The Female Athlete Triad

April 24, 2015

Women in athletics have become much more recognized in our society over the past few decades. However, with the increasing prevalence and participation of women in sports, a syndrome called the Female Athlete Triad has been identified.

The Female Athlete Triad was not officially recognized until 1992, when a clear association among menstrual function, energy availability, and bone mineral density was acknowledged. When these three things are not properly balanced, they can potentially manifest as abnormal or absent menstrual cycles, eating disorders, and low bone mass density (osteoporosis or osteopenia).

The Female Athlete Triad is most prevalent among sports where a lean physique is desired. Distance runners, gymnasts, and dancers are examples. Unhealthy habits can begin to develop when an athlete realizes her performances are improving after she has lost weight. She may think “the more weight I lose the better.” However, if there is not enough caloric intake to sustain the body’s requirements for training, performance can be severely affected. Not consuming a healthy diet and allowing the body to properly recover from workouts can lead to a multitude of issues beyond energy levels and performance.


When an athlete is placing high demands on her body during training and not consuming enough calories, abnormal or absent menstrual cycles can develop. Amenorrhea is the term used for an absence of a menstrual cycle. There are two categories of amenorrhea — primary and secondary. Primary amenorrhea is the absence of a period by the age of 16 (with presence of other sexual development). Secondary amenorrhea is the absence of a period for greater than 3 months after menstruation has begun. Among some groups of athletes, it is unfortunately not unusual for periods to be abnormal so this can be considered “normal” by the athlete and not properly addressed.

Disordered Eating

Key factors to consider in dietary habits are a consistent preoccupation with body image and weight as well as an avoidance of team meals (if the individual is part of a team). Disordered eating can include restricted food intake, use of diet pills or laxatives, or a clinical eating disorder, including anorexia or bulimia.

Adequate caloric intake is necessary for an athlete to sustain their training and to provide their body with the nutrients it needs. Inadequate caloric intake can lead to menstrual dysfunction or osteoporotic bones.

Low Bone Mass

The majority of bone development occurs during childhood and adolescence. Young female athletes can have a reduction of bone mass secondary to their dietary habits and the presence of amenorrhea. The low estrogen levels, specifically, can influence bone growth during the critical development years, leading to weaker bones and an increased risk of stress fractures. When estrogen levels are inadequate, loss of bone mass occurs because bone growth is decreased while bone break down occurs at a higher rate.

How is physical therapy a part of treating the Female Athlete Triad?

Physical therapists can be the first to recognize the symptoms of the Female Athlete Triad. For example, if a female distance runner is receiving physical therapy while recovering from a stress fracture, it may be revealed that she has abnormal menstrual cycles and poor dietary habits. Physical therapists are able to explain what the Triad is, and can help to refer to other medical professionals if appropriate.

Physical therapists have the unique understanding of exercise metabolism, biomechanics, and exercise prescriptions to help patients rebalance themselves. For example, physical therapists can help identify and explain how poor dietary habits can be contributing to a slow recovery from injury.

Physical therapists are adept at identifying issues stemming from the Triad and imparting a multi-disciplinary approach toward a healthy lifestyle. Any treatment of the triad will require an integrated team of family support, physician assistance, and physical therapy. Early treatment is critical for women suffering from the Triad, especially for young, active women.

Pro Motion Physical Therapy has several former female collegiate athletes on staff that have an in-depth knowledge of the uniqueness of female athletes. If you are a female athlete and have any questions or concerns about the Female Athlete Triad, we would love to chat!

Photo credit: Tableatny via Flickr/Creative Commons

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