The Female Athlete Triad

by | Nov 21, 2019

Table of Contents


Female Specific Research – The Gap Is Narrowing

Right to work, right to vote, and in many other ways, women have not always been treated as equal to males. This has also been true in medical care with research being biased toward males. Obviously there are things that are unique to women where the research is certainly about them, but what about other conditions that affect both men and women? Thankfully, in the past 2-3 decades we have seen a shift leading to better understanding how conditions affect women and men differently and how our approach needs to be more specific to achieve success. It has still not gone far enough, but biases are being corrected.

One area where correcting this bias and rewriting practice is important is in sports medicine. Here, old schools of thought/practice not only lead to negative athletic performance but can also cause healthcare issues in the short and long term.


We can do better!

We see this in the way athletes strive for success and might try many different solutions. Some are self-directed based on what they read online or in magazines, and others can be under the guidance of professionals (coaches, PTs, doctors). In both cases, the bias of information may come from evidence or a historical way of doing things that is decades old with no regard for what we know. We only have to look at the recent story of Mary Cain in the New York Times and see how an approach to training that was guided by sports professionals broke female athletes and with it their potential and overall health (both physical and psychological). A big focus that has been alleged by Mary Cain, and since corroborated by both former male and female athletes, is that coaches from top to bottom in the Nike Oregon program were tying weight loss to improved performance. This is a very troubling issue, even moreso that the allegations of doping and a recent ban of the programs lead coach Alberto Salazar, but we’ll leave that for another blog! If you don’t have time to read the news article, check out the video below:

The issue that Mary Cain experienced is one that I have wanted to blog about for a while as I have seen recreational athletes affected in similar ways. Her story is extreme, where a coaching staff were publicly weighing the female athletes in front of each other. But, some of the athletes I see, particularly the younger girls, have the pressure of social media, peers, etc at a time in life that is challenging. We all remember how difficult adolescence was, but those of us in our 30s and above did not have to contend with social media; now that social media has been added to the growing up experience, our kids are feeling even more pressure both from peers and from society. In Mary’s story and that of these young girls we see stress fractures that have developed partly as a result of low caloric intake and high levels of athletic activity. This is now a diagnosis we call:


The Female Athlete Triad


The three parts that make up the diagnosis of the female athlete triad

Hoch AZ, Pajewski NM, Moraski L, et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clin J Sport Med. 2009;19(5):421-8.


When this diagnosis was first recognized all three parts of the triad had to be present to make a diagnosis. However, now the American College of Sports Medicine recognizes that they are so interlinked that only one needs to be present for a problem to exist.1 When the triad exists the long-term consequences are far-reaching and can affect the cardiovascular, endocrine, reproductive, skeletal, gastrointestinal, renal, and central nervous systems. 

First acknowledged in 1992, we have since seen research showing that one of these three factors in athletes and non-athletes is exceedingly common. It is seen in high school, collegiate, and elite athletes2. It is  especially common in sports with subjective judging (gymnastics, figure skating) or endurance sports that emphasize leanness (eg, running)3. It is also common to see in sports that have weight classes for competition.

So, what do we know about each part of the triad?


Low Energy Availability:

This can be either intentional or unintentional. It is often linked with eating disorders, anxiety and depression. Eating disorders are common in female athletes compared to the general population. One study looking at elite athletes found that 31% had eating disorders compared to only 5.5% of the general population4. Sports that tend to define “leanness” as a desirable quality such as track, or ballet, have been shown to have an even higher prevalence (47%) versus those in sports which did not make this emphasis such as basketball, or soccer (20%)5


Menstrual dysfunction

Low energy availability leads to a change in reproductive hormones and the menstrual cycle can become irregular or cease to occur (amenorrhea). Amenorrhea refers to the absence of menstrual periods. It can either be primary (meaning a woman never developed menstrual periods by the age of 15) or secondary (absence of menstrual periods in a woman who was previously menstruating for greater than 90 days). Secondary amenorrhea has been shown to be as high as 69% in dancers and 65% in long distance runners compared with 2-5% of the general population6.


Decreased Mineral Density (BMD)

Low energy availability and amenorrhea lead to a deficiency in estrogen which leads to a reduction in BMD. Lower BMD is called osteopenia, and lower still is defined as osteoporosis. Osteopenia has shown to be present in up to 50% of athletes and osteoporosis 13%7. The general population has rates of 12% for osteopenia and 2.3% for osteoporosis. 

Given that we know that 90% of BMD is attained by the age of 18, if an athlete has low BMD at that age it can mean they can have a lifetime of dealing with associated issues of the triad.


Why should we screen for the triad?

Untreated, we can see fatigue, poor sports performance, osteopenia and osteoporosis (leading to increased risk of stress fractures), anemia, heart arrhythmias, and amenorrhea. It really should be something that is considered at regular visits to a GP/PCP, specialists such as OBGYN, orthopedics, and also Physical Therapists. It has been recommended that screening is considered in the preparticipation screening for high school and collegiate athletes8. The group recommending this set out these questions:

Recommended questions regarding nutritional status menstrual function and bone health for the female athlete

Along similar lines the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Sports Medicine developed this simpler set of questions:

Simple set of questions for female athletes to see if thye are at risk of female athletic triad

Diagnosing the triad can be challenging, especially with respect to subtle changes in energy availability and menstrual disturbance. As such, if this is considered a possible diagnosis there should be involvement of other professionals such as a dietician, OBGYN, mental health professionals, coaches, physical therapists to name a few. Sadly I see many stress fracture patients who have been diagnosed and given initial treatment recommendations from an orthopedic perspective, but very few are asked about their cycle, their diet, or even are suggested to speak to their GP or other professionals about these issues. Very few people are considering the reasons why these people are developing stress fractures, instead just associating it with the sport. While the specifics of their sport can contribute, I see cases where there really is no cause from that perspective and it is appalling that no one has looked for one elsewhere.

If you answered ‘yes’ to some of the questions above, please consider talking to a medical professional to determine if you are being affected by the female athlete triad. (If you are unsure what medical professional would be best see, please do not hesitate to reach out to me! I will be happy to discuss your concerns and help you find the appropriate clinician.) They can help organize the necessary investigations or can refer you to specialists and other professionals as necessary. We need to remove stereotypes that are untrue and unhealthy and highlight women that should be a role model for female athletes. Mary Cain’s is an example of what we shouldn’t do on many levels, but a positive example is that of Gwen Jorgensen, Olympic gold medalist from Rio 2016 who showed by her tweet of a chart of her menstrual cycles that you can be regular and be at the top of your sport.


What should we encourage female athletes to do?

  • Not skip meals and snacks – Calorific intake should not be less than expenditure
  • Consider working with a nutritionist that understands the needs of athletes (check out our previous guest blog on nutrition)
  • Track periods – How regular and how heavy
  • Have adequate rest periods and sleep – working with a coach or physical therapist to help design a good training plan can help with this.
  • Reach out for help when there are concerns. E.g. Excessive fatigue, Pain that is not improving, abnormal periods, etc
  • Advocate for others – Be a good friend, coach, or health professional – Notice the risk factors and help the athlete to acknowledge there is a concern and need to seek help.


If you have questions, do not hesitate to reach out to me. This is something I am passionate about improving and If I cannot directly help you I will try and put you in touch with a professional that can.




  1. Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP; American College of Sports Medicine. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 2007; 39(10):1867–1882. doi: 10.1249/mss.0b013e318149f111.
  2. Thein-Nissenbaum JM, Carr KE. Female athlete triad syndrome in the high school athlete. Phys Ther Sport 2011; 12(3):108–116. doi: 10.1016/j. Ptsp.2011.04.002.
  3. Matzkin E, Curry EJ, Whitlock K. Female athlete triad: past, present, and future. J Am Acad Orthop Surg 2015; 23(7):424–432. doi: 10.5435/ JAAOS-D-14-00168.
  4.  Lynch SL, Hoch AZ. The female runner: gender specifics. Clin Sports Med 2010; 29(3):477–498. doi: 10.1016/j.csm.2010.03.003.
  5. Byrne S, McLean N. Elite athletes: effects of the pressure to be thin. J Sci Med Sport 2002; 5(2):80–94. doi: 10.1016/S1440-2440(02)80029-9.
  6. Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4(4):302-11.
  7. Khan KM, Liu-Ambrose T, Sran MM, Ashe MC, Donaldson MG, Wark JD. New criteria for female athlete triad syndrome? Br J Sports Med 2002; 36(1):10–13. doi: 10.1136/bjsm.36.1.10.
  8. De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013. Clin J Sport Med 2014; 24(2):96–119. doi: 10.1136/bjsports-2013-093218.
  9. Berhardt DR, Roberts WO, editors. Preparticipation Physical Evaluation, 4th Ed. American Academy of Pediatrics, Elk Grove Village, IL, 2010.

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