top of page
  • Writer's pictureDaniel Rockman

The Female Athlete Triad

Given the recent abhorrent allegations made by Australian gymnasts about the abuse they received, I thought it was a good time to shed some light on a topic that is heavily involved in our youth being so poorly mistreated. A clinical condition that can lead to infertility, stress fractures, osteopenia, decreased energy levels and serious psychological ramifications, which is only worsened by the pressures of elite sport.

The Female Athlete Triad

The Female Athlete Triad is three closely related clinical disorders: menstrual dysfunction, low energy availability (with or without an eating disorder) and decreased bone mineral density (BMD).

The phrase was coined after many experts noticed a pattern in adolescent, female athletes. The pattern is much more apparent in sports that emphasize aesthetics or leanness, such as gymnastics, figure skating, ballet or running, to the point that up to 69% of elite female athletes experience one of the symptoms, secondary amenorrhea (a lack of a period), compared with just 2% to 5% in the general population!

With this condition affecting our vulnerable youth, it is important that our coaches, related professionals, parents, future athletes and society understand this problem, how to recognise it and how to deal with it in a healthy way.

What makes up the three components of the triad?

Menstrual dysfunction

There is a wide spectrum of menstrual dysfunctions, some are caused by genetics or diseases, but the most likely causes in young athletes are caused by an energy deficiency and stress. The type of amenorrhea resulting from the decrease in energy availability is called functional hypothalamic amenorrhea (FHA).

FHA is caused by an alteration in the hormones in the body, believed to stem from a decrease in leptin which is released from fat tissue, and reflects an overall lack of oestrogen (the female sex hormone). Anyone who has studied basic physiology knows that when you mess with the delicate balance of hormones in the body, there is a cascade of effects. In this case, negative effects.

For those of you who know what you're talking about, FHA is associated with: overactivity of the hypothalamic-pituitary-adrenal axis (increasing cortisol release) and hypothalamic-pituitary-thyroid axis (resulting in a “sick euthyroid” pattern).

For those of you who don't understand any of those words: the body's normal messaging system is disrupted, resulting in the body being "out of balance", resulting in abnormal menstruation.

This menstrual dysfunction can lead to infertility later in life due to lack of ovarian follicular development, anovulation, or luteal-phase defects.

The low levels of oestrogen that occur with FDH can also lead to cardiovascular disease, increases in LDL cholesterol (the bad one) and the third symptom in the triad - low bone mineral density.

Basically, the lack of a period is a signal that something in the body isn't working properly. In the case of female athletes, this is usually caused by a combination of low energy availability and high levels of stress caused by the sporting environment.

Energy Availability

Low energy availability can be due to the large energy requirements of intense training schedules coupled with a lack of nutritional knowledge, lack of time or lack of appetite large enough. Often these factors are compounded by the pressures of competition such as competing in a certain weight class or looking a certain way. This can lead to clinical eating disorders such as anorexia nervosa or bulimia nervosa, or disordered eating, which is irregular eating behaviors that do not necessarily meet criteria for severe disorders.

Young, female athletes are at risk of developing eating disorders because the athletic population is notoriously bad for giving poor nutrition and weight loss advice.

Many coaches give their own nutritional advice based on anecdotes or outdated knowledge. The sporting association may (accidentally, or not) create an environment in which weight loss is encouraged regardless of the methods employed to attain it (a healthy diet, or not).

There is a certain requirement in the sports realm for a high-performance diet, but this can be done in a healthy way or a harmful way. Healthy dieting is considered a modest lowering of daily calories, while harmful dieting or disordered eating includes restrictive behaviors, such as fasting, skipping meals, use of diet pills or laxatives, and binging and purging.

There is a wide spectrum of disordered eating among athletes that ranges from simple dieting to clinically defined eating disorders. A new term was even created by some researchers, anorexia athletica, to describe a disordered eating pattern seen in the female athlete who has an intense fear of gaining weight, even though she is underweight. Women with anorexia athletica reduce their energy intake while exercising excessively. They may display features of established clinical eating disorders, though not enough to meet the criteria for a diagnosis.

This unhealthy relationship with food, which is influenced by parents, the coaches and the sporting environment (not to mention the usual societal pressures for youthful females) has negative consequences on both menstruation and bone health.

Decreased energy availability can lead to nutritional deficits causing further complications, among which is a reduced rate of recovery leading to decreased performance and increased risk of injuries.

There can also be serious psychological ramifications to low energy availability, such as depression, low self-esteem and various anxiety disorders. It can also be a slippery slope to body image issues and severe eating disorders later in life. Basically, not eating enough food is the gateway drug to an unhealthy relationship with food. Please eat enough food!

Bone health

Bone mineral density is an important indicator of how strong your bones are. A loss of 10% of your BMD can lead to a 2-3 fold increase in risk of fractures. There is a window of opportunity during puberty to increase bone mineral density by eating well and performing regular weight bearing exercise.

Despite the regular exercise, athletes who also have amenorrhea have 10-20% less BMD in their lumbar spine than healthy athletes!

The reason this occurs is due to a process called bone remodelling. Basically, our bones are constantly breaking down and building back up again. When we exercise this encourages more break down of the bone tissue, which in turn, encourages more building of the bone tissue. It works very similar to how muscles grow. Makes sense, right?

Where this goes wrong in the amenorrheic athlete relates back to not getting enough oestrogen in the body, which leads to deceased activity from the bone building cells. Therefore, it is believed this hormone imbalance negates the benefits of weight bearing exercise on the bones, resulting in these athletes missing out on their window of opportunity to put on bone mass.

This low BMD, coupled with menstrual irregularities, malnutrition and intense training can lead to a high rate of stress fractures. For those of you who don't know, stress fractures are when the bone breakdown outweighs the bone build up over an extended period of time. This results in what would normally be a regular force through the bone, such as landing a jump, completely snapping the bone, usually occurring in the lower leg bone (the tibia).

I would link one of the multiple videos of this happening to gymnasts during the Olympics but I'm about to eat soon and I think I'd be sick. You can google it if you really want to, sicko.

As well as a higher risk of injury, these athletes will have a lower peak bone mass, leading to higher rates of osteopenia and fractures later in life. While a healthy resumption of the period can return rates of bone remodelling to normal, these athletes may never catch up to age appropriate numbers.

Notice how the steepest growth occurs during adolescence? If this rate of bone development is not reached, bone mass in later life will be even lower due to the lower starting point. Females are already prone to low bone mass and, as I stated in my article on exercise for older adults, this has a huge impact on quality of life as we get to our golden years.

As you can see, the 3 factors that make up the Female Athlete Triad interplay with each other to cause decreased performance, increased rate of injury, serious detrimental psychological effects, infertility, lower bone strength and can have further negative effects that span the rest of the athletes life.

How to fight this triad in our youth

A multi-disciplinary approach is essential for recovery. It is extremely important to receive support from a sports physician, a dietitian, psychiatrist or therapist, the team coach and family members to increase chances of a successful recovery.

The first step to fighting this condition is screening. Screening should take place as a questionnaire, physical examinations and at annual health checks. Clinicians may also pick up on warning signs when athletes present with related symptoms such as amenorrhea or stress fractures. If one component of the triad is found, the athlete should be screened for the remaining two.

The questionnaire (currently the LEAF-Q is used) focuses on current physical activity levels, past injuries, diet, eating behaviors, and menstrual history. The results can be used to inform further examinations. Athletes who present with fear of weight gain or body image issues should be referred to a mental health care professional for further guidance.

Physical examinations can take many forms, because there are multiple signs to look for in this multi-faceted condition. They can look at signs of low weight, anorexia nervosa, persistent vomiting, hyperthyroidism, stress fractures, disordered eating or BMD. The form of the physical examination is guided based on clinical signs displayed by the athlete, meaning some might require blood tests, while others get bone scans or physical palpations on bones.


The primary goal of treatment is to restore a regular period and enhance the BMD. The first step taken in this process is to modify the diet and exercise routine of the athlete to increase overall energy balance. This means the athlete will draw back in their training and begin trying healthy eating strategies.

This should cause an increase of fat mass which should then lead to the resumption of menstruation, as well as indicate the resumption of normal bone remodeling. These changes may not be immediate, and can be minor if not done at an early age and sustained throughout adulthood.

Many elite athletes are resistant to changes to their training schedule and diet, so some drugs or supplements may be used. The options here are: the oral contraceptive pill, hormonal replacement therapies, transdermal oestrogen, leptin injections, vitamin D and calcium supplements. These therapies often have side effects and equivocal research surrounding their effectiveness, so diet and exercise reduction should always be given time and effort to work first.

There are also specific methods of exercise which can stimulate bone growth without the negative effects of exercising for hours. Vibrating platforms, for example, have been shown to stimulate the bones by loading impacts without being detrimental to bone health. These techniques may help reap the benefits of load bearing exercise for athletes with low BMD, however, more research needs to be done on the effect on young athletes.

The greatest barrier to overcoming the female athlete triad is the psychological component, partly due to athletes often being determined, competitive perfectionists. If an athlete is displaying signs of clinical eating disorders it is imperative that a mental health professional is involved. Creating a contractual agreement outlining their responsibilities as well as the goals of the treatment can be beneficial.

The best way to help is to recognise the signs early and prevent the condition from getting worse. It is the responsibility of the young athlete's social support to be aware of and keep an eye on these things.

So, if you know a young female athlete, or you have one of your own, keep an eye out for the signs. Have they had a recent decline in performance, changes in mood, dramatic weight loss, and frequent injury, particularly fractures? It might be worth having a health check and filling out the LEAF-Q.

Regardless of whether they are an athlete or not, healthy eating habits should always be encouraged. If you're in doubt about what that looks like (or if you think it means cutting out entire food groups) please see a dietician who can help you.

Let's keep our youth safe and healthy, not just for the performance benefits, but for the life-long consequences they have to live with.

Stay strong.

29 views0 comments


bottom of page