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What is the Female Athlete Triad?

Joe Fleming explains the unique health risk for female athletes.

Sports can provide both a physical and emotional outlet for kids at a young age, not to mention a safe social space that teaches teamwork, dedication, and communication skills. For young women, however, researchers are finding that unique health risks associated with playing sports can threaten a female athlete's well-being and ability to continue playing sports safely.

This interrelationship between health risks is three-fold and is known in the scientific and athletic communities as the "female athlete triad." Initially, the triad focused on the presence of three co-existing factors linked to intense training and sports play for a young woman:

  • Menstrual dysfunction (amenorrhea)
  • Decreased bone mineral density (osteoporosis)
  • Low-energy availability (whether from an eating disorder or not)

Recently, however, experts are discovering that the existence of even one of these core triad factors could have adverse long-term effects on a young woman's health.

Bone Loss

The years of adolescence are when critical bone development occurs in a young woman's body. As living tissue, bone is continuously in a flux state of being deposited and withdrawn. For a girl, childhood to adolescence is the only period in her life in which more bone is being deposited than withdrawn, allowing her literal skeleton to grow both stronger (increased bone density) and bigger (increased size). Girls reach peak bone mass around the age of 18.

Young female athletes challenge this natural bone development process. When their bodies cannot keep up with the intense training accompanying adolescent sports play. The hormone estrogen bears crucial responsibility in the bone development process, and excessive exercise and low body weight can disrupt hormone balance and work against the accrual of bone mineral. Survey data also reveals that teenage girls do not consume near enough calcium and vitamin D as they should in adolescence.

These factors make young female athletes more susceptible to bone breaks and similar injuries. Still, it precludes them from developing osteoporosis, a leading cause of morbidity and mortality in elderly adults.

Low-energy Availability

The inability of the body's energy sources to keep up with exercise-related expenditure (also known as energy availability or EA) can land a young female athlete in a medical state of exhaustion and malnutrition with long-term adverse effects on cardiovascular, bone, and reproductive health.

Teens may need anywhere from 1,800 to 2,500 calories a day to maintain a healthy weight and support growth, and that is without engaging in routine physical activity like playing sports. For added exertion like running and dancing, the body requires more calories. However, research has found that teenage girls, in general, tend to eat less than they should, and female athletes, specifically, are often prone to disordered eating habits.

Anorexia and bulimia nervosa, the two most common eating disorders, affect young women both psychologically and physically, resulting in physiological dysfunction and detrimental nutritional deficiencies. Prevalence rates of disordered eating habits in young female athletes range from 16 to 48 per cent, with the highest rates belonging to girls in thin-build sports like ballet and distance running.

Insufficient nutrient consumption affects body weight and energy levels. Still, it can directly impact the body's menstrual and bone mineralization functions, which means period problems and stress fractures for young female athletes.

Menstrual Dysfunction

Higher incidence rates of menstruation disorders in young athletic females versus their non-athletic counterparts are seen mainly as amenorrhea or the absence of a period for three or more months after starting it. Additional signs of dysfunction may also include not starting a period at all until after the age of 15, an absence of an ovulation phase (anovulation), shortened luteal phase and/or low progesterone levels (luteal phase defect), and menstrual cycles greater than 35 days (oligomenorrhea).

A 2014 study published in the British Journal of Sports Medicine found that upwards of 25% of female athletes experience some form of menstrual dysfunction, with athletes who had high aerobic demands, like runners, experiencing the worst.

So why does intense exercise in female athletes disrupt the normal menstruation process? When energy imbalances occur due to insufficient calorie/nutrient intake and exercise, the body's reproduction-related hormones may not get appropriately triggered for release. This "starvation mode" has a domino effect in the body, shutting down critical reproductive processes to prevent pregnancy. Unfortunately, reproductive hormones are vital to bone-building, among other developmental processes in the body too.

What Can Parents and Doctors Do?

The American Academy of Paediatrics published an updated clinical report in 2016 to highlight new findings in the female athlete triad and make both athletes, their parents, and the medical community aware of its dangers. No longer do doctors need to see the presence of all three risk factors (menstrual dysfunction, low EA, and bone loss) at the same time in an athlete; instead, even the existence of just one is a cause for concern and should be addressed.

It is meaningful because research has shown that the incidence rates of the entire triad are low, between 1 and 1.2% of female athletes. However, the incidence rate of at least one risk factor jumps up to as high as 78%, according to a 2009 study published in the Clinical Journal of Sports Medicine though many figures settle around one-third of female athletes.

Obtaining a complete history of exercise, nutrition, fractures, and menstruation is the primary step for any clinician treating a female athlete. Parents should keep a close eye on eating habits and have open and honest dialogues regarding excessive exercise and menstrual irregularities. Multivitamins are beneficial for active women and may be recommended in some cases of younger female athletes. However, experts agree that the diet should mainly supply nutrient intake, and you should consult a doctor before turning to supplements.

Research has found that girls in sports that emphasize leanness and incorporate weight-class, aesthetic, and endurance components are at higher risk for falling prey to the female athlete triad. Awareness, knowledge, and proactive steps can go a long way towards helping young female athletes evade long-term health effects from their training.

Page Reference

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  • FLEMING, J. (2018) What is the Female Athlete Triad? [WWW] Available from: [Accessed

About the Author

Joe Fleming is the President at Passionate about healthy lifestyles and living a full life, he enjoys sharing and expressing these interests through his writing. To inspire others and fight ageism, Joe writes to help people of all backgrounds and ages overcome life's challenges. His work ranges from articles on wellness, holistic health, and ageing to social narratives, motivational pieces, and news stories. For Joe, helping others is vital.