The Female Athlete Triad

Medically Reviewed by Tyler Wheeler, MD on August 12, 2022
5 min read

When 16-year-old "Whitney" made the varsity track team, she noticed that her best times were slower than the older girls, who were extremely thin. So Whitney began eating less. Within two months, she had dropped 11 pounds and reduced her body fat to less than 14%. Although her race times and endurance improved, Whitney's menstrual periods stopped.

Then, in her senior year, Whitney was predicted to qualify for the state track team. While running the day before the meet, she tripped on a tiny rock, fracturing her ankle. Though Whitney was lean, muscular, and appeared to be the picture of health, her doctor became concerned about her excessive dieting, low body weight, and loss of her period. These are all key risk factors for low bone density (osteoporosis) and fractures. He immediately ordered a bone density test, which tests the strength of bones. The test results showed that Whitney had low bone density and that she had the bone strength of a much older woman.

The female athlete triad is made up of three medical conditions that are becoming increasingly common in active teen girls:

  • Energy imbalance with or without an eating disorder
  • Menstrual disturbances
  • Decreased bone mineral density with or without osteoporosis

Low-calorie diets are usually the first sign of eating disorders. Excessive exercise or exercise obsession can be another sign.

Teens that are thin and exercise excessively are at higher risk of amenorrhea, the absence of a period. And amenorrhea is linked to decreased estrogen levels, which may be the cause of osteoporosis. A diet low in calcium and vitamin D can also contribute to low bone density.

Your doctor should evaluate and treat each of these three problems to ensure a healthy outcome.

Teen girls who restrict their eating and have amenorrhea are at highest risk for female athlete triad. Female athletes who try to reach a low body weight for running or dancing are more likely to have amenorrhea, as are those who compete in scoring sports such as gymnastics and figure skating.

The female athlete triad is a combination of three conditions. Each condition has symptoms to alert you that a problem exists:

Characterized by morbid fear of weight gain, certain eating disorders lead to severe restriction of food intake. This results in extreme weight loss or even starvation. Most female athletes are concerned about their body weight and shape, and may follow a strict diet. Avoiding key nutrients could lead to inadequate amounts of protein, iron, calcium, and zinc in the diet.

Women who diet excessively often eliminate dairy products. Dairy products are a primary source of calcium, which is vital for bone strength. Some studies say that less than 25% of adolescent girls get the calcium necessary each day through foods or supplements. This deficit comes at a critical time in the teen's life -- when girls should be building their bone mass to the highest levels.

Amenorrhea and other menstrual irregularities increase the risk of bone fractures. With amenorrhea, teenaged girls experience significant reductions in estradiol, the primary form of the female hormone estrogen.

Young female athletes who appear to be in top physical condition often have the highest risk of low bone density (osteoporosis) and fracture, especially if they experience disordered eating and loss of menstrual period.

Low body weight alone is not enough to explain the loss of menstrual periods. But it seems that amenorrhea happens when you take in fewer calories, so you're getting too little nutrition for the amount of exercise you're doing.

Your weight influences your bone density. For example, a woman who weighs less than 127 pounds is 10 times more likely to have lower bone density than a woman who weighs 150 pounds or more. Your risk of bone loss increases when you have a low percentage of body fat.

Teen girls with female athlete triad are at risk for early broken bones. In fact, a broken bone may be the sign that first alerts the doctor there is a problem. Up to 30% of ballet dancers suffer from repeated stress fractures, which points to problems getting enough bone minerals and to low body weight.

If you are a female athlete, it's important to minimize your risks as much as you can. For instance, be vigilant of training's effects on the body. Take action if you lose menstrual periods or if your body fat decreases significantly.

Athletes with menstrual disorders have lower estrogen levels, which often leads to lower bone mass. Findings show that a young woman who hasn't menstruated in four years may have the bone density of a 50-year-old woman.

Be sure to increase calcium in your diet (or through supplements), and eat enough calories to keep your body fat or weight from dropping too low. People who are too lean - with a body fat below 12% for the teenaged female athlete -- will not maintain strong bones.

Talk to your doctor about your risk factors for the female athlete triad. If you have had a broken bone without an associated major injury, consider a bone density test.

Also, check with your gynecologist about ways to correct very irregular periods. Some teens see their menstrual periods start again once they increase calories or reduce exercise.

Because bone loss is a serious result of female athlete triad, consume about 1,300 milligrams of calcium per day from calcium-rich or calcium-fortified foods. If this is not possible, add calcium and vitamin D through supplements. Also avoid carbonated beverages, which can also contribute to decreased bone density.

If you have a fracture, a sports medicine specialist can help you find other exercises (such as swimming) that will allow you to maintain aerobic fitness while it heals.

Also keep in mind that there are some forms of birth control that are not appropriate for women with calcium loss. If you use birth control, ask your doctor about the potential risks.