The Female Athlete Triad

The Female Athlete Triad is a health concern for active women and girls who are driven to excel in sports. It involves three distinct and interrelated conditions: disordered eating (a range of poor nutritional behaviors), amenorrhea (irregular or absent menstrual periods) and osteoporosis (low bone mass and microarchitectural deterioration, which leads to weak bones and risk of fracture).


Exercise alone does not put someone at risk for developing the Triad; however, an energy deficit, in which caloric intake doesn’t match energy expenditure, is a risk factor. All women face societal pressure that “thin is in.” A young woman or girl who is determined to achieve a lean appearance or athletic success may attempt to excel through compulsive dieting and exercise. (Such athletes are typically goal-oriented perfectionists.) This misguided approach may lead to disordered eating, menstrual dysfunction and lower-than-normal bone mass formation.


Anyone may be affected, but women and girls participating in activities which emphasize leanness are at especially high risk. These activities can include:

  • Gymnastics
  • Ballet
  • Diving
  • Figure skating • Aerobics
  • Running

Weight class sports associated with disordered eating in athletes, including males, are:

  • Wrestling
  • Rowing
  • Martial arts


In response to pressure to lose weight, women and girls may practice unhealthy weight-control methods, including restricted food intake, self-induced vomiting, consumption of appetite suppressants and diet pills, and use of laxatives and compounds to increase urination. Specific eating disorders are anorexia nervosa and bulimia. Many girls and women hide or deny their eating disorders due to embarrassment, shame, fear of losing control of their dieting and a mistaken believe that excessive weight loss enhances performance.


  • Excessive leanness or rapid weight loss.
  • Preoccupation with weight, food, mealtime rituals and body image.
  • Avoiding team meals, or secretive eating.
  • Wide fluctuations in weight.
  • Daily vigorous exercise in addition to regular training sessions.
  • Stress fractures (i.e. microfractures of bones that may progress to complete fractures)
  • Yellowing of the skin.
  • Soft baby hair on the skin.
  • Frequent sore throats despite no other signs of respiratory illness (self-induced vomiting)
  • Chipmunk-like cheeks from swollen parotid glands (self-induced vomiting)
  • Many dental cavities and/or foul breath (self-induced vomiting)
  • Fatigue, light-headedness or dizziness.
  • Depression or low self-esteem.


Eating disorders are serious, chronic medical and psychological illnesses. Individuals with untreated chronic anorexia or bulimia may die prematurely from heart problems, blood electrolyte (i.e., salt) disorders, suicide or other health problems. If these disorders are recognized early, however, treatment may be effective.


An unbalanced diet, inadequate caloric intake relative to exercise level and excessive training may predispose females to menstrual abnormalities. Any female who hasn’t started menstruating by age 16, misses three consecutive periods or has periods that occur at intervals of greater than 35 days should be evaluated by a physician. Before attributing menstrual abnormalities to exercise, other conditions – such as pregnancy, abnormalities of the reproductive organs or thyroid disease – must be ruled out.


Osteoporosis refers to low bone mass and fragility of the skeleton. Low estrogen levels and other hormonal changes, which accompany irregular or absent menstrual periods, may predispose females to osteoporosis, especially in their teens and twenties when bone mass is accumulating. A 20-year-old woman without menses during her critical teenage growth period may have bone mass typical of a 70-year-old woman, predisposing her to stress fractures and fractures later in life. Adequate nutrition fosters good bone formation. Calcium requirements for teenage girls and young women with normal menses is 1,200 mg per day. Females with irregular or absent menses require 1,500 mg of calcium and 400 mg of Vitamin D per day.


Emphasis or pressure to achieve unrealistically low body weight should be avoided by coaches, parents, athletic administrators and health professionals. Out-of-competition “weigh-ins” should be discouraged. Rules governing sports should be examined, and rules encouraging excessive leanness should be eliminated or revised. Athletes and coaches should be encouraged to look for warning signs of eating disorders.


Although individuals with disordered eating or amenorrhea may deny nutritional or health problems and are reluctant to seek care, medical attention is mandatory. An athlete should be reminded that medical care and proper nutrition may enhance performance. If an eating disorder or amenorrhea is suspected, the involved individual should be strongly encouraged or required to seek medical attention. If the individual refuses, the concerned coach, friend or parents should consult with a physician directly. Treatment of the Triad often requires intervention via a team approach, including a physician, nutritionist, psychologist, and the support of family, friends, teammates and coaches.

Republished with permission of the American College of Sports Medicine. Copyright © 2011 American College of Sports Medicine.

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