2025 Update to the Female Athlete Triad Coalition Consensus Statement Part 2 : Clinical Guidelines for Screening, Diagnosis, Treatment, and Return to Play for Adolescents and Adults

The 2025 Update to the Female Athlete Triad Coalition Consensus Statement, Part 2 provides comprehensive, evidence-based clinical guidelines for the screening, diagnosis, treatment, and return-to-play decision-making for adolescents and adults affected by the Female Athlete Triad (Relative Energy Deficiency Syndrome).

Building on Part 1 of the update, this paper reflects over a decade of advancing research and revises prior recommendations to better align with current scientific understanding. Central to the update is a shift away from a rigid energy availability threshold toward a more nuanced model of energy deficiency, recognizing individual variability in physiological response.

The authors emphasize that moderate increases in caloric intake and modest weight gain can reverse energy deficiency related menstrual disturbances, however, restoration of menses alone does not reliably indicate recovery of ovulatory function or normalization of ovarian hormone production until multiple consecutive, regular cycles occur.

The updated guidelines expand the Triad’s bone health spectrum to include bone stress injuries and provide refined recommendations for both non-pharmacological and pharmacological management of low bone density, including discussion of transdermal versus oral estrogen delivery.

Revised diagnostic and treatment frameworks for functional hypothalamic oligo/amenorrhea are presented, with attention to confounding factors such as hyperandrogenemia, psychological stress, and gynecological age.

Importantly, the statement highlights that adolescents represent a distinct clinical population with unique vulnerabilities, necessitating age-specific approaches to diagnosis, treatment, and clearance for sport participation. Return to play decisions are grounded in a risk stratification model that integrates medical, nutritional, psychological, and sport-related factors.

All recommendations are graded according to the strength of available evidence, underscoring the Coalition’s commitment to rigorous, clinically actionable guidance for healthcare professionals caring for female athletes across the lifespan.

Williams NI, De Souza MJ, Misra M, Nattiv A, Joy E, Barrack M, Ricker EA, Gorrell S, Koltun KJ, O'Donnell E, Mallinson RJ, Salamunes ACC, Woodruff K, Fredericson M, Plessow F. 2025 Update to the Female Athlete Triad Coalition Consensus Statement Part 2: Clinical Guidelines for Screening, Diagnosis, Treatment, and Return to Play for Adolescents and Adults. Sports Med. 2025 Dec 31. doi: 10.1007/s40279-025-02332-0. Epub ahead of print. PMID: 41474492.