Female Athlete Triad


Syndrome of three interrelated clinical entities: low energy availability (LEA) (with or without disordered eating [DE]), menstrual dysfunction (MD), and low bone mineral density (LBMD)


  • Female athlete triad first described in 1992 to include DE, amenorrhea, osteoporosis
  • In 2007, the American College of Sports Medicine (ACSM) updated the definition to: components including LEA (with or without DE), MD, and LBMD with each component representing an inter-related spectrum ranging from health to dysfunction.
  • LEA is fundamental to the triad, and full recovery is not possible without correction of it.
  • 2014 Female Athlete Triad Coalition (TC) Consensus Statement largely agreed with the ACSM’s update and included many recommendations (as later briefly outlined in this review).
  • 2014 International Olympic Committee’s position statement from 2014 deviated to consider “Relative Energy Deficiency in Sport” (RED-S) (1).
    • Focus on energy deficiency and its broader physiologic effects beyond bone and menstrual health, ranging from growth to cardiovascular.
    • Emphasized similar syndrome in males
  • Since then, debate has ensued between the classic TC model and RED-S. TC authors assert that RED-S movement is simply “rebranding” >30 years worth of triad research.
  • TC authors have since released papers introducing the concept of the Male Athlete Triad; consisting of LEA, functional hypothalamic hypogonadism, and LBMD.
  • Concept of energy deficiency in men involving reproductive and bone abnormalities
    • Men seem to be more resilient to the effects of LEA compared to women, requiring more severe energetic perturbations before alterations are observed. Recovery of the hypothalamic pituitary gonadal axis can be observed more quickly in men than in women.
    • Male triad needs to be further evaluated.



  • Overall prevalence: 3/3 criteria (LEA, MD, LBMD): 0–16%; 2/3 criteria: 3–27%; 1/3 criteria: 16–60%.
  • DE higher than general population
  • MD: Prevalence of secondary amenorrhea is as high as 60% in female athletes compared to 2–5% in the general population.
  • LBMD: Using the WHO criteria for LBMD, prevalence of osteopenia (T-score between −1 and −2) ranges from 0% to 40% in female athletes, as compared to ~12% in the general population.
  • Full triad is more prevalent in lean sports (1.5–6.7%), including swimming and cross country, versus non-lean sports (0–2%), including volleyball and softball.
  • Increasing recognition that LEA prevalence is very difficult to measure accurately due to variability in methods used for measurement.

Etiology and Pathophysiology

  • Energy availability is defined by energy intake minus exercise energy expenditure.
    • LEA can occur either intentionally or inadvertently. Examples include increasing training or DE (1).
  • When there is an LEA, energy is shunted from reproduction to more critical functions, such as thermoregulation cellular maintenance.
  • Specifically, LEA leads to suppression of luteinizing hormone (LH) pulse frequency and thus MD.
    • This process suppresses ovulation and estrogen concentrations, which can lead to decreased bone formation and increased bone resorption, ultimately leading to LBMD.
  • Triad elements exist along a bidirectional continuum of severity, ranging from “healthy” to “unhealthy.” Importantly, elements exist as a triad, although there is unidirectionally implication from one to another.
    • LEA (with or without an eating disorder) can lead to both MD and LBMD.
  • MD (via hypoestrogenemia) can lead to LBMD.
  • Other effects of LEA seem to include endothelial dysfunction and altered lipid profiles.
  • RED-S considers LEA to lead to broader physiologic effects including metabolic rate, growth and development, immunity, protein synthesis, hematologic, gastrointestinal, cardiovascular, and psychological.
  • TC authors hold that there may be a basis for RED-S, but it is insufficiently supported by evidence at the present time.

Risk Factors

  • History of menstrual irregularities and amenorrhea; history of stress fractures and recurrent or nonhealing injuries; history of critical comments about eating or weight from parent or coach; history of depression; history of dieting; personality factors including perfectionism and/or obsessiveness, overtraining, and inappropriate coaching behaviors
  • Lean physique sports with an aesthetic component (ballet, figure skating, gymnastics, distance running, diving, and swimming) or sports with weight classifications (martial arts and wrestling); frequent weigh-ins, consequences for weight gain, and win-at-all-cost attitude all increase risk.
  • A lack of family or social support; intense training hours; social isolation or entering a new environment (boarding school or college); an athlete with comorbid psychological conditions (anxiety, depression, and/or obsessive-compulsive disorder)
  • Age: A Japanese study found stress fracture in teenagers with the Triad but no stress fractures in athletes in their 20s.

General Prevention

  • Education of athletes (middle school through college), coaches, trainers, parents, and physicians. Young athletes are extremely impressionable and may turn negative comments and unhealthy advice into maladaptive eating and exercising habits.
  • General screening during preparticipation exam (PPE) and annual physicals are endorsed by AAP, AAFP, ACSM, AOSSM, and AMSSM.
  • TC has 11-question screening to use during PPE.
  • Screen athletes presenting with “red flag” conditions such as fractures, weight changes, fatigue, amenorrhea, bradycardia, orthostatic hypotension, syncope, arrhythmias, electrolyte abnormalities, or depression.
  • Screen for other conditions that may accelerate bone loss, including steroid use, tobacco use, alcohol use, and hyperthyroidism.

Commonly Associated Conditions

  • Anorexia nervosa, bulimia nervosa, avoidant or restrictive food intake disorder, and other psychological disorders, including low self-esteem, depression, and anxiety
  • LBMD predisposes athletes to stress fractures and may not be fully reversible. This may lead to a higher rate of fractures after menopause.

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