy availability disappears by 14 years of gynecological age. J Clin Endocrinol Metab, 91(8), 3158-3164. doi:10.1210/jc.2006-0570

Manore, M. M., Kam, L. C., & Loucks, A. B. (2007). The female athlete triad: Components, nutrition issues, and health consequences. J Sports Sci, 25 Suppl 1), S61–S71. doi:10.1080/02640410701607320

McArdle, W., Katch, F., & Katch, V. (2010). Exercise physiology: Nutrition, energy, and human performance (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Retrieved from,+W.+D.,+Katch,+F.+I.,+%26+Katch,+V.+L.+(2010).+Exercise+physiology:+Nutrition,+energy,+and+human+performance.+Lippincott+Williams+%26+Wilkins.&ots=MwumX5eq_k&sig=aR76dvZA9

McComb, J. J. R., Qian, X. P., Veldhuis, J. D., McGlone, J. J., & Norman, R. L. (2006). Neuroendocrine responses to psychological stress in eumenorrheic and oligomenorrheic women. Stress, 9(1), 41–51. doi:10.1080/10253890600591678

Meczekalski, B., Katulski, K., Czyzyk, A., Podfigurna-Stopa, A., & Maciejewska-Jeske, M. (2014). Functional hypothalamic amenorrhea and its influence on women’s health. J Endocrinol Invest, 37(11), 1049-1056. doi:10.1007/s40618-014-0169-3

Melin, A. K., Heikura, I. A., Tenforde, A., & Mountjoy, M. (2019). Energy availability in athletics: Health, performance, and physique. Int J Sport Nutr Exerc Metab, 29(2), 152–164. doi:10.1123/ijsnem.2018-0201

Melin, A., Tornberg, Å. B., Skouby, S., Møller, S. S., Faber, J., Sundgot-Borgen, J., & Sjödin, A. (2016). Low-energy density and high fiber intake are dietary concerns in female endurance athletes. Scand J Med Sci Sports, 26(9), 1060–1071. doi:10.1111/sms.12516

Mitchell J. J., Robert-McComb J. J. (2014). Screening for disordered eating and eating disorders in female athletes. In: Robert-McComb J. J., Norman R. L., Zumwalt M. (eds) The active female. New York, NY: Springer. doi:10.1007/978-1-4614-8884-2_13

Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006). Eating Disorder Examination Questionnaire (EDE-Q): Norms for young adult women. Behav Res Ther, 44(1), 53–62. doi:10.1016/j.brat.2004.12.003

Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N., . . . Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med, 52(11), 687-697. doi:10.1136/bjsports-2018-099193

Mountjoy, M, Sundgot‐Borgen, J., Burke, L. M., Carter, S., Constantini, N., Lebrun, C. M., … Ljungqvist, A. (2014). The IOC consensus statement: Beyond the female athlete triad— Relative Energy Deficiency in Sport (RED-S). Br J Sports Med, 48(7), 491-497. doi:10.1136/bjsports-2014-093502

Mountjoy, M., Hutchinson, M. R., Cruz, L., & Lebrun, C. (2008). Female athlete triad coalition position stand on female athlete triad pre participation evaluation. Retrieved from

Nagel, D. L., Black, D. R., Leverenz, L. J., & Coster, D. C. (2000). Evaluation of a screening test for female college athletes with eating disorders and disordered eating. J Athl Train, 35(4), 431–440. Retrieved from

Nattiv, A., Loucks, A. B., Manore, M. M., Sanborn, C. F., Sundgot-Borgen, J., & Warren, M. P. (2007). American College of Sports Medicine position stand. The female athlete triad. Medicine and Science in Sports and Exercise, 39(10),1867–1882. doi:10.1249/mss.0b013e318149f111

Nazem, T. G., & Ackerman, K. E. (2012). The female athlete triad. Sports Health, 4(4), 302–311. doi:10.1177/1941738112439685

Otis, C. L., Drinkwater, B., Johnson, M., Loucks, A., & Wilmore, J. (1997). American College of Sports Medicine position stand: The female athlete triad. Med Sci Sports Exerc, 29(5), 1-9. doi:10.1097/00005768-199705000-00037

Potgieter, S. (2013). Sport nutrition: A review of the latest guidelines for exercise and sport nutrition from the American College of Sport Nutrition, the International Olympic Committee and the International Society for Sports Nutrition. South African Journal of Clinical Nutrition, 26(1), 6–16. doi:10.1080/16070658.2013.11734434

Practice Committee of the American Society for Reproductive Medicine. (2004). Current evaluation of amenorrhea. Fertil Steril, 82 Suppl 1, S33-39. doi:10.1016/j.fertnstert.2004.07.001

Redman, L. M., & Loucks, A. B. (2005). Menstrual disorders in athletes. Sports Med, 35(9), 747–755. doi:10.2165/00007256-200535090-00002

Richard, N., Palmer, C., & Adams, H. P. (2018). Female athlete triad: low energy availability, menstrual dysfunction, altered bone mineral density. Physician Assistant Clinics, 3(3), 313–324. doi:10.1016/j.cpha.2018.02.001

Robert-McComb, J. J., & Loucks, A. B. (2014). The female athlete triad: Key points for health and fitness specialists. ACSM’S Health & Fitness Journal, 18(3), 12–17. doi:10.1249/FIT.0000000000000033

Rodriguez-Ayllon, M., Cadenas-Sánchez, C., Estévez-López, F., Muñoz, N. E., Mora-Gonzalez, J., Migueles, J. H., . . . Esteban-Cornejo, I. (2019). Role of Physical Activity and Sedentary Behavior in the Mental Health of Preschoolers, Children and Adolescents: A Systematic Review and Meta-Analysis. Sports Medicine, 49(9), 1383-1410. doi:10.1007/s40279-019-01099-5

Rogers, M., Vlahovich, N., Hughes, D., Pyne, D., Halson, S., Lovell, G., . . . Drew, M. (2021). 080 The prevalence of indicators of relative energy deficiency in sport (RED-S) in Australian elite and pre-elite female athletes. British Journal of Sports Medicine, 55(Suppl 1), A33. doi:10.1136/bjsports-2021-IOC.76

Scheerder, J., Thomis, M., Vanreusel, B., Lefevre, J., Renson, R., Vanden Eynde, B., & Beunen, G. P. (2006). Sports participation among females from adolescence to adulthood: A longitudinal study. International Review for the Sociology of Sport, 41(3–4), 413–430. doi:10.1177/1012690207077702

Scheid, J. L., & De Souza, M. J. (2010). Menstrual irregularities and energy deficiency in physically active women: the role of ghrelin, PYY and adipocytokines. Cytokines, Growth Mediators and Physical Activity in Children during Puberty, 55, 82–102. doi:10.1159/000321974

Slater, J., Brown, R., McLay-Cooke, R., & Black, K. (2017). Low energy availability in exercising women: Historical perspectives and future directions. Sports Med, 47(2), 207–220. doi:10.1007/s40279-016-0583-0

Speroff, L., & Fritz, M. (2005). Clinical gynecologic endocrinology and infertility (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Retrieved from,+L.,+%26+Fritz,+M.+A.+(Eds.).+(2005).+Clinical+gynecologic+endocrinology+and+infertility.+Lippincott+Williams+%26+wilkins.&ots=Cy2qSbcCDy&sig=3DX1dD7RxOpk97IOALF3bQ8hsvU

Steiner, H., Pyle, R. P., Brassington, G. S., Matheson, G., & King, M. (2003). The College Health Related Information Survey (C.H.R.I.S.-73): A screen for college student athletes. Child Psychiatry Hum Dev, 34(2), 97–109. doi:10.1023/A:1027389923666

Stickler, L. G., Hoogenboom, B. J., & Brown, J. (2019). The impact of nutritional intervention on menstrual dysfunction in female athletes: a systematic review. SN Comprehensive Clinical Medicine, 1(9),669-676. doi:10.1007/s42399-019-00107-z

Takemoto, D. M., & Beharry, M. S. (2015). What’s normal? Accurately and efficiently assessing menstrual function. Pediatr Ann, 44(9), e213-217. doi:10.3928/00904481-20150910-08

Temme, K. E., & Hoch, A. Z. (2013). Recognition and rehabilitation of the female athlete triad/tetrad: A multidisciplinary approach. Curr Sports Med Rep, 12(3), 190–199. doi:10.1249/JSR.0b013e318296190b

Thein-Nissenbaum, J., & Hammer, E. (2017). Treatment strategies for the female athlete triad in the adolescent athlete: Current perspectives. Open Access J Sports Med, 8, 85–95. doi:10.2147/OAJSM.S100026

Thein-Nissenbaum, J. M., Rauh, M. J., Carr, K. E., Loud, K. J., & McGuine, T. A. (2012). Menstrual irregularity and musculoskeletal injury in female high school athletes. J Athl Train, 47(1), 74–82. doi:10.4085/1062-6050-47.1.74

Torstveit, M. K., & Sundgot-Borgen, J. (2005). Participation in leanness sports but not training volume is associated with menstrual dysfunction: A national survey of 1276 elite athletes and controls. Br J Sports Med, 39(3), 141–147. doi:10.1136/bjsm.2003.011338

Troy, K., Hoch, A. Z., & Stavrakos, J. E. (2006). Awareness and comfort in treating the Female Athlete Triad: Are we failing our athletes? WMJ, 105(7), 21–24. Retrieved from

Valliant, M. W. (2016). The female athlete triad and relative energy deficiency in sport: Knowledge of both can improve the health of female athletes. Strength & Conditioning Journal, 38(2), 35–39. doi:10.1519/SSC.0000000000000201

Valliant, M. W., Emplaincourt, H. P., Wenzel, R. K., & Garner, B. H. (2012). Nutrition education by a registered dietitian improves dietary intake and nutrition knowledge of a NCAA female volleyball team. Nutrients, 4(6), 506–516. doi:10.3390/nu4060506

van Eck, C. F., & Fu, F. H. (2018). The benefits of youth sports participation should outweigh the risks. Ann Transl Med, 6(Suppl 1), S11. doi:10.21037/atm.2018.08.44

Vickers, H., Gray, T., & Jha, S. (2018). Amenorrhoea. InnovAiT, 11(2), 80–88. doi:10.1177/1755738017737101

Weaver, C. M., Gordon, C. M., Janz, K. F., Kalkwarf, H. J., Lappe, J. M., Lewis, R., . . . Zemel, B. S. (2016). The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: A systematic review and implementation recommendations. Osteoporos Int, 27(4), 1281–1386. doi:10.1007/s00198-015-3440-3

Weiss Kelly, A. K., Hecht, S., & Council On Sports Medicine And Fitness, (2016). The Female Athlete Triad. Pediatrics, 138(2). doi:10.1542/peds.2016-0922

Winterer, J., Cutler, G. B. Jr., & Loriaux, D. L. (1984). Caloric balance, brain to body ratio, and the timing of menarche. Med Hypotheses, 15(1), 87–91. doi:10.1016/0306-9877(84)90011-2




How to Cite

Quesnel, D. A., Hefner, T. ., Fernandez-del-Valle, M. ., & McComb , J. . (2022). Menstrual dysfunction in youth female athletes and their management in the context of models of energy deficiency. The Health & Fitness Journal of Canada, 15(1), 3–17.