Female athlete triad

Female athlete triad. What is it, and why we should be aware of it?

The pressures of modern society on young riders to look a certain way can have consequences. The Female Athlete Triad is a health concern for active women and girls, particularly in sports such as gymnastics, riding, dance and combat sports which emphasise leanness.


It involves three distinct and interrelated conditions

  1. Disordered eating (a range of poor nutritional behaviours)
  2. Amenorrhea (irregular or absent menstrual periods)
  3. Osteoporosis (low bone mass)


Disordered eating and low energy availability

  • Continuum of atypical and episodic eating patterns: Eating only low fat or non-fat foods, skipping meals, fasting before a competition, using diuretics or diet pills etc.
  • Subclinical condition; behaviours difficult to recognize or categorize as they are less distinct than clinical eating disorders
  • Often accompany endurance/ aerobic-type exercise




Menstrual dysfunction

  • When energy deficits reach a certain threshold, menstrual cycles can become irregular, causing oligomenorrhea (menstrual cycles occur at intervals >35 days), or they can altogether cease, causing amenorrhea (menstrual cycles are absent for >3 months).
  • Before oligomenorrhea and amenorrhea are diagnosed, other causes for menstrual dysfunction (i.e., tumors, anabolic steroid use, pregnancy, hormonal imbalances) MUST BE RULED OUT


Bone density

  • Menstrual dysfunction, caused by low energy availability during adolescence can limit new bone formation causing a decline in bone mass density and an increase in stress fracture risk. (Zanker & Crooke, 2004; Guest & Barr, 2005)
  • With low bone mass density during adolescence and young adulthood, bone loss and the likelihood of osteoporotic fractures in adulthood are greater and may occur at accelerated rates after menopause (Guest & Barr, 2005).


How are steps 1,2 and 3 interrelated?

  • Low energy availability decreases secretion of leptin, a hormone secreted by fat cells that is needed to maintain normal menstruation. Eventually, a low estrogen state leads either to irregular cycles or to amenorrhea.
  • Low estrogen > low calcium absorption > poor bone health


Measurement/monitoring tools?

  • There are plenty of way to monitor an athlete, some expensive (DXA scanning) and other methods such as weigh-ins or skinfold assessments are too invasive and may further emphasise excessive leanness.
  • Some coaches have had success with Eating Attitudes Test, however, the success of these is dependent on how honest the athlete is.
  • The key steps for any coach should be to build a rapport with your athletes, don’t emphasise weight targets or percentages of body fat. Educate your athletes on the right food choices and avoid of hype of many poorly marketed products whilst checking for warning signs of eating disorders.

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