Article RETRACTED due to malpractice A systematic review of risk factors, diagnostic criteria, and management strategies for the female athlete triad in endurance sports
DOI:
https://doi.org/10.47197/retos.v82.118154Keywords:
Female Athlete Triad, Low Energy, Bone Mineral Density, Health, WomenAbstract
Background: The Female Athlete Triad and Relative Energy Deficiency in Sport (RED-S) remain significant health concerns that affect performance and long-term wellbeing in female athletes. Although individual components of the Triad are well studied, integrated evidence from recent research remains limited.
Objective: To systematically review and synthesize evidence from the most relevant observational studies examining the prevalence, risk factors, and physiological outcomes related to the Female Athlete Triad/RED-S.
Methods: A systematic review adhering to PRISMA 2020 guidelines was conducted using five databases (PubMed, Scopus, Embase, Web of Science, and Google Scholar). Studies from 2000 to 2024 were included if they focused on endurance athletes and addressed at least one component of the Triad. Ten empirical studies met the eligibility criteria. Data were extracted and narratively synthesized due to study heterogeneity.
Results: Most studies (7/10) demonstrated high methodological quality. Low energy availability was consistently associated with menstrual dysfunction and reduced bone mineral density, while validated screening tools such as the LEAF-Q showed strong applicability for early detection. Psychological factors, dietary behaviors, and training load were frequently implicated as risk modifiers. Despite heterogeneity in assessment methods, convergent evidence supports the multidimensional nature of Triad/RED-S risks. Limited longitudinal data and inconsistent diagnostic criteria were common limitations across studies.
Conclusion: The findings reinforce that low energy availability is a primary driver of Triad/RED-S manifestations and that early screening and multidisciplinary monitoring are critical for athlete health. Future research should focus on standardized diagnostic measures, longitudinal outcomes, and diverse athletic populations to strengthen evidence-based prevention strategies.
References
Ackerman, K. E., Eguiguren, M. L., & Barrack, M. T. (2016). Risk Biotypes And The Female Athlete Triad. In Exercise and Human Reproduction (pp. 161–180). Springer. https://doi.org/10.1007/978-1-4939-3402-7_13
Angelidi, A. M., Stefanakis, K., Chou, S. H., & Mantzoros, C. S. (2024). Relative Energy Deficiency in Sport (REDs): Endocrine Manifestations, Pathophysiology and Treatments. Endocrine Reviews, 45(5), 676–703. https://doi.org/10.1210/endrev/bnae011
Barrack, M. T., Ackerman, K. E., & Gibbs, J. C. (2013). Update on the Female Athlete Triad. Current Re-views in Musculoskeletal Medicine, 6(2), 195-204. DOI: 10.1007/s12178-013-9168-9
Beaudry, A., Rizzone, K., Davis, S., Harvey, T., Gordon, P., & Chetlin, R. (2022). Female Athlete Triad Recognition and Knowledge of Collegiate Cross-Country Coaches. Journal of Women's Sports Medicine, 2(3), 112-124. https://doi.org/10.53646/jwsm.v2i2.31.
Cabre, H. E., Moore, S. R., & Smith-Ryan, A. E. (2022). Relative Energy Deficiency in Sport (RED-S): Sci-entific, Clinical, and Practical Implications for the Female Athlete. Deutsche Zeitschrift für Sportmedizin, 73(7), 308–316. https://doi.org/10.5960/dzsm.2022.546
Casey, E. K. (2021). The Female Athlete Triad/Relative Energy Deficiency in Sports. In The Female Ath-lete (pp. 295–310). Elsevier.
Finn, E. E., Tenforde, A. S., Fredericson, M., et al. (2021). Markers of Low Iron Status Are Associated With Female Athlete Triad Risk Factors. Medicine & Science in Sports & Exercise, 53(8), 1721–1728. https://doi.org/10.1249/MSS.0000000000002616
Gibbs, J. C., Williams, N. I., & De Souza, M. J. (2013). Prevalence Of Individual And Combined Compo-nents of the Female Athlete Triad. Medicine & Science in Sports & Exercise, 45(5), 985–996. https://doi.org/10.1249/MSS.0b013e31827f6a6b
Hutson, M. J., O’Donnell, E., Brooke-Wavell, K., Sale, C., & Blagrove, R. C. (2021). Effects of Low Energy Availability on Bone Health in Endurance Athletes and High-Impact Exercise as A Potential Countermeasure: A Narrative Review. Sports Medicine, 51(3), 391-403. https://doi.org/10.1007/s40279-020-01396-4
Khan, K. M., Liu-Ambrose, T., Sran, M. M., et al. (2002). New Criteria for Female Athlete Triad Syn-drome? British Journal of Sports Medicine, 36(1), 10–13. https://doi.org/10.1136/bjsm.36.1.10
Logue, D., Madigan, S. M., Delahunt, E., Heinen, M., McDonnell, S. J., & Corish, C. A. (2018). Low Energy Availability in Athletes: A Review of Prevalence, Dietary Patterns, Physiological Health, and Sports Performance. Sports medicine, 48(1), 73-96.
Melin, A., Tornberg, Å. B., Skouby, S., Faber, J., Ritz, C., Sjödin, A., & Sundgot-Borgen, J. (2014). The LEAF questionnaire: A Screening Tool for the Identification of Female Athletes at Risk for the Female Athlete Triad. British journal of sports medicine, 48(7), 540-545.
Mountjoy, M., Sundgot-Borgen, J., Burke, L., et al. (2014). The IOC consensus statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502
Nose-Ogura, S., Harada, M., Hiraike, O., et al. (2018). Management of the Female Athlete Triad. Journal of Obstetrics and Gynaecology Research, 44(12), 2129–2136. https://doi.org/10.1111/jog.13614
Pienaar, M. (2023). Nutritional Habits and the Relationship With RED-S Of Female Endurance Runners in Johannesburg [Master’s dissertation, University of Witwatersrand]. https://wiredspace.wits.ac.za/handle/10539/34523
Reed, J. L., De Souza, M. J., & Williams, N. I. (2011). Bone Mineral Density and Menstrual Status in Colle-giate Athletes. Journal of Clinical Endocrinology & Metabolism, 96(6), 1880–1887.
Segovia, N., Hastings, K., Skorseth, P., et al. (2020). Prevalence Of Female Athlete Triad Risk Factors and Iron Supplementation Among High School Distance Runners: Results from A Triad Risk Screen-ing Tool. Orthopaedic Journal of Sports Medicine, 8(9), 1–9. https://doi.org/10.1177/2325967120959725
Slater, J., Brown, R., McLay-Cooke, R., & Black, K. (2017). Low Energy Availability in Exercising Women: Historical Perspectives and Future Directions. Sports Medicine, 47(2), 207-220. https://doi.org/10.1007/s40279-016-0583-0
Tenforde, A. S., Carlson, J. L., Chang, A., et al. (2017). Association of the Female Athlete Triad Risk As-sessment Stratification with the Development Of Bone Stress Injuries in Collegiate Athletes. The American Journal of Sports Medicine, 45(6), 1540–1547. https://doi.org/10.1177/0363546516676262o
Torstveit, M. K., & Sundgot-Borgen, J. (2005). The Female Athlete Triad Exists in Both Elite Athletes and Controls. Medicine & Science in Sports & Exercise, 37(1), 144–153. https://doi.org/10.1249/01.MSS.0000150136.67225.1B
Warrick, A. E., Hassid, B., Coleman, B., Cansino, C., & Faustin, M. (2023). Multidisciplinary Physician Sur-vey Assessing Knowledge of The Female Athlete Triad and Relative Energy Deficiency In Sport. Journal of Eating Disorders, 11(1), 70. https://doi.org/10.1186/s40337-023-00800-4
Warrick, A., Irish, J., & Morgenroth, D. (2020). The Female Athlete Triad: A Review of Current Litera-ture. Current Reviews in Musculoskeletal Medicine, 13(4), 458–467. https://doi.org/10.1007/s12178-020-09645-8
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