The Female Athlete Triad



The Female Athlete Triad is a group of three interrelated medical conditions often observed in physically active girls and women. The medical conditions include: 1) decreased energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone mineral density. Up to 60% of female athletes present with one or more of the three Triad components, which can negatively impact health and athletic performance.


Food is to the body, what gas is to a car. A car can’t function without gas and the human body can’t perform without food. The human body requires energy to function and support the power of muscles, the heart, and the brain. Specific to sport, the energy required to train and compete at your best is derived from the food you ingest. Food is fuel and fuel is energy. Energy availability is defined as the energy required to meet everyday demands and is determined by food intake minus, energy used in exercise. Food provides the body with necessary energy for cellular maintenance, thermoregulation (temperature control), growth, locomotion, reproduction, and sports performance. Adequate energy is needed for bodies to perform basic, life-sustaining functions, but professional athletes require additional energy to execute the demands of training and competition. Many athletes, by intent or not, do not consume an adequate amount of energy to match the demands placed upon their bodies. These athletes live in a “low-energy state” resulting in fatigue, poor recovery, inadequate healing, frequent mood fluctuations, and/or lack of improvement despite training. Female athletes with high energy demands may be unaware that they are in an “under-fueled” state, where the gas in their engine is running close to empty due in part to missing meals (i.e. not eating a proper meal after a late match finish), poor nutritional recovery practices (i.e. do not eat or under-eat after matches and practices), avoidance of fat or following a fad diet (i.e. avoidance of certain foods for ‘popular’ reasons, not due to a diagnosed medical reason), or chronically dieting or losing too much weight too fast. Reduction of dietary energy intake and/or increased energy expenditure causes an energy deficiency and may limit the energy available for competition and other normal body processes.

Athletes and their bodies are often scrutinized by media, fans, and even well-meaning supporters on their own team. Athletes may feel pressure to lose weight or desire to be unrealistically thin, which can develop into disordered eating patterns or an eating disorder such as anorexia nervosa or bulimia. Years ago, it was not unusual for coaches to encourage athletes to be unrealistically thin and not have their menstrual period. Today it is widely known that you can be “too thin to win.” Dieting can impair performance and recovery. Regular menstrual cycles are good for your health and are essential to both maintain and build bone strength.

Why worry about low energy availability?

Under-eating makes it difficult to perform at one’s best. Energy deficiency results in decreased power, strength and stamina, often limiting one’s ability to train or compete at high intensity. Energy deficient athletes may experience increased frequency of fatigue, greater susceptibility to illness, and slower ability to recover. These symptoms often result in poorer competition outcomes, disordered sleep, altered moods, irregular menses, and potential bone compromise. If you present with any of the symptoms above, please speak with your Primary Care Physician to assist you in developing a plan of action to get your health and performance on track. Treatment includes a multidisciplinary health care team approach, assessing bloodwork, determining energy intake, and providing guidance on the steps required to restore energy levels with the goal of competing at an optimal level.


Low energy availability from under-eating or an eating disorder will directly disrupt the reproductive system. This system is controlled by the pituitary or ‘master gland’. The pituitary gland identifies when the body has low energy availability and alters the signals that regulate egg production and the menstrual cycle. Changes to the menstrual cycle include lowered levels of estrogen (female hormones). Estrogen is responsible for regulating the menstrual cycle, but also plays an important role in bone formation. An athlete may notice that her periods become irregular or are completely absent. This may be the only sign that there is a problem.
Abnormal menses is characterized as:

  1. Not starting the menstrual cycle by age 16 OR
  2. 3 or more months in a row with NO period OR
  3. Less than 5 periods a year

An athlete identifying with one of the three criteria above should seek medical advice to determine the cause; please speak with a Primary Care Physician for more information.


Bones are living, active structures, which remodel and repair constantly. Both nutritional (low energy availability= problem one) and hormonal factors (menstrual changes =problem two) lead to impaired bone mineralization and development during the active growing years (ages 15-30 years). This may cause:
• Insufficient bone mass or bone density (osteoporosis)
• Bones cannot be remodeled (shaped and strengthened to manage exercise and load)
• Bone cells cannot be replaced (to repair and strengthen bones).
These problems can lead to stress fractures and “weak” or osteoporotic bones (low bone density) in young women. Bone loss is worsened by overall energy deficiency and insufficient amounts of important nutrients such as calcium and Vitamin D.

Research identifies that young women with absent or irregular menstrual periods had lower than normal bone density for their age. They are young women with “old bones,” with the bone density of a 70-year-old woman!

Athletes most likely to develop the Female Athlete Triad are those who have created a low energy state due to:

  • Under-fueling
    o Not eating enough due to constant dieting, following food fads, missing meals, and/or eliminating specific foods or food groups
  • Eating Disorders
    o Eating disorders are serious medical and mental health illnesses.
    o Characterized by irregular eating habits and severe distress or concern about body weight or shape.
    o Symptoms may include:
    o Obsession with calories or fat/carbohydrate content of food
    o Constant weight fluctuations
    o Body dissatisfaction: untrue belief that changing body size/shape will result in being a better or happier athlete
    o Body dysmorphia: distorted perceptions of body size and shape
    o Unhealthy eating behaviors, such as “strict” dieting, fasting (not eating any solid food), or switching from period of overeating and fasting
    o Binge eating and purging behaviors (such as self-induced vomiting, use of supplements, or excessive exercise) to lose weight
    o Avoidance of social functions, family and friends (to avoid food or protect eating rituals)


The Triad can impact many aspects of life. In addition to menstrual disorders, reproductive dysfunction, and damage to bone strength and health, eating too few calories can lead to dehydration, fatigue, increased muscle soreness, anxiety, depression and/or irritable feelings, decreased performance, and frequent illnesses or injuries. Athletes who are under-fueled often report they are training harder, but not seeing improvements.

  • An athlete does not have to have all three components of the Triad to be at risk for health problems.
  • Pay attention to early warning signs, such as irregular or absent periods, injuries like stress fractures, inconsistent dietary habits, and intrusive or constant thinking about weight or body size and physical appearance.
  • If any of these symptoms are present, seek help from a primary care physician for an interdisciplinary assessment and treatment by a team that includes a nutritionist, medical doctor, and qualified mental health professional.


  • If your periods are irregular, you need to complete a full medical examination to identify the cause and devise the correct intervention. See your primary health care provider to assist you with this.
  • A Registered Sports Dietician can advise you on the proper amount of fuel required according to training load and on healthy nutrition, hydration, and recovery practices.
  • Seek help from a Clinical Psychologist for strategies to help with obsessive thinking, anxiety/fears about food, weight, body image or appearance and for general management of stress and tennis performance concerns.


The information provided within this Physically Speaking topic is for informational purposes only and should not be treated as medical, psychiatric, psychological, health care or health management advice. If you have any health or related questions or concerns, please consult your physician or other qualified health care professional.

A special thanks to Dr. Carol Otis, author of “The Athletic Woman Survival Guide,” for her contribution to this topic.

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