Everything Experts Want You to Know About the Female Athlete Triad

For female athletes of all ages and fitness levels, involvement in sports and exercise has been proven to offer a host of benefits like improved self-esteem and stronger, healthier bodies. But for some athletes, prioritizing exercise over adequate recovery and nutrition can occur, resulting in a relatively common condition: the female athlete triad.

According to a 2000 article in American Family Physician, the female athlete triad consists of three components:

• Disordered eating. Without ample nutrition to fuel and repair the body, the athlete may become fatigued and/or not perform as well as they should, said Bridget J. Quinn, M.D., a sports medicine physician in the Female Athlete Program at Boston Children’s Hospital and head medical advisor for the Boston Ballet.
• Irregular periods. Poor nutrition, low calorie intake, and high energy demands from exercise can cause irregular periods or lead to amenorrhea, which is the loss of the period. “If your menstrual cycle is being influenced, that’s a vital sign that something in the body is malfunctioning,” Quinn said.
• Low bone mineral density. If periods stop, subsequent hormone changes can disrupt bone-building processes, which can weaken bones and cause osteoporosis (low bone mineral density) in severe cases.
  
  

The triad is especially prevalent in endurance sports such as track and field, swimming, gymnastics, figure skating, and rowing. But it can strike athletes of any age and ability, Quinn said.

According to “Female Athlete Series: Female Athlete Triad,” published by Boston’s Children Hospital Sports Medicine, if left untreated, the female athlete triad can have severe consequences like infertility, an increased risk of heart disease, and heightened vulnerability to stress fractures.

The female athlete triad falls under the umbrella of relative energy deficiency in sport, or RED-S, a syndrome of health issues and declining athletic performance due to a lack of sufficient calories to support the energy demands of training, according to Boston Children’s Hospital.

Because the symptoms fall on a spectrum, the female athlete triad can be tricky to diagnose. For one, the three conditions may ebb and flow. For example, overexercising may take the main stage while someone continues to menstruate.

Alternatively, despite an athlete programming correctly, their period may be lost due to low caloric intake. “It’s not necessarily an either-or scenario,” Quinn said.

To receive a diagnosis and map out a treatment plan, it’s crucial to visit a doctor or comparable licensed medical professional. Quinn shared that key factors will be considered during these initial reviews to result in a diagnosis such as:

• Miss several periods in a row
• Get a bone stress fracture in sports
• Think you might have disordered eating

However, Quinn encouraged athletes to think outside these factors. “Low energy availability affects so many systems in the body,” she said. The triad may also show up as:

• Frequent gastrointestinal (GI) issues, such as bloating and constipation
• Chronic fatigue
• Nagging injuries

Bottom line: If things feel “off,” see your family physician.

Be ready to give your doctor a complete medical history. The American Academy of Orthopaedic Surgeons recommends going over what you eat, any changes in your weight, whether you’ve missed any periods, and your injury history.

The doctor will give a physical exam that may include checking height and weight, blood pressure, vision, and heart and lungs, and examining your muscles, bones, and joints. They may also use laboratory tests to check for pregnancy, thyroid disease, and other medical conditions to rule out other potential causes of your symptoms. And if symptoms and medical history suggest weakened bones, the doctor may recommend a bone density test. This will arm the athlete with insights to train and recover the best way possible for their body — while lowering the risk of stress fractures and other commonly related injuries.

If you get a triad diagnosis, the doctor may refer to a team of specialists for treatment. “It’s an interdisciplinary approach,” said Michelle T. Barrack, Ph.D., R.D., C.S.S.D., F.A.C.S.M., and president of the Female and Male Athlete Triad Coalition.

Depending on symptoms and health issues, these specialists may include a sports dietitian, counselor or psychologist, and a gynecologist and/or endocrinologist.

The primary goal of treatment is to improve nutrition to build a healthy body weight, replenish energy, and restore the menstrual cycle.

Should the athlete also receive an eating disorder diagnosis, it’s essential to work with a mental health practitioner and a registered dietitian if possible.

The female athlete triad is a sneaky syndrome, Quinn said. Be aware of the warning signs, and reach out to a doctor or other licensed medical professional for help earlier than later. “The earlier that treatment begins, the easier it will be to optimize energy and nutrition and prevent long-term consequences, especially to bone health,” Barrack said.

Words by Lauren Bedosky