The Female Athlete Triad

The Female Athlete Triad refers to 3 clinical entities: Menstrual Dysfunction, Low Energy availability and Bone mineral Density (BMD).

The female athlete triad (the triad) is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density; it is relatively common among young women participating in sports. Diagnosis and treatment of this potentially serious condition is complicated and often requires an interdisciplinary team.

Articles from 1981 to present found on PubMed were selected for review of major components of the female athlete triad as well as strategies for diagnosis and treatment of the conditions.

The main goal in treatment of young female athletes with the triad is a natural return of menses as well as enhancement of bone mineral density. While no specific drug intervention has been shown to consistently improve bone mineral density in this patient population, maximizing energy availability and optimizing vitamin D and calcium intake are recommended.

Treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members. Prevention of this condition is important to minimize complications of the female athlete triad.

Keywords: female athlete triad, disordered eating, amenorrhea, bone mineral density

In 1992, this triad was described by the American College of Sport Medicine after it was observed among adolescents and young females involved in sport activities. We have faced for the last decade, the challenge to treat these adolescent female athletes suspected to suffer from such triad.

The prevalence of menstrual irregularities mixed with eating disorders and low Bone Mineral Density varies widely in the general population and in the female who participle in sports like ballet or running activities. A high prevalence of secondary amenorrhea in relation to their desire to stay lean is also observed and often we will find many sufferings of Anorexia Nervosa and/or Bulimia Nervosa.

It is believed that at least 70% of elite athletes need to keep their weight class in following a strict diet often in a disordered pattern with the hope of reducing weight prior to a competition. A higher rate of injury with a long-term osteoporosis, a low fertility rate with poor health is also expected. 15 to 45% of young female athletes will fall in this category especially when they are required to meet the standard of weight to compete. Early identification is key in screening adequately the one at risk. Never less, it can be difficult to diagnose and/or reverse a decrease in bone mineral density as well as treating associated complications.  Always remember that a major component of the triad may be psychological.

It is easier to prevent the triad in encouraging healthy eating habits and in improving bone mineral density and menstrual function but the best way to oversee these athletes is with a team approach including, Psychologist, Nutritionist, Obstetrician, Endocrinologist, Orthopedist etc.

The female athlete Triad has 3 interrelated conditions:

A lack of Energy with or without an eating disorder

Disturbances in Menstrual periods like Amenorrhea, Oligo amenorrhea

Bone loss and Osteoporosis

The energy deficiency is the main cause for the Triad because this is an imbalance between the amount of energy consumed versus the amount expended during the activities. A conscious restriction of food in the goal of holding the body image, may resulting in eating disorders like Anorexia or Bulimia.

The most serious menstrual problem associated with the triad is Amenorrhea (no menstrual periods) for 3 months or more. Occasionally, athletes with regular menstrual periods may also be affected. Late in the picture, a low bone mass will translate signs of Osteoporosis, leading to stress fractures.

The story repeat itself. By example a young athlete eager to compete in track and field or in team sport is being asked by her coach to be in shape and lose some weight. She opted to cut on calories intake in skipping meals while still performing in extensive hours of training with the goal to improve her performance. This poor diet influences her menstrual periods becoming less and less affluent until they became rare or irregular or stopped. It is only once she injured herself with a stress fracture, that she started thinking more about her lack of menstrual periods.

Although she believed that her poor diet and training conditions may be responsible of her problems. She remains conscious that exercise and sports activities are fundamental to a healthy lifestyle. Students involved in sport activities are known to have better grades and are less likely to suffer of depression once they stay away from alcohol, smoking and drugs. Parallelly some girls participating in sport activities may never even get their first period because they have been training so hard. Others may have had their periods to see them diminished or stopped with intense training practice. In any way, a missed period does not mean “female trial Athlete”, it could be also pregnancy or any other medical condition. If you are having sex while you are practicing sport and missing periods, talk to a physician.

The level of Estrogen is low in the female athlete suffering of the triad. Low estrogen with poor habits in nutrition, with low calcium intake, can lead to osteoporosis. This condition can ruin the athlete’s career especially when she starts developing stress fractures or other injuries. One will remember that the teen years is the period when girls need to build their bone mass to a high level.

Who is at risk for the triad?

Any female athlete will develop concerns about the seize and the shape of their bodies to accommodate training and improve their performance. Any sport classifying athlete by weight class will place them at a disadvantage especially if bad eating habits is used to reach the goals. Sport like Rowing, Gymnastics, Figure Skating, Diving, Athletism are known to require a lean body shape. Coaches may suggest a loss of weight as well.

In fact, often losing the few pounds does not improve performance at all. The muscles will starve when the girls cut back on food and will interfere with the healthy body processes such as menstruation and bone development. Finally, many of these girls have low self-esteem with a tendency toward perfectionism. We need also to add on the pressure that members of the family place on their performance.

The risk factors for female athlete triad can be suspected in girl experiencing weight loss, Fatigue and inability to concentrate, Menstrual disturbances, Stress Fractures and other injuries associated to eating disorders. Some will use laxatives and present brittle hairs and nails, dental cavities, sensitivity to cold, low heart rate and low blood pressure, occasionally, chest pain and heart irregularities.

In conclusion, the physician needs to find a way to pin-point the young athlete at risk for the Female Athlete Triad through their computer system, assuring that a complete medical evaluation is preformed, that Menstrual periods, Nutrition and Exercises habits are documented as well as Medications and Sleeping habits. Physicians of many specialties included mental health, Coaches and Trainers as well as Parents, Physical Therapists, Dieticians, need to work as a team to approach the physical and emotional problems that a girl suffering with female athlete triad can develop.

Some may need hormonal supplementation like estrogen to prevent further bone loss as well as Vitamin D and Calcium. Athletes should record their menstrual periods, avoid skipping meals, visit the dietician and nutritionist regularly for iron, calcium and protein supplementation and avoid pressures from teammates and coaches.

The American Academy of Pediatrics and the American Academy of Orthopedic Surgery stressed that Exercises should be promoted in the life any young females for health and enjoyment. The medical issues found in this triad are important and should be approached with method to assure a successful treatment in order to allow the young female athlete to compete safely in reaching her goals.


1-   Hoch, AZ, Pajewski, NM, Moraski, L et al (Sept 2009) “Prevalence of the female athlete triad in High school athletes’ students”. Clin J Sport Med 19 (5): 421-428.

2-      Torstveit et al. 2005. ‘The Female Athlete Triad: Are Elite Athletes at Increased Risk?’ Medicine and Science in Sports and Exercise. vol. 37, no. 2. p. 184-93.

3-     Hobart. JA; Smucker, DR (June 1, 2000) “The Female athlete Triad”. American Family Physician 61(11): 3357-64.

4-     American College of Sport Medicine. “The Female AthleteTriad”. Medicine and Science in Sports and Exercises. 39(10) 1967-1982.

5-     Ott, Susan. 2007 Estrogen: Mechanism of Bone Mechanism of Bone Action. Department of Medicine University of Washington 2007-10-24

6-     Matzkin, Elizabeth; Curry, Emily J.; Whitlock, Kaitlyn (2015-07-01). “Female Athlete Triad: Past, Present, and Future”. Journal of the American Academy of Orthopaedic Surgeons. 23 (7): 424–432. 

Maxime Coles MD

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