The female athlete triad is a group of 3 medical conditions—low energy availability, menstrual changes and weak bones—seen in some competitive female athletes. These issues may start when athletes don't eat enough to fuel the energy they use in training. The triad is considered part of a broader condition called Relative Energy Deficiency in Sport (RED-S).
Preventing the female athlete triad is important, since it can interfere with normal growth and development and lead to injury and loss of strength. Knowing the signs early can help keep your teen healthy and strong.
The 3 conditions of the female athlete triad
Low energy availability
Energy availability issues (not having enough energy to fuel the body) occur when athletes eat fewer calories than their bodies need for growth, development and exercise.
Some athletes choose to limit their calories to improve performance or appearance. Other athletes are unaware that they aren't eating enough calories to meet the energy demands of their sport. An athlete may be eating enough for a nonathlete but not enough for an athlete.
For example, if an athlete only eats 2,000 calories per day but uses 3,200 calories, they are eating 1,200 calories less than their body needs. Not having enough calories (energy) can hurt performance, slow growth and development, and increase the risk of injury and illness. Eating disorders, such as anorexia or bulimia, are one cause of inadequate food intake.
Athletes of any sport may have low energy availability. However, athletes in sports that emphasize leanness may be at greater risk of low energy availability. Examples include gymnastics, dance, diving, figure skating, long-distance running and cross-country skiing, or sports that use weight classifications, such as wrestling, martial arts and rowing.
Menstrual problems
Not eating enough calories can cause menstrual periods to become irregular (oligomenorrhea) or stop (amenorrhea). In young athletes who aren't eating enough calories, menstrual periods may not start when they should.
Primary amenorrhea is when menstrual periods don't start before 15 years of age.
Secondary amenorrhea is when regular menstrual periods stop for 3 months or more.
Oligomenorrhea is when the time between menstrual periods is longer than 35 days.
All types of amenorrhea can be caused by not eating enough calories for energy expended; they are not caused by low body fat or the stress of exercise.
Weak bones & stress fractures
When a young athlete doesn't eat as many calories as their body needs and has menstrual problems, their bones do not develop the normal strength. When this happens, a 16-year-old girl can have bones as weak as those of a 60-year-old woman.
Weak bones raise the risk of stress fractures and, in severe cases, compression fractures in the spine. Bone loss continues until normal periods return. Even then, while some bone strength can be regained, they may never fully catch up to where their bone density should be.
Preparticipation screening questions for the female athlete
During a sports preparticipation examination female athletes may be asked the following questions related to the female athlete triad. If components of the female athlete triad are suspected, the doctor may perform an expanded physical examination.
At what age did you begin menstrual periods?
How often do you have a menstrual period?
How long do your periods last?
When was your last menstrual period?
Have you ever taken birth control pills? If yes, when?
How many meals and snacks do you usually eat each day?
List the foods and drinks you had yesterday.
List the foods and drinks you try to avoid.
Do you drink milk or calcium-fortified orange juice? Do you eat yogurt or cheese? How much each day?
What has been your highest weight, and when?
What has been your lowest weight in the past 2 years?
Are you happy with your current weight?
What do you feel your ideal weight would be?
Have you ever tried to control your weight by dieting? Vomiting? Laxative use? Diuretics? Exercise?
What sports do you participate in?
How much time do you spend training for each sport each week?
Do you do extra workouts, such as aerobic classes, in addition to your sports training? How much extra time do you spend?
Have you ever had a stress fracture? When?
Preventing female athlete triad
The female athlete triad can be prevented by eating enough calories, including fat, protein and carbohydrates. Most female athletes need a minimum of 2,000 to 2,400 calories per day. Not only will this prevent menstrual problems and weak bones, it will help the athlete perform better!
If an athlete develops menstrual problems, they need to see a doctor. It is not normal to skip periods or stop having periods. If they cut out the fats or carbohydrates in their diet, decrease the amount of food they eat, lose weight or skips period, they should tell their doctor. Finally, if an athlete feels they need to lose weight, they should consult their doctor first.
Treatment & recovery
An athlete not having regular menstrual periods should tell her doctor. The doctor needs to make sure there are no other reasons, such as thyroid disease, for menstrual problems.
If a lack of enough calories is the cause of the menstrual problem: It is important that the athlete increase their food intake. They will need to eat all the nutrients their body needs, which include carbohydrates, fats and protein. They may find it helpful to see a registered dietitian for nutrition counseling. The athlete should gradually increase their food intake until their menstrual periods return.
If it is difficult for the athlete to increase their food intake: They may need to decrease their exercise and sports activity instead. Once menstrual periods return, the athlete can slowly increase their activity again while increasing their food intake to maintain menstrual periods.
If an athlete is not having regular menstrual periods: They need to eat 5 servings of calcium per day. A serving would be 1 cup (8 ounces) of milk, yogurt or calcium-fortified orange juice or 1 ounce of cheese. Vitamin D is also needed because it helps the body absorb and retain calcium. Adolescents who do not get 600 IU of vitamin D per day through foods should check with their doctor about taking a supplement.
If an athlete struggles with increasing their food intake: Their doctor may refer them to a mental health professional, such as a psychologist, for additional counseling.
More resources