Female Athlete Triad

The Female Athlete Triad

The female athlete triad consists of the combination of disordered eating, amenorrhea, and osteoporosis. Each factor is interdependent and the normal precursor is frequent and intense athletic participation.

Disordered Eating

Anorexia Nervosa and Bulimia are the most known forms of eating disorders because of their severity, but there’s a range which starts simply with a preoccupation with food or body image.

In our society it’s nearly impossible to objectively examine nutritional habits and caloric intake due to our over-emphasis on "thinness." Sports with subjective judging are usually most correlated with female nutritional problems, for example dancing, figure skating, diving, and gymnastics. Although, sometimes these women starve themselves, often times they are encouraged by their parents or coaches to strive for a body built (stereotypically) exact for their specific sport.

The prevalence of eating disorders ranges from 15% to 62% depending on the sport. Athletes in sports with weight classifications tend to be more prone to eating disorders, for example martial arts and rowing. For maximum performance the major factor is lean body mass, not percentage body fat, and what often happens is during extreme dieting muscle mass gets lost along with fat, resulting in hampered performances.

Lots of times coaches and trainers advise athletes on ideal body fat percentage by using underwater weighing techniques, which is the traditional way to calculate body composition, but based on a standard value for bone density. The problem is that with women with amenorrhea and decreased bone density these formulae with over-estimate the percentages of body fat, forcing them to want to lose yet more weight. 0.5% to 1% of adolescent and young adult women have anorexia nervosa, and 2% to 4% of them have bulimia. Over 90% of athletes with anorexia or bulimia are adolescent girls and women. Anorexia Nervosa was first described in the late 19th century and bulimia was first defined in 1976.

Diagnostic Criteria For Anorexia Nervosa

  • Refusal to maintain body weight at or above a minimally normal weight for age and height.
  • Intense fear of gaining weight or becoming fat, even though underweight.
  • Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
  • In post-menarcheal females, amenorrhea, ie, the absence of at least three consecutive menstrual cycles.

Diagnostic Criteria For Bulimia Nervosa

  • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g.. a feeling that one cannot stop eating or control what or how much one is eating).
  • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
  • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
  • Self-evaluation is unduly influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of anorexia nervosa.

The consequences of eating disorders can be from impaired performance to death. Women with untreated anorexia and bulimia may die, 10% to 18% of these women may die from suicide, blood chemical abnormalities, and cardiac problems. Also, insufficient caloric intake can lead to menstrual disturbances and subsequent osteopenia.

Athletic Amenorrhea

Excluding pregnant women amenorrhea is present in up to 5% of the general population, and 10% to 20% of intensely exercising women. The prevalence may reach upwards of 50% for elite runners and professional ballet dancers. Normal ovulatory function is directly correlated with the stress of intense training.

Amenorrheic athletes are extremely likely to have begun earlier than normally menstruating athletes. Body fat used to be thought of as the sole reason for Amenorrhea, but it is now known that body fat does play a role, but the stress of training and nutritional status are equally important.

Amenorrhea is classified in two categories, primary amenorrhea which is defined as no pubertal changes, such as breast buds, by 14 years of age, or no menstrual bleeding by the age of 16 years. Secondary amenorrhea is defined as no menstrual cycles in a 6-month period in a woman who has had at least one episode of menstrual bleeding.

Athletic amenorrhea is thought to be a form of hypothalamic amenorrhea in which pulsatile gonadotropin releasing hormone is deficient, absent, or inappropriately secreted. Even without weight gain or change in body fat some athletes have return of menses during intervals of rest. Normal menstrual cycles may take months or years after stress is relieved to be restored, and prolonged amenorrhea can cause osteoporosis.


In 1984, the loss of bone mineral in the spines of young amenorrheic athletes was first described by Cann and associates. During adolescence if a young female athlete is amenorrheic and doesn’t lay down a normal amount of bone at this time, she may always have decreased bone mass. Restoration of normal menses may retard the rate of further bone loss, but the bone already lost is not replaced, and as a result these women are at risk for future hip and spine fractures. As a result even in the present when a young female athlete presents with a stress fracture, a consideration must be the possibility of early osteoporosis related to amenorrhea.

History and Physical Examination

Body weight history, nutritional history, and menstrual history are all essential when treating young female athletes. The age of menarche, frequency and duration of menstrual periods are things that needed to be questioned when inquiring about menstrual history. Also, the date of the last menstrual period and the use of hormonal therapy should be questioned. Nutritional history should include a 24 hour recall of food intake, the usual number of meals and a list of forbidden foods. Lastly, body weight history should include the highest and lowest weight ever of the athlete.


Treating the female athlete triad is very difficult and requires a group or team approach. Treatment often consists of physicians, a nutrition specialist, and either a psychologist or a psychiatrist. When the athlete is in high school or college, the athletic trainer, team doctor, and coach should also participate in treatment. The team physician is in ideal position to screen for any eating disorders and abnormal menses during pre-participation physicals.

The orthopaedic surgeon should be very aware of the athletic triad when dealing with stress fractures and there’s no history of overuse. Counseling and nutritional assessment should be given from someone who understands athletics and caloric requirements. An adequate diet is more than just the appropriate amount of caloric intake, but also 1,500mg of calcium per day. Depending on the athlete a physician may need to regulate when it is safe to get back to participating in sports.

Psychological help and counseling may be needed as well, especially if there’s a true eating disorder, such as anorexia or bulimia. Counseling is really beneficial because stress reduction techniques are particularly useful in the competitive athlete because it often helps relieve performance anxiety.