Female athlete health: the evidence base

Updated IOC consensus on Relative Energy Deficiency in Sport (formerly RED-S), including the REDs CAT2 assessment tool.

• Reframes low energy availability as the root cause of a syndrome affecting many body systems, not only bone and menstrual health, in male and female athletes.
• Introduces the REDs Clinical Assessment Tool version 2 (IOC REDs CAT2) to stratify athletes by risk and guide return-to-training decisions.
• Recommends a multidisciplinary approach to prevention, screening and management rather than reliance on any single biomarker.

Our appraisal: An expert consensus (large author panel with structured review) that sets the current framework for assessing energy availability; it standardises language and screening rather than proving that any specific intervention restores health or performance. Treat the CAT2 risk categories as a structured clinical aid, not a validated diagnostic test.

International consensus on the treatment, clearance and return-to-play decisions for the female athlete triad, built around a cumulative risk assessment.

• Defines the triad as the interrelationship of low energy availability, menstrual dysfunction and low bone mineral density, on a spectrum from health to disease.
• Provides a cumulative risk assessment tool that scores athletes across triad components to guide sport clearance and return to play.
• Recommends a multidisciplinary treatment team and prioritises restoring energy availability, usually through increased intake or reduced expenditure.

Our appraisal: Structured expert consensus rather than trial evidence, so its risk-stratification tool organises decision-making without being prospectively validated as an outcome predictor. It remains the most concrete triad-specific guide to clearance, and it complements rather than replaces the broader REDs model.

The American College of Sports Medicine position stand defining the female athlete triad as a spectrum linking energy availability, menstrual function and bone health.

• Recasts the triad as three interrelated spectrums, energy availability, menstrual status and bone mineral density, rather than three discrete disorders.
• Identifies low energy availability, with or without disordered eating, as the driving factor.
• Recommends early screening and intervention to prevent progression to amenorrhoea and osteoporosis.

Our appraisal: A foundational position stand that shaped how the triad is understood; it is expert consensus from 2007 and has since been extended by the 2014 Coalition statement and the broader REDs framework, so read it as origin rather than the current last word.