MILAN, Italy — If social media from the Milan‑Cortina 2026 Winter Olympics collect likes on videos of athletes rating pasta, pizza, and tiramisu in the Olympic village cafeterias, the nutritional reality for many female athletes is far more concerning. The athletes we see appearing light and graceful in figure skating, those who launch from ski-jumping ramps and those competing in endurance events such as cross‑country skiing — disciplines in which a low body‑weight‑to‑power ratio can be advantageous — are among the most at risk for energy deficiency caused by highly restrictive diets combined with intense training. Prolonged inadequate caloric intake disrupts ovarian function and estrogen production, compromising the normal process of bone remodeling and increasing the risk for osteoporosis and fractures. Low energy availability, menstrual dysfunction, and altered bone remodeling constitute the syndrome known as the “female athlete triad.”

In December of last year, ahead of the Games, the Female Athlete Triad Coalition, an international nonprofit organization of health professionals, published a two‑part consensus statement: The first reviews the latest research findings on the topic, and the second lays out recommendations for appropriate and timely treatment.

The Mechanism

Adipose tissue is not merely an inert storage depot but a true endocrine organ. “It secretes adipokines, hormones that act on the hypothalamus‑pituitary‑gonadal axis,” explained Sabrina Corbetta, associate professor of endocrinology at the University of Milan. “If the percentage of body fat is too low, adipokine production falls and the chemical signaling that controls ovarian function is altered.”

The consequences vary depending on the extent and duration of the energy deficit. They range from menstrual irregularities to complete amenorrhea and cessation of estrogen production by the ovaries, the endocrinologist continued. “Bone health depends on estrogen action. Prolonged hormone deficiency interferes with bone turnover: Old bone matrix is resorbed, while formation of new bone decreases. The result is osteoporosis and an increased risk of fractures, including micro stress fractures caused by repeated application of excessive loads during training. These small injuries, which often affect the metatarsals, the tibias, and the rib cage, cause inflammation and pain.”

Adolescents at Greatest Risk

The Female Athlete Triad Coalition’s consensus statement pays particular attention to very young athletes engaged in competitive sports. Energy deficiency can have more severe consequences for bodies that are still developing. “By about age 25, an individual reaches the maximum bone density allowed by their genetic potential and other factors. After that peak, bone density stabilizes and then declines with age,” Corbetta explained. The higher the peak at age 25, the lower the risk for osteoporosis later in life. Dietary restrictions and reduced estrogen production during adolescence lower that peak bone mass and therefore increase future osteoporosis risk. We have no evidence of full recovery later; this is, therefore, an irreversible harm.”

Prevention is essential for young athletes entering competitive sports.It includes adapting to a balanced, personalized diet and, when necessary, supplements such as calcium and vitamin D to strengthen bones. When there is a significant estrogen deficiency, taking an estrogen‑progestin oral contraceptivemay not be sufficient. Sometimes hormone replacement therapy, preferably administered transdermally.

The Psychological Component

Eating disorders and dysfunctional behaviors such as compulsive exercise can also contribute to the energy deficit that underlies the female athlete triad. For this reason, the Female Athlete Triad Coalition consensus statement recommends a multidisciplinary treatment approach that involves both a sports dietitian and a mental‑health professional.

The sports medicine specialist responsible for certifying fitness for competitive activity also acts as a sentinel for eating disorders such as athletic anorexia, which is considered a presentation of anorexia nervosa in the sports context rather than a separate diagnostic category. It is not characterized by body‑image distortion but is instead driven by the pursuit of improved performance, and it is often underdiagnosed because it is normalized within the sporting environment.

This story has been translated from Univadis Italy, part of the Medscape Professional Network.