Female Athlete Triad

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Editor: Lyle J. Micheli
Date: 2011
Encyclopedia of Sports Medicine
Publisher: Sage Publications, Inc.
Document Type: Topic overview
Pages: 3
Content Level: (Level 5)

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Page 497

Female Athlete Triad

Since the passage of Title IX in 1972, female participation in high school athletics has increased by 800%. While such participation has had a remarkably positive impact on girls, women, and sports, some pressures of athletics and training have placed athletic females at risk for overtraining, undereating, menstrual irregularity, low bone mass, and other adverse health consequences. In 1993, the American College of Sports Medicine coined a term, the female athlete triad (triad), to refer to a syndrome commonly seen in athletic women. It involves disordered eating, irregular menstrual cycles, and low bone mass. Athletic women with the most extreme form of this disorder have severe eating disorders (e.g., anorexia or bulimia), amenorrhea (absence of menstrual periods), and osteoporosis (low bone density with increased risk of fractures). However, the syndrome is a continuum, and athletes may have one, two, or all three parts of the triad.


Prevalence of the triad in a population of young women athletes is difficult to ascertain as most statistics are obtained from surveys and self-reporting. Women may not want to admit that they have menstrual irregularities or eating disorders. Underreporting is common in such surveys.

Page 498  |  Top of Article

The prevalence of amenorrhea in the general population is 3% to 6%. In specific female athlete populations, amenorrhea has ranged from 3.4% to 69%. The prevalence of disordered eating is 5.5% to 9% in the general population, while surveys have shown a prevalence of 15% to 62% in female college athletes and 25% to 31% in female elite athletes.

Disordered Eating

Female athletes may try to lose weight or maintain a low body weight to improve their athletic performance. For example, a runner may try to lose weight to enhance her speed. A dancer may strive to be thin to improve her jumps and to achieve a certain ideal appearance on stage. Athletes are pressured by coaches, teammates, parents, and/or friends to lose a “few extra pounds” to enhance their performance. This can lead to poor body image and unhealthy eating behaviors.

Disordered eating as part of the triad includes restricting the intake of calories and/or certain types of food (e.g., fat). Some athletes have unintentional nutritional deficits because the calories burned during exercise consistently exceed the calories ingested, but the athlete is not aware of this imbalance. In other instances, athletes engage in very distinctive behaviors signifying the severe eating disorders, anorexia nervosa or bulimia nervosa. Athletes may fast, use diet pills, use laxatives or enemas, purge, try fatfree dieting, or even try excessive sweating through layering clothes in hot weather or sitting in saunas. At-risk athletes include those who restrict dietary intake, exercise for prolonged periods of time, or are vegetarian. Regardless of the type of disordered eating or weight control behavior, the nutritional deficit disrupts many hormonal processes in the body.


Rapid changes in weight, loss of specific nutrients, and prolonged nutritional deficits can lead to significant menstrual irregularities. Studies in animals and humans show that reduction of energy availability to less than 30 kilocalories/kilogram of fatfree mass (FFM) per day causes dramatic changes in the normal patterns of hormone secretion. Energy availability is calculated using caloric intake, exercise energy expenditure, and FFM. Low energy availability alters the levels of numerous hormones that can affect the menstrual cycle, including luteinizing hormone (LH), insulin, cortisol, growth hormone, insulin-like growth factor 1 (IGF-1), thyroid hormone, leptin, and ghrelin.

Menstrual irregularities in female athletes are caused by disruptions in the normal hormonal signaling between the hypothalamus, pituitary gland, and ovaries. A variety of menstrual abnormalities may occur, including luteal suppression (shortened luteal phase of the menstrual cycle), anovulation (impairment of follicular development), oligomenorrhea (>35 days between cycles), primary amenorrhea (delayed menarche or the absence of menses by age 15 in girls with secondary sex characteristics such as breast development and pubic hair), and secondary amenorrhea (absence of at least three consecutive menstrual cycles after menarche has occurred).


Severe nutritional deficits due to disordered eating (including inadequate calcium and vitamin D), low sex hormone levels (including estrogen, progesterone, and testosterone) due to amenorrhea, and high cortisol levels due to stress can all lead to low bone mineral density (BMD). In women, 90% of adult bone mass is acquired by age 16, and peak bone mass is achieved by around age 30. Thus, disruptions in the menstrual cycle during adolescence and early adulthood have a profound effect on bone health and may result in a lost opportunity to attain peak bone mass. Women with low BMD can fracture more easily with minimal trauma. Initially, this may present in a female athlete as repetitive stress fractures. Later in life, debilitating spine and hip fractures may occur.


In general, screening for the triad should be done in preparticipation exams, in annual health visits, and whenever an athlete seems to exhibit some of the characteristics or consequences of the triad (weight loss, abnormal eating behaviors, stress fractures, etc.).

Information about dietary habits, weight fluctuations, workout routines, menstrual patterns, body image, stresses, and history of fractures should all be obtained. As mentioned previously, Page 499  |  Top of Articleathletes may exhibit all or parts of the triad, so when one abnormality is noted, screening for the other two components should be performed.

Some health professionals rely on BMD scans, such as dual-energy X-ray absorptiometry (DXA), to diagnose low BMD. However, these should be interpreted with caution in both adolescents and athletes. Adolescents may not have attained their total peak bone mass, so the results need to be compared with those of adolescents of comparable developmental age—which is based on both chronological age and age at menarche. In general, athletes have higher BMDs than the sedentary controls used as the reference populations for BMD guidelines. Much of the activity athletes engage in involves weight bearing, which can increase bone remodeling and BMD. Thus, if an athlete has a BMD result on the low end of normal compared with the reference population, this may indicate a lower than expected value and is a matter of concern.

In addition, menstrual irregularity in a female athlete should not automatically be assumed to be the result of her exercise and/or dietary habits. An athlete with amenorrhea should always be referred to a physician who is comfortable investigating the cause of the menstrual disorder. Absence of menses may be caused by energy and nutritional deficits in an athlete, but other causes such as pregnancy, pituitary tumors, polycystic ovarian syndrome, and other endocrine abnormalities should be considered.


Unfortunately, there are no universal guidelines for management of women with the female athlete triad. Treatment of amenorrheic women with estrogen and progesterone replacement has not been effective in improving BMD. Instead, correction of the energy deficit has proven much more successful in restoring BMD. Estrogen is only part of the bone-building equation, as other hormones affected by caloric restriction (insulin, cortisol, growth hormone, IGF-1, thyroid hormone, leptin, and ghrelin) all play critical roles in skeletal health. Improving the energy deficit to allow weight gain and resumption of the normal menstrual cycle has shown the greatest benefit.

Achievement of optimal health for the female athlete with the triad requires a team approach. Some athletes improve with help from a nutritionist and a physician. The nutritionist may help target nutritional deficits, estimate caloric needs, and give suggestions for increasing the intake of various vitamins and macronutrients. Physicians can help manage bone healing, rule out other causes of menstrual irregularity, and possibly add medications to treat comorbidities such as depression. Other athletes need the services of these two professionals, along with a psychologist/psychiatrist, an exercise specialist, and other resources.

Addressing the causes of disordered eating, focusing on maximizing training benefits for performance and health, and finding other ways to assist the athlete in her recovery are keys to improving the female athlete’s condition. With a multidisciplinary approach involving coaches, trainers, friends, family members, and health professionals, female athletes at risk for the triad, as well as those already affected by it, can receive the help they need to remain physically active and healthy for the rest of their lives.

Kathryn E. Ackerman

Further Readings

Beals KA, Meyer NL. Female athlete triad update. Clin J Sport Med. 2007;26(1):69–89.

Lebrun CM. The female athlete triad: what’s a doctor to do? Curr Sports Med Rep. 2007;6(6):397–404.

Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP; American College of Sports Medicine. American College of Sports Medicine position stand: the female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867–1882.

Warren MP, Chua AT. Exercise-induced amenorrhea and bone health in the adolescent athlete. Ann N Y Acad Sci. 2008;1135:244–252.

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Gale Document Number: GALE|CX1959700206

Disclaimer:   This information is not a tool for self-diagnosis or a substitute for professional care.