The Female Athlete Triad

By Laurence Mermelstein, M.D.

Over the last 30 years, the numbers of girls and women participating in competitive sports has increased exponentially. With the passing of Title IX in 1972, the numbers of girls competing in high school and collegiate sports has increased over ten times.  Along with these numbers has come the realization that female athletes can develop specific sports medicine issues.  The term “female athlete triad” was coined in 1992 to describe three interrelated conditions that often appear together in the competitive female athlete: amenorrhea, eating disorders and osteoporosis.  The bottom line with this syndrome is that more energy is expended than is consumed over a prolonged training regimen.  The secondary problems these patients encounter cannot only cause orthopedic injuries that can impair performance, but also have long-term effects on the athletes’ health in general.

Amenorrhea is defined as the absence of menstrual cycles. Menarche has been shown to be delayed in athletes that start heavy training before puberty. Amenorrhea as found in this syndrome occurs after the onset of puberty and is a loss of normal cycles after they begin.  Amenorrhea has been know to occur with heavy physical activity and is directly proportional to the intensity of training.  Of course there are many other causes of amenorrhea that need to be ruled out – pregnancy, thyroid disease, polycystic ovarian syndrome, pituitary dysfunction, etc.  Originally this was thought to be secondary to low body weight and low percentage of body fat, but subsequent research has found this not to be the case.  The etiology is now thought to be multifactorial, and probably different in different athletes.  Heavy training has been thought to cause increased mental stress, skeletal immaturity, a low-estrogen state and perhaps a relative increase in androgen (male) hormones.  All of these stresses have been thought to affect the hypothalamus and its relationship to the hypothalamic-pituitary axis. The effects on the “master gland” in turn de-synchronizes the hormone pulses necessary to cause normal ovulation and menses. This athletically induced menopause can be associated with a decrease in bone density just as in senile menopause. This can cause a serious increase in risks of stress fractures and other fractures.


The female athlete that suffers from an eating disorder is unlikely to be diagnosed with anorexia nervosa or bulimia.  Athletes most likely to have eating/nutritional issues are involved in sports that emphasize leanness (running, cycling), sports that are subjectively scored (figure skating, gymnastics, diving) or sports that have weight categories. These stresses, plus the societal standards, peer pressure, and pressure from coaches and parents cause many young women” to have unrealistic goals and perceptions of the ideal body weight. The end effect of this “dieting” is and imbalance in energy expenditure and intake.  Lack of nutritional training will compound the ultimate negative effects on general health and physical performance. Chronic malnutrition will negatively effect the immune system as well as cause deplete muscle energy (glycogen) stores, dehydration, loss of muscle mass and anemia.


The presence of hormonal dysfunction and nutritional issues are intimately related to the third arm of the “triad”-  osteopenia.  It is important to note that most of the athletes with this syndrome do not have formal “osteoporosis” – the Bone Mineral Density (BMD) does not usually fall into this range – and the athletes are not usually found to have classic “fragility” fractures (hip fractures, wrist fractures, etc) Instead, the athletes are at risk for “stress fractures” associated with repetitive training regimens.




As with most medical conditions, the best treatment for the Female Athlete triad is prevention. Trainers, coaches and parents must be educated about the signs, symptoms and dangers of the Triad.  A specific emphasis needs to be placed on adequate nutritional intake for not only normal growth and development, but also for the increased energy requirements for the specific intensive training regimen.


Specific screening history should be obtained at the time of a pre-participation sports physical.  The questions should concentrate on the three critical issues involved with this syndrome – nutritional history, menstrual history and specific training history.


Specific treatment involves ensuring adequate nutritional intake and specific psychological treatment for eating disorders. A reduction in intensity of training maybe necessary until return of menses.  Calcium/ Vit D supplements have been shown to be able to increase Bone Mineral Density (BMD) up to 14% in adolescent girls. Approximately 1,500 mg /day dose is recommended in girls with scarce or absent menses. Many physicians are treating the amenorrhea with Hormone replacement therapy or “birth control pills”.


Adequate long-standing intervention often requires a multidisciplinary approach involving not only the athlete and physician, but also the parents, trainers, coaches and sports psychologists.  Recognition and treatment of this syndrome early can prevent significant long-term morbidity to the highly competitive athlete.

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