# From amenorrhea to pregnancy: spontaneous recovery of the female athlete triad during the COVID-19 pandemic

## TL;DR

A professional triathlete recovered from a health condition affecting her menstrual cycle and bone health during the pandemic due to reduced training and better nutrition.

## Contribution

This case report demonstrates the spontaneous recovery of the Female Athlete Triad through reduced training and improved energy balance.

## Key findings

- Menstrual cycles resumed and pregnancy occurred after a decrease in training and improved energy intake.
- Bone health metrics improved following the reduction in exercise volume and better dietary habits.
- The case highlights the reversibility of the Female Athlete Triad when energy balance is restored.

## Abstract

The Female Athlete Triad (Triad) and Relative Energy Deficiency in Sport (RED-S)
are conditions associated with low energy availability (EA) that can lead to
menstrual dysfunction, impaired bone health, and metabolic disturbances. This
case report describes the remission of Triad in a professional triathlete during
the COVID-19 pandemic. A 24-year-old female triathlete was evaluated in 2018.
She reported bulimia nervosa from 12–15 years old and hypothalamic amenorrhea
since she was 21 years old. Her training volume was approximately 20 hours per
week (swimming, cycling, and running), and the amount of EA was critically low
(< 10 kcal/fat free mass/day). The athlete had lower than expected BMD at DXA
scan (lumbar spine Z-score -2.3 SD) and lower cortical and trabecular vBMD and
trabecular number by comparison with HR-pQCT normative data for young Brazilian
women. During the 2020 pandemic, training centers were closed, leading to a
decrease in exercise volume and a more balanced energy intake. Menstrual cycles
resumed and she conceived spontaneously in the same year. Pregnancy and
postpartum recovery were uneventful. She returned to competitions post pandemic,
but no longer as a professional athlete. Chronic energy deficiency significantly
affects the hypothalamic-pituitary-gonadal axis and bone health. A forced
reduction in training intensity and improved dietary intake were key factors in
the restoration of menstrual function and reproductive health. This case
highlights the potential reversibility of the Female Athlete Triad when energy
balance is restored. Awareness and early intervention are essential for
preventing long-term consequences in female athletes.