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female athlete triad

Female athlete triad: This profound risk remains under-recognised by support professionals

The recent Olympic games put the world’s top athletes on display in more ways than one. As well as appreciating the extraordinary performance achievements, we were able to admire the extremes of physical development to which elite athletes hone their bodies. And as we are less used to seeing muscly and highly toned female bodies, it is the women who particularly stand out, from the solidly-muscled tiny frame of a Kelly Holmes, to the willowy, fat-free physique of Paula Radcliffe, the powerful stick-thinness of the high jumpers or the lithe and unfeasibly supple bodies of the gymnasts.

Most women would never dream of trying to attain such extremes. And for most, the lifetime benefits of moderate exercise far outweigh any risks to our bodies. But some younger women, particularly if they are embarking on a sporting or dance career, are vulnerable to a condition known as ‘the female triad’ (female athlete triad), a combination of three dysfunctions that can spiral their bodies into injury and very serious long-term health consequences.

Health professionals dealing with female athletes – and especially adolescents – need to be aware of the female triad. It is complex and insidious: apparently physically fit and healthy women may be suffering from it and the condition needs to be caught early before the big damage sets in.

What is the female triad?

The American College of Sports Medicine coined the term in 1992, to describe a group of three disorders seen in adolescent and young female athletes(1). The three conditions are:

  • disordered eating
  • amenorrhoea
  • osteoporosis.

Each of the three has been recognised for years in its own right, and sometimes in combination. Specialists in eating disorders have studied their various forms (notably anorexia and bulimia) and the link with amenorrhoea (disappearance of menstrual cycle or in younger women delayed onset of menstruation). Scientists have also been aware of the links between exercise-induced amenorrhoea and osteoporosis for the past 15 years. However, the consequences of the three disorders acting together have really only started being studied in the past 10 years(2).

How common is it?

There have been many studies looking at the eating habits of athletes, but none of them gives us a reliable measure of the prevalence of the female triad. Under-reporting, false information by study participants and variations within different sports make it hard to get an accurate picture of the true extent of the phenomenon. One study found amenorrhoea in 50% of female runners and ballet dancers, and disordered eating in 15-62% of female athletes (the very wide range in this latter finding is thought to be explained by athletes’ outright denial or failure to recognise the signs as a problem)(2).

Are certain athletes prone to it?

The female athlete triad is more common in sports where it is important for participants to keep within a strictly imposed weight threshold, and/or where the aesthetics of the sport demand that an athlete should be thin, for instance, ballet, running, gymnastics and swimming. But it would be a mistake to assume that any sport is immune to this condition and the presence of a well-muscled body does not exclude the development of the female triad.

Part of the problem with recognising the condition is that the athlete may look ‘normal’ for that sport. However, it is the role of the coach and other allied sports support professionals to advise on adequate nutrition and sufficient energy intake to meet the demands of the training regime.

Simple height and weight measurements should be kept and support staff should make regular assessments of both body fat and body mass index. Questioning a female athlete about her menstrual cycle is not inappropriate and it should be part of your routine health monitoring.

Other important clues may come from your athlete’s behaviour. How is she with her team mates? What does she eat? Does she go off to the toilet often during training? Is she constantly self-critical about her body shape and weight? Is she training excessively? What family and sponsorship pressures is she under?

You should be on the lookout for signs of anorexia or bulimia. Loss of muscle bulk, dry skin and hair, cold hands and feet, puffy face and ankles, erosion of tooth enamel, bite marks on knuckles from vomiting and bloodshot eyes could all be warning signals(3,4).

To detect osteoporosis without resorting to a bone mineral density scan is harder. However, female athletes presenting with stress fractures should put you on immediate alert. In particular, fractures of tibia, fibula, inferior pubic ramus and L5 pars interarticularis should arouse suspicion. The combination of poor dietary intake of calcium and amenorrhoea both contribute to the development of osteoporosis.

The decrease in oestrogen levels that occurs when menstruation stops has been likened to an early menopause in its effects on bone density. The drop in density occurs quickly and studies are beginning to emerge that suggest that bone density is never completely regained after the athlete ends their career(5).

How can it be prevented?

Education has to be the key. At all levels, but especially when young women are starting to get serious about a possible sporting or dance career, sports professionals have a great responsibility to ensure these young people’s goals are compatible with their basic body type. To continue to push athletes to strive for the genetically impossible will set them up for long-term injury. It is also crucial to promote a healthy, nutritionally complete diet, supplemented if necessary to take account of the specific demands of the sport.

The female athlete triad needs to be caught and confronted early; management will probably require the collaboration of a multi-disciplinary team of nutritionists, doctors, psychologists and physiotherapists.

Simple steps can be:

  • Reduce training activity by 10- 20%, but couple this with an increase in resistance training. This is important for two reasons: psychologically the athlete still feels that they are progressing in their hard-fought fitness and development; and the resistance training may also help to stimulate the bone metabolism.
  • Assess dietary patterns and start a gradual increase in calorific intake.
  • Agree an increase in body weight over a set time period.
  • Introduce multivitamins and minerals into the diet, especially calcium.
  • Educate the athlete and her family.
  • Assess the pressures being placed on the athlete to succeed and remove some of those pressures, eg sponsors.

It is important to remember that the female triad has complex triggers: it is not just the athlete’s problem alone. To overcome this condition, you will need to examine and advise changes to the lifestyle both of the athlete and also her family and friends. The sports professionals dealing with the athlete, including the coach, must reassess their training methods and style to ensure that you are not unwittingly encouraging, or at least offering an excuse for the athlete to stick to her unhealthy pattern of behaviour.

The female athlete triad does have long-term consequences for the health of women. Failure to develop strong well-mineralised bones at an early age can lead to osteoporotic fractures, which will not just cause a premature end to their athletic careers but will also have implications for their future lifestyle, fertility and health into old age.

Diane Back and Marianne Smethurst


  1. Otis CL et al ‘American College of Sports Medicine position stand: The Female Athlete triad’. Med Sci Sports Exerc 1997; 29 (5) i-ix
  2. Teitz C The female athlete. Rosemont IL American Academy of Orthopaedic Surgeons 1997
  3. Smith A, et al ‘The Female Athlete Triad, Causes, diagnosis and Treatment’. Phys. Sports Med 1996, 24(7) 67-8
  4. Nattiv A et al. ‘The Female Athlete Triad’. Clin Sport Med. 1994 13(2) 405-418
  5. Mickelsfield LK et al. ‘Bone mineral density in mature pre-menopausal ultramarathon runners’. Med Sci Sports Exec 1995, 27: 688-696

female athlete triad