Female Athlete Triad

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What is Female Athlete Triad?

The “triad” that makes up the Female Athlete Triad are 3 interrelated health problems: 1) Energy imbalance 2) Abnormal menses, and 3) Osteopenia.  The reason for the verbage, “female athlete triad” is due to the observation that this condition predominantly affects female athletes.  Starting at energy imbalance, the cascade begins and affects hormone secretion centrally and subsequently affects menses and bone strength.

  • Energy imbalance:  The concept of energy imbalance essentially is taking in too few calories than what you are expending.
  • Abnormal menses and amemorrhea:  Amenorrhea, or the absence of menses (period) is due to the shutdown of the hypothalamus in the brain.  Normally, the hypothalamus secretes GNRH (gonadotropin releasing hormone) which gives the signal to the posterior pituitary gland to release luteinizing hormone (LH) and follicle stimulating hormone (FSH).  These in turn travel in the bloodstream to the ovaries and regulate menses.  With the shutdown of the hypothalamus by way of the energy imbalance, the “axis” is essentially not working and the ovaries are not getting the signal from LH and FSH for menses regulation, leading to an overall decrease in estrogen as well.  Prolonged menses(days between periods) are usually the first signs of female athlete triad, with amenorrhea being a more worrisome late sign.
  • Osteopenia:  The last chain in the triad, osteopenia is due to the falling levels of estrogen, which is essential in maintenance of bone health.  Bone mineral density (BMD) is then decreases, which puts the athlete at risk for stress fractures and eventual osteoporosis.

What are the signs and symptoms?

Insidious in onset, the signs and symptoms might at first be missed by patients or clinicians.  Patients may exhibit patterns consistent with eating disorders.  Furthermore, patients may also state changes, irregularities or complete cessation of their menses.  In the latter stages, patients may exhibit stress fractures of generalized bone pain or persistent aching.  The constellation of these symptoms should alert clinicians, coaches and parents to the possibility of the diagnosis.   Other symptoms related to ion imbalances from disordered eating include fatigue or depression.

How is it diagnosed?

As mentioned, diagnosis may be delayed or missed if suspicion isn’t high enough for the presence of the triad.  Screening questions regarding eating habits and checking for eating disorders may prove useful.  Laboratory studies and bone mineral density scans can also be used to help with diagnosis and the severity of the condition.  Blood tests usually include evaluation of centrally produces hormones, estrogen levels, and other nutrition markers.  Vitamin D and iron  can be directly measured as well.  Bone density scan (DEXA scans) can be utilized if suspected prolonged low estrogen levels that have caused osteopenia or osteoporosis, and is typically done after 6 months of amenorrhea. Amenorrhea has been found to be prevalent in a high percentage of endurance female athletes as opposed to the 2-5% of the normal population.


A multidisciplinary approach may be the most useful for patients to address the many different issues contributing to the issue.  This includes typically a sports physician, sports neuropsychologist, a nutritionist and of course a primary care physician.  The goal for the patient should include proper eating and a agreed upon proper weight for the patient.  It is also important to address any issues that the patient may be experiencing psychologically related to societal, peer, and coach pressures to be low weight.  Monitoring of the patients progress should be closely followed.  HRT, or hormone replacement therapy, can be considered, but it is not typically used and studies remain unclear whether or not this helps with for the prevention or reversal of any bone loss.  Furthermore, the root cause of the bone loss in this instance isn’t being directly addressed (energy imbalance)- which needs to be at the forefront of care. Vitamin D supplementation of 1000-2000 mg/day can also help for absorption of calcium- leading to good bone health. Higher doses may be used for those who are Vitamin D deficient .


The most critical aspect of prevention for the Female Athlete Triad is education for parents, coaches, and adolescent athletes.  Because of pressures for female athletes to be thin and lean for performance they may find themselves developing energy imbalance with insufficient caloric intake compared to expenditure.  Athletes and coaches alike need to understand that amenorrhea or irregular menses isn’t due to good athletic conditioning, but rather a sign of energy imbalance that needs to be addressed.  This can prove challenging, in particular for male coaches to speak with their female athletes about.  In this instance, screening during annual physical examinations from primary care providers regarding the patient’s eating habits and period regularity can help in catching issues early on.

By Clayton Andrews and Mo Mortazavi, MD