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What is Female Athlete Triad?

Women and teen girls who are competitive athletes are vulnerable to a condition that their male counterparts aren’t: female athlete triad (or “triad”). Triad, first identified in 1992, is a syndrome of three clinical factors created by nutrient depletion that disrupts/halts menstruation, accelerates bone aging and energy fluctuations as well as disrupts menstruation.

According to American Family Physician, female athlete triad is defined as “a spectrum disorder of three interrelated components: (1) low energy availability due to disordered eating, eating disorder, or lack of nutrition relative to caloric expenditure; (2) menstrual dysfunction; and (3) low bone mineral density (BMD).” Authors of one journal article underscore that in triad, “low estradiol concentrations due to amenorrhea decrease bone mineral density (BMD).”

Competitive female athletes are by necessity fixated on body weight and fat percentage, no matter the sport. However, in this quest to attain the most powerful, perfect and poised physical vessel, many women practice extreme eating behaviors (or “disordered eating”) as calorie count and composition are rather fanatically monitored.

According to certified sports nutritionist and endurance sports coach Matt Fitzgerald (author of Racing Weight), for women athletes, desirable body fat (BMI) ranges swing from 12% for runners,12-16% cycling,19-21% swimming,12-15% triathlete, and11% cross-country skiing. Healthy BMI for female non-athletes who work out regularly is between 18.5 and 24.9%.

Authors of another journal report explain that any female athlete can develop triad. “However, females participating in endurance sports such as track and field, swimming, and rowing or those requiring subjective judging like gymnastics and figure skating are most at risk.”

Given that exercising, i.e., training, working out, is a daily priority to remain in competitive shape, the other daily activity that needs rigid control is diet. It is the intensity of both interdependent activities that can often set the stage for triad to develop. As the American College of Sports Medicine position paper elaborated, the triad envelops “the interrelationships among energy availability, menstrual function, and bone mineral density, which may have clinical manifestations including eating disorders, functional hypothalamic amenorrhea, and osteoporosis.” 

In female athletes, estrogen and progesterone levels are impacted significantly by continuous, strenuous training. When the hormonal profile fluctuates excessively, menstruation is impacted, potentially causing amenorrhea (when periods stop altogether).  According to one triad expert, female athletes with triad-induced amenorrhea have up to a four-fold increased risk of stress fracture as well as a 10 to 20% reduced lumbar spine bone-mineral density compared to athletes with normal menstruation. 

Although it seems counterintuitive, female athletes who are in enviable physical shape can be more at risk for bone fractures if they have triad. In one study of 239 female athletes who reported either irregular period or amenorrhea (triad risk) one or more bone stress injuries occurred in 10.5%. 

Data collected in 2018 show that 36% of female high school athletes reported low energy availability, up to 54% have menstrual irregularity, and up to 19% have low bone mineral density (BMD). In aesthetic and endurance athletes (eg, gymnastics and track, respectively), 10% to 15% have at least two components of the female athlete triad. 


Triad becomes noticeable when the female athlete experiences more frequent musculoskeletal injuries and more bouts of low energy that affects competitive performance or training. Long-term risk of triad can be infertility, habitual disordered eating and early-onset osteopenia.


The anchor in triad development is, without a doubt, food consumption, or simply diet. In triad, female athletes exhibit several key characteristics in their dietary habits. Energy restriction tends to also prohibit the female athlete’s intake of protein, making her daily levels fall short. According to the Gatorade Sports Science Institute, “To preserve lean tissue during periods of energy restriction, protein intake (g/kg body weight) needs are greater than during periods of energy balance.”


Additionally, they pointed out, “The micronutrients most likely to be low in the diets of active women are iron, zinc, calcium, vitamin D and the B-vitamins (folate, B-6, thiamin, riboflavin) especially if energy is restricted, poor food choices are made, or gastrointestinal issues are present.”


For active females, a diet of less than 1,800 calories a day suppresses the ability to obtain nutrients required for energy metabolism, maintenance of bone and blood, and general health.


Therefore, say authors of a review, “The cornerstone of treatment is improving mismatched energy balance.”

Tips to Stay Fit and Healthy

If you plan on becoming competitive or training, you don’t have to resign yourself to believing that triad is in your future. There are things you can do, according to one resource.

Monitor your nutrient intake. The ages-old mantra of consuming a diet free from junk and rich in good fats, protein, and carbs from vegetables is the right way to eat. This diet too provides an abundance of a wide scope of micronutrients (vitamins, minerals, enzymes and antioxidants). 

Eating enough carbohydrate to match the energy demands of sport will assure adequate glycogen replacement and the potential for high-level performance.


Adequate protein is necessary for maintaining and repairing muscle and bone, and good health. Protein needs can range from 1.2-2.0 g/kg body weight per day and intake should be spread throughout the day.

Get plenty of rest.  When you are asleep or at rest, your body is better able to repair, rejuvenate, refresh and renew. According to an article in Yoga Journal, “When you’re in it to win it, take a 15- to 20-minute nap just before a competition. The short snooze will help you deliver physically and mentally.”

Get counseling if needed. Don’t be afraid to reach out for help if you find yourself obsessing over your calories both incoming and outgoing and have altered your life to hyper-focus on this interrelationship. This is a common cognitive behavior among athletic women, and it can be resolved through counseling so that you can remain healthy and active and keep triad from setting in. You can re-learn how to correct the energy imbalance by either or both increasing calories consumed and reducing calories expended via workouts.

Use creative visualization. According to one source, soccer star Carli Lloyd (who was the 2015 US Soccer Female Player of the Year) said that prior to each competition, she spends a few dedicated moments visualizing what she wants to happen during the game. In the 2015 World Cup Final, she envisioned scoring four goals – she scored three. 


Many women who set their sights on getting into outstanding physical shape to compete or just to be in outstanding physical shape should keep in mind that it might take longer, or extremely low BMI won’t be achieved – but paying attention to diet will have many benefits beyond just athletic ability and looking great. 

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