The female athlete triad: It takes a team

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The female athlete triad is a syndrome consisting of low energy availability (ie, burning more calories than one is taking in), menstrual dysfunction, and low bone mineral density, although all 3 components need not be present. Many providers, physical therapists, and coaches are unaware of it and thus do not screen for it. Early intervention using a team approach is essential in patients with any component of the female athlete triad to prevent long-term adverse health effects.


  • Low energy availability is the driving force of the triad, causing menstrual irregularity and subsequent low bone mineral density.
  • Recognizing that men as well as women can suffer from energy deficiency and that it can affect more than the female reproductive system and skeleton, the International Olympic Committee has proposed calling the disorder relative energy deficiency in sport.
  • Screening for the triad with a specific set of questions is recommended during the preparticipation assessment.
  • Early intervention and treatment prevents serious health consequences including life-threatening arrhythmias, amenorrhea, and osteoporosis.



Striving for athletic excellence, many young women—and some young men—create an energy deficit from increased exercise, decreased intake, or both. In women, the resulting energy deficit can suppress the menstrual cycle and in turn lead to bone demineralization in a syndrome called the female athlete triad .

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Primary care physicians should be aware of this syndrome because it can lead to short-term and long-term health complications, and they are in a good position to screen for, diagnose, and treat it. However, a study of 931 US physicians in 2015 found that only 37% had heard of it. 1


In 1972, Title IX of the Education Amendment Act was passed, prohibiting sex discrimination in any higher education program or activity receiving federal financial aid. Since then, female athletic participation in the United States has increased more than 10-fold. 2

Also increasing has been awareness of the link between athletics, eating disorders, and amenorrhea. The American College of Sports Medicine coined the term female athlete triad in 1992, describing it as the constellation of disordered eating, amenorrhea, and osteoporosis (all 3 needed to be present). 3 They broadened the definition in 2007 so that the syndrome can be diagnosed if any of the following is present 4:

  • Low energy availability (with or without an eating disorder)
  • Menstrual dysfunction
  • Decreased bone mineral density.

Recognizing that low energy availability can affect athletes of either sex and have consequences beyond the female reproductive system and skeleton, in 2014 the International Olympic Committee introduced a broader term called relative energy deficiency in sport .5,6 Like the triad, this condition occurs when energy intake falls below energy output to the point that it negatively affects an athlete’s physical and mental health.


The female athlete triad can be seen in high school, collegiate, and elite athletes 7 and is especially common in sports with subjective judging (gymnastics, figure skating) or endurance sports that emphasize leanness (eg, running). 8

In a review of 65 studies, Gibbs et al 9 found that the prevalence of any one of the triad conditions in exercising women and female athletes ranged from 16.0% to 60.0%, the prevalence of any 2 ranged from 2.7% to 27.0%, and the prevalence of all 3 ranged from 0% to 15.9%.

Low energy availability is categorized as either intentional (ie, due to disordered eating) or unintentional (ie, due to activities not associated with eating). Sustained low energy availability is often associated with eating disorders and subsequent low self-esteem, depression, and anxiety disorders. 4

The prevalence of eating disorders is high in female athletes—31% and 20% in 2 large studies of elite female athletes, compared with 5.5% and 9%, respectively, in the general population. 10,11 Another study found that the prevalence of disordered eating was 46.7% in sports that emphasize leanness, such as track and gymnastics, compared with 19.8% in sports that did not, such as basketball and soccer. 12

Calorie restriction is common. In a study of 15 elite ballet dancers and 15 matched controls, the dancers were found to consume only about 3/4 as many calories per day as the controls (1,577 vs 2,075 kcal/day, P ≤ .01). 13


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