Female Athlete Triad

The female athlete triad is a syndrome affecting women, but most commonly teenage girls. The syndrome consists of three elements; osteoporosis, eating disorders or nutritional deficiencies, and amenorrhea. Amenorrhea is the official term for skipped periods or the total cessation of menstruation.

The female athlete triad is a highly serious problem and can have far reaching consequences that can last for life, and can lead to many health problems developing in later life. The three components of the triad need not all be experienced all together, and one, two or all three may affect an individual. Typically eating disorders or poor nutrition lead to amenorrhea, and a lack of minerals and vitamins for bone health contribute to early onset osteoporosis.

Risk Factors for the Female Athlete Triad

The female athlete triad is commonly associated with teenage girls and young women who are in training for sports, athletics and gymnastics. Whenever there is pressure to stay lean or to maintain a low body weight, the risk of this syndrome increases. Athletics and gymnastics are two sports which have a particularly high incidence of the female athlete triad among its participants, especially at the higher levels of the sport. Pressure to keep the body weight down invariably leads to a reduction in the intake of high fat foods such as dairy products, which are also the main source of dietary calcium.


Calcium deficiencies along with vitamin D deficiencies can cause weakening of the bones; termed osteopenia which progresses into osteoporosis. Osteoporosis involves thinning of bone tissue and a severe loss of bone density. Osteoporosis is reasonably common with older women due to hormonal changes around the time of the menopause when estrogen levels decrease, although the female athlete triad can cause this condition to occur in early adulthood, especially when vitamin and mineral deficiencies occur during the key growth phase of bones.

In the case of the female athlete triad, it can result in abnormally low estrogen levels which can trigger the early onset of osteoporosis, which is exacerbated by poor nutrition. Osteoporosis is a highly serious disorder in later life, yet for young women who train hard it can have even more serious consequences, not just in terms health but the ability to take part in competitive sports.

Short term, the female athlete triad can dramatically increase the risk of developing stress fractures in the bones, in particular in the feet, ankles, hips and pelvis. Since the teenage years are the primary period for the development of strong and healthy bones, a lack of dietary calcium and other minerals and vitamins necessary for good bone health this early in life can have far reaching implications for future health.

Eating Disorders and Food Avoidance

Eating disorders are commonplace among young girls and women in sport, and teenage girls are especially susceptible to develop conditions such as anorexia nervosa and bulimia nervosa in an attempt to control body weight and stay in shape. While these two extreme eating disorders are sadly all too common, simply avoiding certain foodstuffs to prevent weight gain can be all that it takes for the bones and health to suffer. One of the main problems is the avoidance of dairy products due to fat content, but avoidance of the main sources of dietary calcium can have serious implications for bone health.

Dairy products are the main source of dietary calcium, and avoidance of milk, cheese, and yoghurt can lead to calcium deficiencies which in turn can cause early onset osteoporosis. Eating disorders also include fasting and binge eating and the taking of medications to restrict metabolism such as laxatives. When insufficient calories are taken in the body becomes weak and cannot maintain certain bodily functions, with menstruation one of the first ‘non-essential’ biological processes to be forfeit.

Eating disorders and fluctuating energy levels lead to a disruption of the hormone production, in particular that of the gonadotropins or sex hormones. It is the restriction of production of FSH, LH and GRH hormones which is the problem, with these three hormones responsible for controlling the release of estrogen from the ovaries. This then disrupts the menstrual cycle, or prevents it from starting. Low estrogen release can lead to amenorrhea – classed as cessation of periods for 3 months or more. With the female athlete triad this can be a cessation of the period if puberty has already been reached, or a delay in the onset of the first menstruation (menarche). This can cause fertility problems and may even prevent the individual concerned from ever being able to have children.

Symptoms of the Female Athlete Triad

The problem with diagnosing the female athlete triad is that if an individual has any eating disorders, they are unlikely to be freely discussed with a doctor, and menstruation problems can be a difficult topic for young women to discuss. It is all too easy for doctors to miss the symptoms of the female athlete triad, so it is therefore important for parents, guardians and sports coaches to look out for the signs and symptoms of the female athlete triad. One of the main symptoms of the triad is weight loss, which will undoubtedly be seen as a benefit by the sufferer since that is often the driving force behind the onset of eating disorders.

The symptoms of the female athlete triad also include the following:

  • Weight loss
  • Inability to concentrate
  • Bone pain
  • Fatigue
  • Frequent and persistent muscle injuries
  • Stress fractures
  • Delay of the menarche or a cessation of menstruation
  • Brittle hair and nails
  • Low heart rate and poor circulation
  • Dental problems requiring excessive fillings
  • Anemia and low energy levels

Female Athlete Triad Treatment

Treatment of the female athlete triad is not straightforward and a multidisciplinary approach is often best. Girls need to seek help initially from a doctor for a diagnosis, followed by a nutritionist or dietician to correct the eating disorder and to work towards weight gain to get the body back to an agreed and normal level. In addition to adopting a healthy and balanced diet, vitamin and mineral supplements will almost certainly be necessary to correct any deficiencies. Increasing the intake of calcium and vitamin D is important to promote healthy bones, B vitamins may be recommended or shots provided. Training may need to be reduced during recovery, although generally only by around 10%.

In cases where the menarche has not occurred, doctors may recommend taking estrogen and progesterone tablets to induce the first period, such as by taking oral contraceptives.

The female athlete triad is a serious condition which can affect long term health and it is vital that it is avoided or spotted early and treatment started. It is therefore wise for training young female athletes to keep a diary of their menstrual cycle to be aware of any potential problems, and for parent and guardians as well as sports coaches to be aware of the condition to keep an eye out for the onset of this syndrome.