NEDA TOOLKIT for Coaches and Trainers
The Female Athlete Triad
By Kathryn Ackerman, MD, MPH
The Female Athlete Triad (the Triad), a term coined
in 1993 by the American College of Sports Medicine,
refers to a syndrome commonly seen in athletic
women. It involves the interrelated symptoms of
disordered eating, menstrual irregularity and low
bone mass. Although the exact prevalence of the Triad
is unknown, studies have found that nearly three-
quarters of female athletes have at least one sign of the
Triad, according to a 2009 study in the Clinical Journal
of Sports Medicine.
The idea of the Triad has evolved to include different
stages of a continuum on which many of our athletes
live. At one end of the spectrum are athletes with
mildly disordered eating (e.g., missing certain nutrients,
skimping on calories) who have irregular periods
(oligomenorrhea) and/or possibly experienced a stress
fracture. At the other end are women who have eating
disorders such as anorexia or bulimia, have long-
standing amenorrhea and have bone density in the
osteoporosis range. Low bone mass results in bones
that are easily fractured. For an athlete, apart from
being painful, such injuries can impair or even put an
end to a promising athletic future.
The interrelationship between food intake, menstrual
dysfunction and poor bone health is still being
elucidated. In general, when an athlete eats too
few calories, it causes brain hormone levels to
change, disrupting signals to the ovaries to produce
estrogen, which helps build and maintain bones.
Studies in individuals with anorexia have shown that
the restoration of normal menstrual periods via the
normalization of food intake and reduction of exercise
is the only effective way to begin improving bone
density. This is particularly important in adolescent girls, as
90% of peak bone mass is attained by age 18, with only
mild gains up to age 30. This means that disrupting
the menstrual cycle during adolescence and early
adulthood has a profound effect on bone health. If
caught early, however, some of the deleterious effects
of the Triad on bone health may be corrected. Through
their 30s, women’s bone densities tend to plateau if
diet and exercise are adequate. Bone density then
declines abruptly around menopause and usually
remains on a modest decline through the rest of the
lifespan. If young female athletes begin good habits
early, their peak bone mass is expected to be higher
than that of their sedentary counterparts, thus greatly
reducing the risk of osteoporosis later in life.
Causes of the Triad
Recent research has helped increase understanding of
what causes the Triad. One factor is the maintenance
of adequate body fat levels. Although some athletes
mistakenly believe that leaner is always better, this
isn’t the case. If an athlete tries to maintain a body fat
percentage that is too low for her individual genetic
makeup, it can result in hormonal abnormalities that
lead to Triad symptoms.
However, low body fat alone doesn’t cause the Triad — in
fact, symptoms have been documented in females with
adequate body fat. The triggering factor appears to be
prolonged inadequate energy intake, even without any
weight loss. The stress of strenuous physical activity
without sufficient energy replacement can cause the
body to shut off reproductive functions, as it doesn’t
have the energy to maintain a pregnancy. Therefore,
increasing nutritional intake and/or decreasing activity
should be the first line treatment for athletes with Triad
symptoms. How do you detect the Triad?
The signs and symptoms of the Triad are very broad,
and they involve all of its three components: eating and
exercise habits, menstrual irregularity and poor bone
health. • Low bone mass may manifest as stress
fractures or full fractures (e.g., in a long bone
such as the tibia or fibula or as a compression
fracture in the spine). Some stress fractures
are secondary to overuse and sports technique
(such as an uneven running gait), while others,
such as lumbar and femoral stress fractures,
are highly correlated with disordered eating.
Fractures are often early signs of low bone
density. Other low bone mass risks include a
history of malabsorption (e.g., Crohn’s disease,
ulcerative colitis, celiac disease), low calcium
and/or vitamin D intake, excessive alcohol
consumption, steroid use, and those with
either or both of the other two aspects of the
Triad. Low bone density can be detected by a
dual x-ray absorptiometry (DXA) scan.
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