What is the female athlete triad? 3 components & causes to watch for

What are the three components of the female athlete triad? Signs and symptoms to watch out for.

By Amity Lui

You may have heard of the “female athlete triad” but what is it exactly and is it only for females? As the name suggests, the female athlete triad is a combination of three interrelated conditions– low energy availability, menstrual dysfunction and decreased bone mineral density. 

A female can have one, two, or all three components of the triad. Athletes with one part of the triad are at risk of developing other symptoms. It’s common for signs and symptoms of the triad to go unrecognized, which can be problematic for performance and long-term health. Early screening by coaches and health care professionals may help prevent the development of the triad. 

What is the female athlete triad?

The female athlete triad consists of 3 parts: low energy availability (with or without an eating disorder), menstrual dysfunction, and decreased bone mineral density. Let’s take a look at each of these conditions below. 

Low Energy Availability

Low energy availability means not eating enough to support your activity level. It’s common knowledge that participating in sports requires calories, but athletes often forget that the body needs an individualized amount of energy to function normally. In other words, your body needs a certain amount of calories to breathe, pump blood, digest food and perform other bodily functions. 

Couple that with the calories your body needs to train, especially at high intensity or long duration, and you may need more calories than you think. As a matter of fact, many athletes underfuel for their activity level. Unintentional weight loss may be one of the first signs of low energy availability. 

It’s important to note that low energy availability and the female athlete triad can occur with or without an eating disorder. That said, examples of disordered eating habits include restrictive dieting, binging, and purging. 

Menstrual dysfunction 

Abnormalities with monthly periods can result from a prolonged calorie deficit. Not eating causes stress to the body, which alters hypothalamic function and estrogen levels. 

The hypothalamus is a part of the brain that acts as the body’s control center. It’s responsible for regulating body temperature, blood pressure, hunger, thirst, and sleep. The hypothalamus produces a hormone called gonadotropin-releasing hormone (GnRH). GnRH tells the ovaries to produce estrogen. When the body is under stress from not eating enough, the hypothalamus doesn’t function properly, leading the ovaries to stop ovulation and the menstrual cycle.  

It may sound great to not get your period, but the absence of one can impact fertility and bone health. 

The absence of menstruation, aka amenorrhea, comes in two forms: 

1. Primary amenorrhea is marked by the absence of the first period.
2. Secondary amenorrhea is classified as not getting a period for more than 3-6 months

Decreased bone mineral density 

There are two types of cells in the bone–osteoblasts and osteoclasts. Osteoblasts are cells that are responsible for bone formation, while osteoclasts are cells that break down bone. Breaking down bone may sound bad, but it’s a necessary step of the bone growth process. 

Problems arise when there is an imbalance between the two types of cells. Low levels of estrogen lead to an increase in osteoclast activity, and this imbalance may result in net bone loss. Ultimately, low estrogen from undereating may reduce bone density and increases fracture risk. 

The best way to measure bone mineral density is through a bone density scan, also known as a DEXA scan. DEXA stands for dual-energy X-ray absorptiometry and it provides a snapshot of your body composition, including bone density, body fat, and muscle mass. However, DEXA scans are not widely available and can be pricey. 

Without access to a DEXA scan, a telltale sign of low bone mineral density often begins with a stress fracture. This will then prompt physicians to run diagnostic exams to figure out the underlying cause. Most reported stress fractures in athletes occur between the range of 10-30 years old. If you think you may have low bone density, it’s best to talk to your doctor. 

Who is at risk for the female athlete triad? 

The most common conditions to experience the female athlete triad are:

• Females participating in any sport can develop one or more components of the triad; however, aesthetic or weight class-based sports like figure skating, gymnastics, running, diving, rowing, and wrestling are at greater risk. 
• Athletes engaging in a high training load
• People with a history of dieting, poor body image, and/or disordered behaviors 

What’s the difference between the female athlete triad and RED-S?

Low energy availability is the cornerstone of the female athlete triad, but this phenomenon is not isolated to women. Males athletes also commonly eat less than their needs. 

In 2014, the International Olympic Committee coined the term RED-S (relative energy deficiency in sport) to reflect that negative health and performance impacts of undereating affect all athletes, not just females. 

Male athletes can also suffer from low energy availability, hormone imbalances, and decreased bone mineral density. In males, hormone imbalances can include low testosterone levels, which not only impacts fertility but also libido, bone mass, fat distribution, muscle mass and strength. However, it’s important to note that low testosterone levels can derive from other factors, so it’s always a good idea to check with your doctor if you think your hormones are out of whack. 

Considerations for young athletes

For young athletes, poor nutrition has the potential to stunt development and/or growth. Puberty is a period of growth and maturation, with the greatest growth in bone mass typically occurring between the ages of 11-14 years. Up to 90% of peak bone mass is acquired by the age of 18 in females and 20 in males. 

Studies suggest that women with an onset of amenorrhea before the age of 18 had lower bone mineral density than those who developed amenorrhea after the age of 18. Unfortunately, bone mineral density may never be regained even after the restoration of weight and regular menses. 

What are the health outcomes of the female athlete triad?

The female athlete triad can have some serious side effects. In the short term, you may experience: 

• Increased musculoskeletal injuries and stress fractures 
• Decreased immunity 
• Decreased performance 
• Infertility if energy availability, hormones, and menses do not normalize 
• Mental and physical disorders 

Longer term effects include: 

• Premature osteoporosis
• Improperly healed stress fractures can result in nerve damage, joint discomfort, and decreased range of motion and/or strength
• Infertility
• Increased risk of prolonged disordered eating 
• Psychological implications  

Treatment options

Treatment of the triad may require a collaborative effort among coaches, athletic trainers, parents, physicians, dietitians, and therapists/mental health specialists. The initial priority of treatment is to correct the underlying cause and to establish energy balance to restore normal bodily functions. 

In many cases, this may include lifestyle changes like decreasing exercise or increasing energy intake or a combination of both. Secondary goals of treatment include restoring regular menstrual function (if applicable), improving and maintaining bone health, and remedying any mental distress. Seeking professional treatment from a multidisciplinary team is the best way to ensure that individual needs are being met and on the road to recovery. 

Can the triad be prevented?

Yes! There are a number of things you can do to help prevent symptoms of the triad, including: 

• Know the signs and symptoms of the triad
• Focus on fueling for overall performance and health
• Don’t focus on weight loss or changing body composition during a training season
• Eat enough to support your body’s baseline needs + any extra activity 
• Include variety in your diet
• Increase exercise slowly each week, if applicable 
• Get plenty of sleep (at least 7-8 hours per night) 
• Manage stress
• See your doctor regularly and don’t be afraid to ask questions

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Amity Lui is a dietetic intern at Teachers College, Columbia University, where she also completed her Master’s of Science degree in Nutrition and Exercise Physiology. As a lifelong athlete and marathon runner, Amity has struggled with body image and failed to connect the importance of nutrition and performance outcomes. Upon realizing that athletes’ needs are highly individualized, Amity decided to use her experience and knowledge to empower athletes to utilize nutrition as a tool for enhancing performance and recovery. When Amity is not running or lifting weights, she is probably outdoors, cooking, trying different restaurants in NYC, taking care of her 300 houseplants, or creating nutrition content for her Instagram @eat.to.run.nutrition.