The Female Athlete Triad


The female athlete triad involves the interrelated components of Disordered Eating, Amenorrhea, and Osteoporosis. The Triad usually begins with disordered eating and can occur in all sports, although it occurs more frequently in sports emphasizing thinness/leanness.  It can negatively affect athletic performance.  The goal should be healthy, well adjusted athletes.  In general, healthy, well-adjusted athletes will out-perform those who are unhealthy.

Disordered Eating includes the spectrum of abnormal eating behaviors from excessive dieting to clinical eating disorders.  Disordered eating can be inadvertent but usually involves the willful restriction of caloric intake for the purpose of becoming thinner or leaner.  Disorderered eating occurs in all sports but is more prevalent in sports that emphasize a thin or small body size or shape.  Symptomatic athletes must receive treatment.  Recovery without treatment is unlikely.

Physical/Medical Signs and Symptoms: 

  1. Amenorrhea
  2. Dehydration
  3. Gastrointestinal Problems
  4. Hypothermia (Cold Intolerance)
  5. Stress Fractures (and overuse injuries)
  6. Significant Weight Loss
  7. Muscle Cramps, Weakness, or Fatigue
  8. Dental and Gum Problems

Psychological/Behavioral Signs and Symptoms: 

  1. Anxiety and/or Depression
  2. Claims of “Feeling Fat” Despite Being Thin
  3. Excessive Exercise
  4. Excessive Use of Restroom
  5. Unfocused, Difficulty Concentrating
  6. Preoccupation with Weight and Eating Situations
  7. Avoidance of Eating and Eating
  8. Use of Laxatives, Diet Pills, etc.

When encountering any one of the components of the Triad, it is imperative to thoroughly evaluate the athlete for the other components.

Amenorrhea involves the loss of menstruation.  Any athlete who has been without a menstrual period for three months should be referred to a physician for an evaluation.  Athletes with prolonged amenorrhea are at risk for loss of bone mass and stress fractures.  Amenorrhea is common in athletes, but is not normal or healthy.  It should be treated.  Menstruation must be restored through an increase in eating, a decrease in training, and/or medication.

Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissues, resulting in bone fragility and increased risk of fracture.  Adequate nutrition is necessary for bone growth and health but can be compromised due to disordered eating.  Bone loss can result from amenorrhea and can worsen by disordered eating.

What to do when you have directly or indirectly obtained information regarding possible disordered eating by an athlete:

  1. The initial contact with an athlete suspected of having an eating problem is the most important step.
  2. The person who makes the initial contact should be a person in authority who has a good relationship with the athlete or has a good way of relating. 
  3. The athlete should be approached privately and non-critically.
  4. Referrals should be made to behavioral health and nutrition specialists knowledgeable about eating disorders.

Recovery without treatment is unlikely. The physical and psychological state of the athlete, athletic performance, and related symptoms will worsen without treatment.  Treatment cannot become subordinate to sport participation because it communicates to the athlete that her performance is more important than her health.

Prevention: Coaches can play an integral role in preventing Disordered Eating and the Triad by:

De-emphasizing weight, which can be accomplished by:

  1. Focusing on improving basic health issues (i.e. nutrition, sleep/rest, absence of substance use such as alcohol, illegal drugs, nicotine, and “ergogenic” supplements).
  2. Providing mental skills training.
  3. Improving communication with their student athletes.

Providing their athletes and staff with the education that they need, especially nutrition education, as well as information regarding menstrual functioning, and bone health.

All above information was developed by Roberta Sherman, Ph.D., FAED, and Ron Thompson, Ph.D., FAED, Co-chairs of the Athlete Special Interest Group of the Academy of Eating Disorders, in conjunction with the NCAA.