female athlete triad

runner sillouette[source]

If you’re a female athlete you’ve probably heard of the female athlete triad – even if you didn’t know that’s what it was called. The female athlete triad is a combination of the following:

1. eating disorders or disordered eating

2. low bone mineral density

3. menstrual irregularity

There are varying degrees of each of the above and an athlete with the triad may display one condition more than another, but all three are closely related (1). Although female athletes from any sport can exhibit the triad, it is most common in sports that emphasize leanness or a low body weight for performance – gymnastics, ballet, distance running, and weight class sports.


In competitve sport environments, the pressure to perform can lead athletes to develop disordered eating behaviors. In fact, traits that make good athletes are also often the same as those the put one at risk for an eating disorder – perfectionism, high achievement orientation, and obsessive-compulsive tendencies (2,3). Disordered eating is different from a diagnosed eating disorder and can include things like avoiding certain foods/food groups, severely limiting calories to achieve a desired weight or body composition, and skipping meals. While many athletes may not meet all of the specific criteria for an eating disorder, a large number display disordered eating behaviors.

Some athletes may not even intend to alter their eating behaviors but, due to large training volumes, fail to meet their energy requirements and end up in an energy deficit, meaning they aren’t consuming enough calories to meet thier energy needs for daily life and training (4,5,6). Most websites and fitness apps do not provide reliable health and nutrition information, especially for an athlete training at a high level. Working with a sports dietitian is the best way to ensure that you’re meeting your specific energy requirements.


Whether intentional or unintentional, consuming fewer calories than your body requires forces your body to make several changes in order to survive. Processes that your body doesn’t feel are necessary for survival are essentially cut out in order to save energy for processes that are required for survival (7). This is why many female athletes struggle with menstrual irregularity or complete absence of the menstrual cycle (called amenorrhea). Reproductive function isn’t absolutely necessary for survival, so the body decides to take the energy that would usually be spent on normal menstrual function and use it elsewhere.

Although this may sound rather convenient, the hormones associated with normal menstrual function serve several other functions in the body, like normal bone and cardiovascular health (1,8). An abnormal menstrual cycle in the teens and early 20s when bones are still developing can lead to weak bones, stress fractucres, or even osteoporosis.


Hormone replacement therapy is often prescribed to athletes struggling with menstrual irregularity, but research suggests that this is not enough to overcome the hormal imbalance caused by inadequate energy intake and protect against bone loss or other detrimental effects (1, 9, 10, 11, 12, 13). The preferred method of treatment is increasing energy intake (1, 14, 15). However, for an athlete with an eating disorder, this is much easier said than done. If you or someone you know struggles with an eating disorder, seek help from medical professionals. A doctor, psychologist, and registered dietitian are all important parts of the team in helping an athlete overcome an eating disorder.

Although the main focus here is on females, male athletes can also suffer from disordered eating/eating disorders and, as a result, poor effects on their health. Recently, relative energy deficiency in sport (RED-S) was proposed as a new way to describe the effects of not consuming enough calories to support physical activity as a way to recognize that males can suffer from the consequence of under fueling as well (16).


1. Nattiv A, Loucks A, Manore M, Sanborn C, Sundgot-Borgen J, Warren M. The female athlete triad. Med Sci Sports Exerc 39: 10: 1867-1882, 2007.

2. Thompson R, Sherman R. “Good Athlete” Traits and Characteristics of Anorexia Nervosa: Are They Similar? 7: 3: 181-190, 1999.

3. Leon G. Eating disorders in female athletes. 12: 4: 219-27, 1991.

4. Loucks A. Low energy availability in the marathon and other endurance sports. 37: 4-5: 348-52, 2007.

5. King N, Lluch A, Stubbs R, Blundell J. High dose exercise does not increase hunger or energy intake in free living males. Eur J Clin Nutr 51: 7: 478-83, 1997.

6. Hubert P, King N, Blundell J. Uncoupling the effects of energy expenditure and energy intake: appetite response to short-term energy deficit induced by meal omission and physical activity. Appetite 31: 1: 9-19, 1998.

7. Wade G, Schneider J, Li H. Control of fertility by metabolic cues. Am J Physiol -Endocrinol Metab 270: 1: E1-E19, 1996.

8. Hoch A, Dempsey R, Carrera G, Wilson C, Chen E, Barnabei V, Sandford P, Ryan T, Gutterman D. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med Sci Sports Exerc 35: 3: 377-383, 2003.

9. Cobb K, Bachrach L, Sowers M, Nieves J, Greendale G, Kent K, Brown Jr B, Pettit K, Harper D, Kelsey J. The effect of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc 39: 9: 1464-1473, 2007.

10. Braam L, Knapen M, Geusens P, Brouns F, Vermeer C. Factors affecting bone loss in female endurance athletes – A two-year follow-up study. Am J Sports Med 31: 6: 889-895, 2003.

11. Keen A, Drinkwater B. Irreversible bone loss in former amenorrheic athletes. Osteoporosis Int 7: 4: 311-315, 1997.

12. Warren M, Brooks-Gunn J, Fox R, Holderness C, Hyle E, Hamilton W, Hamilton L. Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study. Fertil Steril 80: 2: 398-404, 2003.

13. National Institutes of Health Consensus Development Panel. Osteoporosis prevention, diagnosis, and therapy. 285: 6: 785-795, 2001.

14. Arends J, Cheung M, Barrack M, Nattiv A. Restoration of Menses With Nonpharmacologic Therapy in College Athletes With Menstrual Disturbances: A 5-Year Retrospective Study. Int J Sport Nutr Exerc Metab 22: 2: 98-108, 2012.

15. Mallinson R, Williams N, Olmsted M, Scheid J, Riddle E, De Souza M. A case report of recovery of menstrual function following a nutritional intervention in two exercising women with amenorrhea of varying duration. J Int Soc Sport Nutr 10: 34, 2013.

16. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED- S). Br J Sports Med 48: 7: 491-+, 2014.



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