The female athlete triad: What you need to know

By Dr. Amanda Schafenacker, pediatric resident at CHOC Children’s

The female athlete triad, commonly called “the triad,” is a significant phenomenon being seen more and more in middle school and high school female athletes. The triad consists of three health concerns: disordered eating, low bone density (osteoporosis), and loss of periods (amenorrhea). While we always encourage children and adolescents to exercise, the triad can be seen in females involved in sports.

The triad occurs when the calories a female athlete is consuming doesn’t compensate for how much exercise girls she’s doing. To make it simpler, the amount the teen is eating is not enough to support the energy needs for daily life plus exercise. This has adverse effects on reproductive, bone and cardiovascular health.

The full triad occurs in 1 percent of all high school girls and 16 percent of all female athletes—but many adolescents may only exhibit one or two of the components, which can still have adverse effects on health. This also means a higher percentage are at risk for the full triad over time if their nutritional habits do not improve.

Disordered Eating

While some athletes may be obsessively counting calories, or practicing other unhealthy weight loss techniques such as unnecessarily restricting food items or entire groups, vomiting, diuretic or laxative use, some athletes may simply be unaware they are not consuming enough calories to support their active lifestyles. When the calorie intake does not equal the calories consumed by the body, the body starts to break itself down, which can lead to problems in different organ systems.

Potential triggers for disordered eating includes prolonged periods of dieting; weight fluctuations; coaching changes; injury; and casual comments about weight from coaches, parents, or friends. Many athletes falsely believe that losing weight will improve their athletic ability and that thinner means faster or more agile, but this is not true. This is dangerous. These ideas are common among dancers, gymnasts and swimmers, but can also be seen among runners, soccer players, and in wrestlers or boxers as athletes fluctuate through periods of “cutting weight” and gaining weight.

Loss of muscle mass happens quickly after you begin restricting food intake. This leads to decreased speed, decreased agility, decreased coordination, and increased risk of injury of muscles or bones.  Parents should be vigilant if they notice significant weight loss, their children restricting food, or purging habits (like inducing vomiting or laxative use), and bring their child to the doctor.

It is important for any athlete to remember, if a coach or family member feels it is necessary for the teen to gain or lose weight, to do so safely with the help of a doctor.

If you or your teen have questions about how much food the body needs to keep up with natural metabolism and athletic activities, talk to your doctor or a pediatric nutritionist to get more information.

Bone Disorders

As teens continue to grow, this is a critical time for bone mass creation. Without enough energy for daily function and exercise, bone growth and strength (also known as bone mineralization) can diminish. Decreased bone mineralization leads to muscle and ligament injuries, or even as bone fractures. Bone growth during the teen years is critical to prevent osteoporosis (weak bones) in adulthood. Peak bone mass usually occurs between ages 20 and 30, but up to 90 percent of bone mass is obtained by the time teens finish high school.


After the first menstrual period, adolescents’ periods should become regular within one to two years. Going without a period for more than three months is called amenorrhea. There are many causes of amenorrhea in teens, but considering low or inadequate caloric intake is necessary in all female athletes. Without enough calories to support the hormones that cause periods, female athletes may stop having their periods or start having irregular periods. Studies have shown that athletes with period irregularities can be three times as likely to have bone injuries and other muscle or ligament injuries than those athletes who maintain normal periods. The usual treatment for regulating periods is increasing nutritional intake (eating more) or decreasing vigorous activity, or a combination of both.

What should I do if I suspect this is me?

Talk with your doctor! At any sports physical, your doctor should be evaluating you for all of the above. At your visit, you can expect to have your vital signs taken (things like blood pressure, heart rate, weight and height) and have a thorough physical exam performed. Your doctor may ask you to have some blood tests done, especially if you are not having regular periods. In extreme cases, your doctor may have a bone scan done to see how your bones are growing.

What happens if I’m diagnosed with female athlete triad?

The ultimate goals are to restore normal periods and weight safely. Overall, you need to start increasing the amount of healthy calories you consume to get the energy your body needs on a daily basis. Treatment plans often include decreasing exercise while increasing calories in meals. To restore bone density and growth, your doctor may encourage vitamin supplements including vitamin D and calcium. You may be referred to a multi-disciplinary team where a doctor, a dietitian, and a mental health professional can help set appropriate nutrition and exercise goals.

Explore adolescent medicine services at CHOC

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