My periods stopped in a hard block. Will the pill fix it?
Not by the 2025 Triad guideline: it advises against the combined pill to restore periods or bone (Level A); it can mask recovery. A doctor rules out other causes first.
Main caveat: Consensus, not a systematic review. Section teams reviewed the literature and the panel graded its own statements.
This is the second of two papers updating the 2014 Female Athlete Triad Coalition consensus on treatment and return to play, and it says it supersedes it. The Triad is energy status, reproductive function and bone health, each on a continuum from healthy to pathological, driven by energy deficiency with or without disordered eating.
The update makes five changes to the adult model: "energy deficiency" replaces "low energy availability" (energy availability becomes one indicator among low or falling weight, low BMI and "metabolic compensation" — a lowered resting metabolic rate and low T3, IGF-1 and leptin); bone stress injuries join the bone continuum; oligomenorrhoea of hypothalamic origin joins amenorrhoea as functional hypothalamic oligo/amenorrhoea (FHOA), with a warning that oligomenorrhoea is often hyperandrogenic rather than energy-driven; induction and recovery are drawn at different rates, induction faster; and bone recovery carries a question mark.
A separate adolescent model and risk tool are added. A single energy-availability threshold (for example under 30 kcal/kg fat-free mass a day) is not recommended, because menstrual disturbances occur above it and energy availability is hard to measure outside the laboratory.
Functional hypothalamic oligo/amenorrhoea, the energy-related cause of missing or infrequent periods, is "largely a diagnosis of exclusion": pregnancy, thyroid disease, high prolactin, primary ovarian insufficiency, other causes of low gonadotropins, hyperandrogenic conditions including PCOS, outflow obstruction and medications (depot medroxyprogesterone, the progestin IUD, glucocorticoids and others) are ruled out first.
Recovery means successive cycles under 36 days with rising ovarian hormones (Level A), because in the authors' REFUEL trial periods often returned within months while ovulation and hormone exposure lagged a year of refeeding; an extra 300-600 kcal a day will likely start recovery (Level B); bone density did not improve in 12 months of refeeding.
The combined pill is not recommended to restore periods or bone (Level A); the pill, and progestin IUDs or implants offered as alternative contraception, may mask the return of periods (Level B); when hormone replacement is indicated after 6-12 months of energy repletion without spontaneous periods, physiologic transdermal 17β-estradiol with a progestin is the recommended form (Level A).
For clearance, the six-factor cumulative risk assessment (dietary restraint, BMI/weight, delayed menarche, oligo/amenorrhoea, low bone density, bone stress injury) predicts bone stress injury (Level B).
Our reading: this fills the base's gap for a clinical guideline on working up and treating missing periods and Triad-related bone loss in athletes (the base held the IOC REDs framework, REF-341, and the AAP report on girls, REF-1066) — it backs the base's "watch the signs, not the arithmetic" stance with a consensus, adds that hormonal devices other than the pill can mask, and makes the missing-period rule a referral rule with other causes excluded first; it does not cover the life stages (breastfeeding, perimenopause) for which the base's missing-period lines now carry an exception (2026-10-28), so that carve-out remains physiology and the base's inference.
Protocol
Design: consensus statement and clinical guideline; Part 2 of the 2025 update (Part 1: state of the science and the adolescent model). The text says these recommendations "supersede the previous 2014 Triad Consensus Statement".
Panel: "An independent expert panel of 16 individuals" (15 authors are listed) covering eating disorders, psychology, exercise physiology, nutrition, women's health, paediatric and adult endocrinology, bone, orthopaedics, physical therapy, reproductive medicine and sports medicine; co-chairs De Souza and Williams.
Process: one in-person meeting, video meetings and e-mail; section teams reviewed the literature and drafted evidence-based statements; wording and grades agreed in group discussion; confidential online voting (agree / neutral / disagree), repeated after revision until every statement had more than 85% "agree" and no "disagree"; peer-review changes re-voted. No systematic search strategy, inclusion criteria or risk-of-bias appraisal is described.
Grading (as defined in the paper): Level A — consistent pattern of findings based on substantial data from RCTs and/or observational studies; Level B — strong evidence from RCTs and/or observational studies with some inconsistent results; Level C — a smaller number of observational and/or uncontrolled or non-randomised trials, generally suggestive; Level D — insufficient evidence for A-C, panel consensus judgment.The taxonomy is the one used in ACSM position stands and by the Agency for Healthcare Research and Quality, in which RCTs and observational data are both "the highest level of evidence".
What is graded (our count): 29 evidence-based statements in the text (4 Level A, 22 Level B, 3 Level C) plus graded recommendation tables — DXA indications for adults and adolescents, DXA sites and low-BMD definitions (Tables 5-8, Level B each) and hormone and drug therapy (Table 9: 3 Level A, 2 Level B, 1 Level C). No statement is graded Level D.Much of the text (the move away from an energy-availability threshold, the diagnostic work-up, the risk-tool scoring, adolescent return to play after an eating disorder) is ungraded narrative.
Scope: screening, diagnosis and treatment of energy deficiency, eating disorders and disordered eating, menstrual dysfunction and bone health, and clearance and return to play, for adolescents and adult (premenopausal) women.
Funding and interests (as printed): "No funding was involved in the manuscript preparation or completion." The process section says "No funding was involved in the recruitment or work of the panel.No conflicts of interest were declared." The competing-interests declaration then reads: "Dr. De Souza is a consultant for the California Prune Board, Regeneron Pharmaceuticals, and for the CocaCola Company." Dr. Gorrell is supported by the National Institutes of Mental Health and the Brain & Behavior Research Foundation (NARSAD Young Investigator Award)."Dr. Misra has served as a key opinion leader for Lumos Pharmaceuticals, consultant for Regeneron, receives study drug donation from Tonix Pharmaceuticals, and honoraria from UpToDate." Dr. Fredericson holds grants related to the subject (co-principal investigator, Pac-12 Conference grant on bone health and bone stress injuries in Pac-12 distance runners; co-investigator, US Department of Defense shockwave-therapy trial for stress fractures) and is "an Advisory Board member of Hinge Health".Dr. Nattiv has received support as co-principal investigator of the same Department of Defense and Medical Technology Enterprise Consortium trial and the Pac-12 grant, and as a consultant for the National Football League Research and Innovation Committee. Dr. Salamunes is supported by Fulbright Brazil and CAPES."The other authors declare that they have no conflicts of interest relevant to the content of this article." A disclaimer covers the Uniformed Services University, the Department of Defense and the Henry M. Jackson Foundation.
Key Results
The graded recommendations most relevant to an athlete's questions (grades as printed):
| Statement (shortened; quoted where in quotation marks) | Grade |
|---|---|
| Energy deficiency is best shown by serial decreases in weight, % expected body weight, BMI (BMI-for-age in adolescents) or energy availability, or rising dietary restriction scores, and where resources allow metabolic markers (RMR ratio, T3, IGF-1, leptin, ghrelin); measures most useful serially at the same time of day | B |
| From a single time point, high risk if weight under 85% of expected, BMI under 17.5 kg/m², energy availability "much less than 45" kcal/kg fat-free mass a day, adolescent BMI-for-age under the 5th percentile, or a low RMR ratio or T3 | B |
| Eating-attitude questionnaires (drive for thinness, dietary restraint) are useful proxies of energy deficiency; compulsive exercise, inadvertent undereating and time-restricted eating are associated with it | B; C |
| "All female athletes should be screened for Triad risk factors"; the Preparticipation Physical Evaluation can assess bone health, menstrual dysfunction and eating risk | B |
| Athletes can have any type of eating disorder at any weight; atypical anorexia nervosa may not present at a low weight | A; A |
| In some exercising women with menstrual disturbances, energy deficiency may co-occur with hyperandrogenaemia | B |
| Define reproductive recovery as successive cycles under 36 days with rising ovarian steroids, not the first period | A |
| An extra 300-600 kcal a day will likely start reproductive recovery; menstrual history, baseline status and weight, relapse and psychosocial stress predict timing and success | B |
| Reverse energy deficiency (more food, better nutrition and/or less exercise energy expenditure) to restore weight and periods; optimise calcium and vitamin D | B; B |
| A multidisciplinary team, at least a physician and a registered (preferably sports) dietitian | A |
| Continue non-drug therapy for at least 6-12 months before other therapies unless bone worsens or new fractures arise | C |
| DXA for adults with at least one high-risk factor — among them "No menses for > 90 days", fewer than 6 menses in 12 months, a restrictive eating disorder, BMI under 17.5, menarche at 15 or later, a prior Z-score of −2.0 or lower, or a high-risk (or two low-risk) bone stress injury — or two moderate-risk factors, or 6 months or more on bone-affecting drugs including depot medroxyprogesterone acetate | B |
| Low bone density: Z-score under −1.0 in weight-bearing sports, −2.0 or lower in non-weight-bearing sports | B |
| Oestradiol with a progestin if periods do not return after 6-12 months at a healthy weight / energy replete, particularly with worsening bone or new fractures | A |
| "We recommend against using combined oral contraceptive pills to re-establish cyclic menses or improve bone density" | A |
| Caution pill users that it "may mask spontaneous menstrual resumption" and does not improve bone; progestin IUDs or implants as alternative contraception, "although this approach may mask menstrual resumption" | B |
| Physiologic transdermal 17β-estradiol with a cyclic or continuous progestin as hormone replacement | A |
| No androgen replacement or recombinant leptin | B |
| Non-hormonal bone drugs only with a low Z-score plus a significant fracture history and no response to 6-12 months of non-drug and hormone therapy, or severe repeated fractures | C |
| Risk factors add up for low bone density and bone stress injury; the Coalition's cumulative risk score predicts bone stress injury, especially at trabecular-rich sites | B |
| Lean-sport athletes have more Triad risk factors; higher MRI grade and high-risk sites (femoral neck, navicular, anterior tibia, fifth metatarsal) delay return | B |
| Objective signs of prolonged metabolic compensation mean at least "Provisionally Cleared" | C |
Numbers behind the statements:
Refeeding (REFUEL RCT, oligo/amenorrhoeic exercising women, 12 months): energy intake +330 ± 65 kcal a day (+18 ± 4%) improved menstrual regularity, with weight +4.9%, fat mass +18% and T3 +16%; most of those who recovered did so in the first 3 months, but 12 months did not re-establish regular ovulatory cycles or normal hormone exposure; at about 350 kcal a day, bone density did not improve at any site (the hip fell).Bone-turnover indices moved in a favourable direction, not significantly (p > 0.05).
Recovery definitions (Table 4): occurrence of menses, ≥1, ≥2 or ≥3 cycles under 36 days; only at ≥3 is an increase in ovarian steroid exposure "more likely".
Hormone RCT (oligo/amenorrhoeic athletes 14-25 years; [REF-576] in the base): a 100 µg transdermal 17β-estradiol patch with cyclic micronised progesterone raised bone density at the spine (2.75%), femoral neck (5.25%) and total hip (1.85%) against the pill (30 µg ethinyl estradiol with desogestrel) or no treatment; the pill raised SHBG and suppressed IGF-1, the patch did not.
Risk score: six items scored 0-2. In 239 collegiate athletes, 29% scored moderate or high risk, with 2.6 and 3.8 times the likelihood of a bone stress injury; in a 4-year prospective study of female runners each extra point went with 13% more risk (95% CI 1-26%); each point raised the risk of a trabecular-rich injury by 26% and a cortical-rich one by 14% (p = 0.054).
Time course (narrative): at least 6-12 months of non-drug treatment for periods and 12 months or more to see bone improve; calcium 1000-1300 mg and vitamin D 600 IU a day as the minimum intake.
Return to play: anorexia nervosa with BMI under 16 or moderate-severe bulimia (purging more than four times a week) — categorically restricted until treated (panel recommendation in the clearance figure, ungraded).
Things that do not add up: the DXA statement is graded Level B in the text and Level A in the summary Table 12; the text says "All evidence-based statements are compiled in Table 12", but Table 12 omits the hormone and drug recommendations of Table 9; the panel is 16 individuals with 15 authors listed; the process section says "No conflicts of interest were declared" while the declarations list industry consultancies.
Mechanisms
Measured (in the trials cited): a moderate increase in energy intake for 12 months raised menstrual frequency within months while ovulation, ovarian hormone exposure and bone density lagged; induction of menstrual disturbance by diet and exercise within 3 months went with weight loss, lower RMR and lower T3, IGF-1 and leptin, in proportion to the energy deficit; transdermal oestradiol raised bone density where the oral pill did not.
Authors' interpretation: energy deficiency suppresses the hypothalamic-pituitary-ovarian axis, and the resulting low oestrogen independently harms bone; the oral pill fails for bone while the patch works partly because only the pill raised SHBG and suppressed IGF-1 (with other bone-signalling changes on the patch); menses can return before ovulation does, so the first period is not recovery; induction and recovery run at different rates (in the trials cited, disturbance appeared within 3 months while 12 months of refeeding did not restore ovulatory cycles; "faster" is our reading); a single energy-availability cut-off misclassifies because menstrual disturbance occurs above it and free-living energy availability is hard to measure; gynaecological maturity (gynaecological age 14 years or more) may protect against energy-related menstrual disturbance, and psychosocial stress may add to it.
Authors' interpretation (position): the REDs model (REF-341) includes outcomes "for which no RCTs are available to support their causal link to low EA" and is applied to men without causal data, while its highest-risk indicators are the Triad components; this is the Coalition's position in a dispute between frameworks, not a finding.
Inference: on the combined pill the monthly bleed is a withdrawal bleed that comes regardless of energy status, so it says nothing about recovery; with a progestin IUD or implant, periods may be light or absent by design. Either way, menstrual status stops being a usable sign, which is why the risk tool scores the history from before the method was started.
Practical Application
My periods stopped in a hard block. Will the pill fix it? Not by the 2025 Triad guideline: it advises against the combined pill to restore periods or bone (Level A); it can mask recovery. A doctor rules out other causes first.
A missing or lengthening period is a doctor's work-up, not only a fuelling question: the guideline calls FHOA "largely a diagnosis of exclusion" — pregnancy, thyroid disease, high prolactin, ovarian insufficiency, PCOS and other hyperandrogenic conditions, and medications are ruled out first — and adds that oligomenorrhoea "has been proposed to be more commonly related to hyperandrogenism than energy deficiency".The base's lines on a missing period (SYNTH-37 referral lines; SYNTH-54 stop rules and REF-748, "a fuelling question first"; the PHYS-32 card) are right that in a young athlete in hard training energy is the first suspect (the Triad is energy-driven), but by this guideline the athlete still goes to a physician, who decides the cause; since 2026-10-28 they say so (not from this paper; the base's own practice): SYNTH-37 reads "Missing cycles → a doctor's work-up", with low energy availability the first suspect in a young athlete in a hard block or a cut, and SYNTH-54 and REF-748 add "a doctor's work-up all the same".
Life stages are outside this guideline: it names pregnancy only as a cause to rule out (with a pregnancy test) and says nothing on breastfeeding or perimenopause.That a period can be absent because of pregnancy, while breastfeeding or with the irregular cycles of the menopause transition, and that those should not be labelled REDs, is physiology and the base's inference, not this paper's; the guideline's only age-related hint is that gynaecological maturity may make energy-related loss of periods less likely, which argues for weighing other causes more in older athletes (inference).The first year after birth: REF-1394; menopause hormone therapy: REF-1406.
Contraception hides the signal: the base said the pill can mask amenorrhoea (REF-341 entry; SYNTH-54); this guideline extends the caution to progestin IUDs and implants (Level B), which SYNTH-54 and SYNTH-37 now carry, and tells clinicians to score menstrual risk from the history before contraception began.Not from this paper; the base's own practice: on any hormonal method, ask about weight, eating and bone injuries rather than relying on periods. Which method to use, start or stop is a clinician's decision.
The first period back is not the finish line: recovery counts as several consecutive cycles under 36 days with rising hormones (Level A); in the refeeding trial an extra 300-600 kcal a day started recovery (Level B), but bone did not improve within 12 months of refeeding. Not from this paper; the base's own practice: keep the extra fuelling going after periods return and do not read one cycle as clearance to cut again.
Screening questions to carry: the Preparticipation Physical Evaluation asks about weight worry, attempts or advice to gain or lose weight, special diets or avoided food groups, past eating disorders, age at first period, last period, number of periods in the past 12 months, and past stress fractures (Level B for screening all female athletes). They overlap the base's screen (SYNTH-54: missed or lengthening periods, bone stress injuries).
No single kcal number: a threshold such as 30 kcal/kg fat-free mass a day "is not recommended" for diagnosis; the base's PHYS-32 already lists a universal cut-off as contested, and this consensus backs that.
What it is good for as a source: the current clinical framework for the Triad — what counts as energy deficiency, how a missing period is worked up, what recovery means, which hormonal approaches the clinicians recommend for or against and how strongly, when to scan, and how risk is scored for clearance. What it does not show: anything about pregnancy, the year after birth, perimenopause or men; a validated energy-availability number; that the risk score's updated version (with substitutions for contraception users or missing DXA) has been validated — the authors say that work remains.
Limitations
Consensus, not a systematic review. Section teams reviewed the literature and the panel graded its own statements; no search strategy, inclusion criteria or appraisal are reported, and much of the guidance (the threshold change, the diagnostic work-up, the updated risk tool) is ungraded narrative.
Self-citation and a framework dispute. Key reproductive and bone statements rest mainly on the authors' REFUEL trial and the risk tool on studies by panel members; the text argues against the REDs model. The base treats those passages as the Coalition's position.
Transfer. Hormone and drug evidence includes trials in adolescents and young women with anorexia nervosa, not athletes; the hormone RCT in athletes was 14-25-year-old weight-bearing athletes.
Who is not covered. Pregnancy (only ruled out), the breastfeeding months, perimenopause and men. Adolescent recommendations come with their own tool.
Internal inconsistencies in grading and reporting (DXA grade B vs A; hormone statements missing from the summary table; 16 panellists vs 15 authors; "No conflicts of interest were declared" vs the declarations).
Funding and interests: no funding; several authors declare consultancies or roles with pharmaceutical companies (Regeneron, Lumos, Tonix), a food board (California Prune Board), a beverage company (Coca-Cola), a digital physiotherapy company (Hinge Health), UpToDate and the NFL, and grants from the Pac-12 Conference and the US Department of Defense, as printed above. No device maker or data platform is named.
How this entry was checked and changed
Why this level
a major consensus and clinical guideline (rubric: consensus / position statement = A, as for REF-1066 and REF-341). Held below A+ because no systematic search or appraisal is described (the rubric's A+ needs a governing-body consensus built on systematic review), the panel grades its own statements, and several key statements rest mainly on the authors' own trials (the REFUEL refeeding RCT) or, for hormone therapy, partly on trials in adolescents and young women with anorexia nervosa. A grade in this entry (Level A, B, C) is the guideline's own grade of a statement, not the base's level
Full text (checked 2026-10-28)
Evidence Level A: Consistent pattern of findings based on substantial data from RCT(s) and/or observational studies; Level D: Insufficient evidence for categories A–C; panel consensus judgment (full text)
An independent expert panel of 16 individuals; consensus when > 85% of writers "agreed" with no instances of "disagree" (full text)
The use of an EA "threshold" (e.g. < 30 kcal/kg FFM/day), is not recommended due to more recent data demonstrating that menstrual disturbances occur in exercising women at EA levels above this threshold (full text)
Single time point: body weight < 85% of expected body weight, or BMI is < 17.5 kg/m^−2, EA is much less than 45 kcal∙kg/FFM^−1∙day ^−1; Grade: Level B (full text)
Practitioners must rule out pregnancy and other endocrinopathies to confirm a diagnosis in athletes and exercising women, and as such, FHOA is largely a diagnosis of exclusion; rule out medications such as depot medroxyprogesterone acetate and the progestin releasing intrauterine device (full text)
Oligomenorrhea, in general, has been proposed to be more commonly related to hyperandrogenism than energy deficiency (full text)
A more advanced gynecological age may reduce an individual's susceptibility; protective effect of gynecological maturity, for example, gynecological age ≥ 14 years (full text)
Reproductive recovery: the goal of achieving successive menstrual cycles with lengths of < 36 days and increasing ovarian steroid concentrations. Grade: Level A; Definition 4: ≥ 3 cycles of < 36 days (full text)
REFUEL: a modest increase in daily energy intake (330 ± 65 kcal/day, + 18 ± 4%) for 12 months improved menstrual regularity, with increased body weight (4.9%), fat mass (18%), and TT3 (16%) (full text)
A nutritional intervention designed to increase energy intake between 300 and 600 kcal/day will likely initiate reproductive recovery. Grade: Level B (full text)
After a 12-month intervention (REFUEL RCT) of approximately 350 kcal/day in oligo/amenorrheic exercising women, BMD did not improve at any site (full text)
DXA in adults: No menses for > 90 days OR history of < 6 menses over the preceding 12 months at irregular and inconsistent intervals of 42–90 days after 1–2 years post menarche; ≥ 6 months on medications that may impact bone, such as Depot medroxyprogesterone acetate; Evidence Grade: Level B (full text)
We recommend against using combined oral contraceptive pills to re-establish cyclic menses or improve bone density; Evidence Grade: Level A (full text)
Pill users cautioned that these medications may mask spontaneous menstrual resumption; alternative methods include progestin containing IUDs or implants although this approach may mask menstrual resumption; Evidence Grade: Level B (full text)
We recommend using physiologic replacement doses of transdermal 17β-estradiol with a cyclic or continuous progestin (for endometrial protection) as hormone replacement; Evidence Grade: Level A (full text)
Patch group: increases in BMD at the spine (2.75%), femoral neck (5.25%), and total hip (1.85%) compared to those receiving the pill or no treatment (full text)
239 collegiate athletes: 29% moderate or high Triad CRA scores, 2.6 and 3.8 greater likelihood of a BSI; each 1-point increase associated with a 13% increased risk for BSI (95% CI: 1–26% increase in risk) (full text)
Calcium and vitamin D: 1000–1300 mg daily of elemental calcium and 600 IUs daily of vitamin D (full text)
"Dr. De Souza is a consultant for the California Prune Board, Regeneron Pharmaceuticals, and for the CocaCola Company"; "No funding was involved in the manuscript preparation or completion" (full text)