Female Athlete Triad

February 13, 2019

By Ethan Konoza SCAT, ATC, NASM-PES, Athletic Trainer 

The three components of the female athlete triad include: 1) low energy availability; 2) menstrual dysfunction; and 3) low bone mineral density (Nazem & Ackerman 2012;De Souza et al., 2014; Powers & Howley, 2018).

According to the literature on the female athlete triad, energy availability seems to be the biggest risk factor for developing both menstrual dysfunction and low bone mineral density (American College of Sports Medicine [ACSM], 2007). As outlined in the ACSM’s position statement on the female athlete triad (2007), energy availability is defined as a dietary energy intake minus exercise energy expenditure. An imbalance in terms of dietary intake and energy expenditure results in the inability to support cellular activities to maintain homeostasis as well as inadequate energy available required for skeletal muscles to function in sporting activities or even activities of daily living (Powers & Howley, 2018; Matzkin, Curry, Whitlock, 2015). Per ACSM’s (2007) definition, this low energy availability is due to insufficient energy intake, which may or may not be associated with disordered eating. While eating disorders may be the cause in this low energy availability seen in the female athlete triad, this does not necessarily have to be case. Through physical exertion during training and exercise, athletes can expend large amounts of energy and burn a significant amount of calories. This alone can create a low energy availability balance and may not be the result of an eating disorder; rather the athlete is just not consuming an adequate amount of energy to meet requirements of their expenditure.

Looking specifically at the development of menstrual disorders within female athletes, there can be many factors that play into this including; overtraining, psychological stress, and as previously stated low energy availability (Powers & Howley, 2018; Kelly & Hecht, 2016; De Souza et al., 2014; Javed, Tebben, Fischer, Lteif, 2013). Amenorrhea is the absence or cessation of menses, which is the most common menstrual disorder associated with the female athlete triad. The incidence of amenorrhea within female athletes compared to non-athletes is significantly higher, with the highest rate of incidence seen in sports that need low percentage of body fatness like distance running, competitive cheer, ballet, and gymnastics (Kelly & Hecht, 2016; Warren & Chua, 2008). Specifically looking at distance runners, it has been shown that there is a linear relationship with training distance and incidence of amenorrhea (Powers & Howley, 2018). While there may be several factors as to why this relationship may affect the menstrual cycle and lead to amenorrhea such as changes in levels of hormones, exercise induced stress, and inadequate fat stores, for the purpose of this discussion we will focus on the possibility of low energy availability being the cause in the case of the female athlete triad. Increased levels of exercise or training will result in higher levels of energy expenditure. This increase in energy expenditure coupled with inadequate dietary energy intake (with or without an eating disorder) will ultimately result in low energy availability at a cellular level. This low energy availability can impair normal reproductive signaling processes and result in amenorrhea (Nazem & Ackerman, 2012; Warren & Chua, 2008). The resulting cessation or absence of menses can lead to the ovaries reducing the amount of estrogen produced leading to decreased levels of estrogen in the blood. The decreased estrogen blood levels due to amenorrhea will increase the risk of bone mineral loss and could result in osteoporosis (De Souza et al., 2014; Kelly & Hecht, 2016; Powers & Howley, 2018). Furthermore, inadequate dietary intake can lead to deficiencies in calcium as well as vitamin D contributing to an even greater loss of bone mineral density when coupled with low estrogen levels in the blood (De Souza et al., 2014; Kelly & Hecht, 2016).

As previously stated, the components of the female athlete triad are interrelated. Irrespective of the cause of low energy availability, this depletion of availability of energy can play a role in the development of the two other components of the triad; disturbances in the menstrual cycle and decreased bone density (Nazem & Ackerman 2012; Javed, Tebben, Fischer, Lteif, 2013; De Souza et al., 2014; Kelly & Hecht, 2016; Powers & Howley, 2018). The recommended goal of treatment across the literature is to restore regular menstrual cycling and enhancing bone mineral density (Nazem & Ackerman 2012). This can be achieved through modification of diet and training plans to increase energy availability. That is creating greater energy availability through reducing energy expenditure and maximizing energy intake. Specifically increasing vitamin D and calcium intake is key for increasing bone mineral density and overall bone health especially in younger female athletes (Nazem & Ackerman 2012;De Souza et al., 2014; Kelly & Hecht, 2016; Warren & Chua, 2008). Adjusting diet and altering exercise and training regimen may be difficult initially, however with education from health care professionals, coaches, and parents this process can be made easier.

The female athlete triad is a condition that may have serious and negative implications to many young women participating in athletics. Prevention, early recognition, diagnosis, and multidisciplinary treatment of the female athlete triad is paramount in ensuring the more severe health problems associated with this condition do not develop. The current literature suggests that focus should be placed on proper nutrition to ensure adequate energy availability and resumption of a normal menstrual cycle is vital. Health care professionals, coaches, and parents should educate themselves and their athletes on this condition with the aim to prevent development of any one of these components of the female athlete triad.


De Souza, M. J. et al. (2014). 2014 Female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. British Journal of Sports Medicine. 48(4):289.

Javed, A., Tebben, P. J., Fischer, P. R., Lteif, A. N. (2013). Female athlete triad and its components: toward improved screening and management. Mayo Clinic Proceedings. 88(9):996-1009.

Kelly, A. K. W., & Hecht, S. (2016). The female athlete triad. American Academy of Pediatrics Clinical Report. 138(2).

Matzkin, E., Curry, E. J., Whitlock, K. (2015). Female athlete triad: past, present, and future. Journal of the American Academy of Orthopaedic Surgeons.23(7): 424-432.

Nazem, T. G., & Ackerman, K. E. (2012). The female athlete triad. Sports Health. 4(4): 302-311.

Powers, S. K., & Howley, E. T. (2018). Training for the female athlete, children, special populations, and the masters athlete. In Exercise physiology: Theory and application to fitness and performance (508-513). New York, NY: McGraw-Hill Education.

Warren M. P. & Chua, A. T. (2008). Exercise-induced amenorrhea and bone health in the adolescent athlete. Annals of the New York Academy of Sciences. 1135: 244-252.