Relative Energy Deficiency in Sport (RED-S)

There’s been increasing talk over the past few years on the topic of body image, eating disorders, and the importance of moving these topics into normal conversation. Some particularly powerful posts have come from Janelle Greer and Jessie Diggins who opened up about the struggles they have faced and overcome. Although there is increasing talk on these topics there are still a lot of unknowns and a general lack of education. Just last month New York Times wrote an article citing normal female development as a “cruel twist” in youth sports, suggesting that girls who develop normally might not be able to maintain their speed. Hopefully with more discussions, research, and the continued growth in female sport there will be an increase in the education of athletes, coaches, and the general public resulting in a healthier environment for female athletes and perhaps greater female athlete retention.

Relative Energy Deficiency in Sport (previously called The Female Athlete Triad)  

Low energy availability, functional hypothalamic amenorrhoea, and osteoporosis (1). What do these three conditions have in common? They form the Female Athlete Triad – a syndrome of three interconnected conditions that occurs when energy intake does not meet energy output (2).  However, in more recent years this condition has been replaced by Relative Energy Deficiency in Sport (RED-S): a complex syndrome caused by insufficient energy intake that effects females and males and has a wide range of negative physiological and psychological consequences including: impaired metabolic rate, decreased bone health, decreased immunity, depression, increased injury risk, and impaired menstrual function (3).

April 2017

I’ve never had a consistent period and usually lose it during the race season. However, after Nationals in 2017 it never came back. At the time I didn’t think too much of it: I’d had a solid Nationals, was feeling fine, and had lost some weight over the course of the ski season which I was happy about because I’d been worried I was overweight – everybody says it’s a good thing to lose weight, right? And people are always pointing out that thinner girls tend to be faster. Training restarted, new goals were set, and I decided that my big goal for 2017/2018 was to finally put on some muscle, an area I had always struggled with. Around this time I went in for an annual appointment with my sports med doctor who diagnosed me with amenorrhoea (abnormal loss of menstruation), something I had never heard of before. However, my BMI was now at a normal level and thus we weren’t sure what was actually causing my amenorrhoea. So, I was referred to see an ultrasound technician, a dietitian, a gynaecologist and get my blood tested.

Because of waiting lists and general busyness these various appointments took place over the course of the summer, fall, and winter.  Thus, training was ongoing and with my goal of gaining muscle and getting stronger I was going to the gym a lot. And, surprise, surprise, I started gaining weight; over the course of the summer I gained just over 10lbs (from around 125-135lb). This I found terrifying. As a society we tend to praise someone who steps on the scale and sees a lower number, so seeing the numbers climb each time I stepped on was to me a sign that I was getting fat and that my body was out of my control. I wasn’t really sure what to do and just ended up worrying about it for the next number of months.

The Dietitian 

To make a long story short, the conclusion was that I was eating a healthy balanced diet but perhaps not refuelling at the proper times (ex. during, immediately after workouts). There were a few things she mentioned that really stuck with me:

  1. It’s super normal to see athletes gain weight over the off season and to lose weight over the race season.
  2. If you’re working to gain muscle, you need to give your body the fuel it needs, and it’s possible that you’ll gain a bit of fat too. If you are under-fueled, your body is just going to try and find energy from other areas, and one of these areas is muscle. (This is what makes refuelling during and after workouts so crucial!)
  3. It’s important to listen to your body’s hunger cues to know when to eat. However, sometimes these hunger cues aren’t reliable, so try to recognize this and keep your body well nourished!
Post Race = Cookie time! (Thanks Sheila!)

After seeing the dietitian I was a bit less worried about my increase in weight but was still concerned. Because of this I decided to start monitoring caloric intake with the plan of cutting things back. This was obviously not the smartest plan, especially because it was a volume block, and resulted in me bonking hard in a workout at the end of the week. That made me second guess my dieting idea and I decided to talk to my coach to get a second opinion.

I’ve been very fortunate to have a coach who, although male, has created an environment where I feel comfortable talking about topics like body image and amenorrhea. He’s also done a good job of making sure that the focus is on health instead of weight: in answer to my question about whether I should be on a diet, he rationally pointed out the importance of properly fueling one’s body. After talking to my dietitian and coach my worry about my weight gain somewhat subsided. But, at the beginning of the race season this worry returned. I wasn’t losing as much weight as I had been hoping to, and I again didn’t properly refuel, woke up in the night starving, and ended up having a pretty crappy race the next day. After the months of worrying and the conversations I finally realized that I had gotten a bit carried away. In my mind I had confounded a lighter weight with a faster time. But, I realized that at the end of the day my goal is to have the fastest time on the race course not the lowest BMI. It can be easy to get caught up in losing weight to potentially be faster in a race or two, but skiing is a long term sport. I don’t want to just race fast this year; I also want to be racing fast four years from now, and that means giving my body the energy it needs now.

At the end of January my period returned. I would lie if I were to say I was excited; periods suck, but I was reminded that this means that my body has enough energy, so check mark!

March 2018

The Gynaecologist 

In February I finally had my appointment with the Gynaecologist. She took a look at my blood test from July and pretty much freaked out about my hormone levels, telling me that I needed to get on birth control to produce a consistent period. Otherwise, I would run the risk of decreased bone density – bone growth and remodelling requires healthy hormones.  However, I wasn’t entirely convinced and decided to consult a number of other individuals before I made the decision of whether birth control was the right choice for me. (I also asked if I could retake the blood test now that my period had returned the previous month.)

I talked to fellow athletes, my coach, and read a bunch of articles on the subject. There are still many unanswered questions on whether hormonal therapy actually increases bone mineral density or reduces stress fracture risk (2). There has also been some concern on birth control having some negative outcomes.  And, I felt like taking birth control to restore my period wouldn’t fix the real problem: If I’m not having my period then perhaps I am not meeting my energy needs and I would rather address the real problem than mask it. When I met with my doctor and we went over my more recent blood tests results my hormone levels had returned to a normal level and she agreed that it was okay to not go on birth control as long as I was getting a period at least every two months.

*Whether or not to go on birth control is a super personal/individual decision and although I decided that it wasn’t the right one for me that doesn’t mean taking birth control is a “wrong” decision. Everyone is different and must do what works best for themselves.



I haven’t been able to get a clear answer on what precisely caused my amenorrhea but I think it was a combination of things; the body is super complex, and I wouldn’t be surprised if it was a combination of not enough energy intake (especially during the race season), the physical stress that I place on my body from all the training/racing, and the mental stress from life in general (#studentathlete). But, although I may not have a clear answer, I did learn a lot; if I could distill it into 3 key takeaways they would be:

  1. Listen to your body. If you’re not getting your period use it as a sign that your body is trying to tell you something – pay attention and talk to your doctor.
  2. Support. Surround yourself with people who will listen to you when you’re feeling insecure or unsure and who will be a rational voice when you can’t be one for yourself.
  3. Development is normal and good. Yes, you may gain some weight but you will also get stronger –  you will not only rock in the gym, but you will also destroy that race course!

Love yourself more cause you, my friend, are worth it.

– Zoë


  1.  Nose‐Ogura, Sayaka, et al. “Management of the female athlete triad.” Journal of Obstetrics and Gynaecology Research (2018).
  2. Kelly, Amanda K. Weiss, and Suzanne Hecht. “The female athlete triad.” Pediatrics (2016): e20160922.
  3. Mountjoy, Margo, et al. “The IOC consensus statement: beyond the female athlete triad—Relative Energy Deficiency in Sport (RED-S).” Br J Sports Med 48.7 (2014): 491-497.

Further Reading