The Female Athlete Triad

Some physically active women are at risk for a group of symptoms called the Female Athlete Triad. This often unrecognized disorder is a combination of three conditions:

  • Disordered eating
  • Amenorrhea (lack of menstrual periods)
  • Osteoporosis

It's important to know that in the context of Female Athlete Triad, disordered eating includes both intentional and non-intentional under-consumption of calories. This can occur both as a function of poor eating habits and as a function of too intense exercise. When the body perceives too great a gap between energy expenditure and energy intake, estrogen levels in the body drop and menstrual periods cease. Normal estrogen levels are needed to maintain calcium content in bone. The result of lower estrogen is that the bones become progressively more porous, resulting in ostopenia, and eventually, osteoporosis.

Who's at risk?

If you are a physically active woman, you are at risk for the Triad. The competitive nature and strong discipline that can help make you a good athlete may also be part of the equation leading to this disorder. Competitive athletes may be at a higher risk than the more casual athlete due to a more rigorous training schedule and the "play-to-win" nature of their sports. You are particularly at risk if you participate in endurance sports, like cross-country running; aesthetic sports, like gymnastics or ballet; and sports which require formfitting uniforms, like swimming. The emphasis on a certain "look" and the perception that carrying less weight will universally improve performance lead to this risk.

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How will the Triad affect my performance?

Each part of the Triad can impair health and sport performance.

Disordered eating: an underfueled athlete is a slowed and weakened athlete. No matter what the sport, if your muscles lack sufficient and proper fuel, performance is impaired. At first there might just be some early fatigue. As the fuel deficit worsens, actual loss of strength and muscle size can occur as the body uses skeletal muscle in order to fuel essential body functions, like heart function and breathing. Lack of fuel can also lead to your inability to concentrate, not a quality befitting an athlete. If you are an athlete with strength losses and poor concentration, you can be more easily injured. Injuries then are slow to heal in a poorly fueled body.

Amenorrhea: Loss of menstrual periods may signal a change in your body's intricate and complicated hormone system. Hormone imbalance from underfueling your body can result in lowered estrogen production. There are also other causes of lowered estrogen levels. A diminished estrogen level can have many effects; the most immediately apparent one can be bone loss. Amenorrhea can often go unreported to medical providers because of the common belief it is "just part of the training effect." We do know that the bone loss that occurs as a result of this is NOT "just part of the training effect" and can start to occur after just a few months with no period. Click for more information on amenorrhea.

Osteoporosis: Loss of bone, especially if you are an athlete, can be an unfortunate setup for an injury. Stress fractures can sideline sports activity and be slow to repair if you are underfueled. Repeated stress fractures and unexplained injuries should be a red flag to further evaluate your eating and exercise patterns. Bone loss that occurs because of amenorrhea can be permanent; osteoporosis is not just a disease grandmothers get!

What are the warning signs?

From the NCAA Handbook on Managing the Female Athlete Triad: Signs and Symptoms of  Disordered Eating:

“The fact that an athlete displays some of the characteristics below does not confirm that the athlete is engaging in disordered eating or has an eating disorder.  However, the likelihood increases as more signs and symptoms are evident.  Also note that this list does not include all possible symptoms, but rather the most common ones.

Physical/Medical Signs and Symptoms

  • Amenorrhea
  • Dehydration
  • Gastrointestinal problems
  • Hypothermia (cold intolerance)
  • Stress fractures (and overuse injuries)
  • Significant weight loss
  • Muscle cramps, weakness, or fatigue
  • Dental and gum problems

Psychological/Behavioral Signs and Symptoms

  • Anxiety or depression
  • Claims of “feeling fat” despite being thin
  • Excessive exercise
  • Excessive use of the restroom
  • Unfocused, difficulty concentrating
  • Preoccupation with weight and eating
  • Avoidance of eating and eating situations
  • Use of laxatives, diet pills, etc."

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Prevention of the Female Athlete Triad

Prevention of the Female Athlete Triad is the best way to stay healthy so you can enjoy participating in your sport. Try these tips:

  • Choose an activity that complements your natural body strengths and suits you as an individual.
  • Realize your health is more important than competitive success. Taking health risks for a perceived competitive edge will make you lose in the long run.
  • Be wary of those who value your competitive success over your well being.
  • According to the NCAA, weight should be de-emphasized as a factor in performance.
  • Frequent weigh-ins, weight comments and punitive consequences for weight gain may increase an athlete's risk for the Triad.
  • Appreciate your own healthy, active body. Don't compare yourself to others, especially those portrayed in the media. Optimal weight for health AND performance is different for everyone.
  • Realize the thinnest athletes are not necessarily the fastest or the strongest.
  • Think of fuel as the ultimate performance enhancer! Before choosing a weight-loss diet, consult with a nutritionist who can provide personalized recommendations to promote a healthy weight and boost athletic performance.
  • Don't starve your bones. Part of your fuel mix should include several servings a day of good calcium sources like milk, yogurt, cheese, calcium-fortified juices and soy products. If you are lactose-intolerant, try some of the no-lactose dairy products available. Green leafy vegetables, almonds and beans also have some calcium. Women with female athlete triad are encouraged to consume 1500 mg/day of calcium until the amenorrhea is resolved.  The best outcome appears to be achieved with a combination of dietary and supplemental calcium sources. Supplements should also include vitamin D to help increase calcium absorption.
  • Be a role model with both your words and actions. Speak up when you hear others making negative comments about weight or body shape. Compliment friends and teammates on their talents and personality, not their looks. Take a positive attitude about fueling yourself and enjoying foods.

What about the pill?

Until recently, female athletes diagnosed with the Triad were often started on oral contraceptives as a means of supplying them with estrogen and producing a menstrual period. Multiple studies have shown, however that the pill is not effective in protecting bones from demineralization. Only when estrogen levels have been restored by supplying the body with adequate calories, can bone losses be reversed. Meeting with a nutritionist who can assess an athlete’s nutritional needs relative to their energy expenditure, and who can help them to strategize their eating accordingly, is an important part of preventing or treating the Triad. Sometimes, if the caloric gap between intake and expenditure is too great to address solely with nutrition, it may be necessary for an athlete to modify their training, in addition to increasing their dietary intake.

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How do I help a friend who has an eating disorder?

If you are worried that a friend has an eating disorder, click for information and resources.

Resources at Brown

BWell Health Promotion 401.863-2794
Located on the third floor of Health Services.
Confidential information or care is available through individual appointments or phone consultation with a Nutritionist.  Students can discuss personal eating concerns, as well as any concerns they may have regarding a friend, a roommate, or a teammate. Health Promotion also offers workshops, pamphlets, and reading materials covering these and related issues. There are no fees for Health Promotion services.

University Health Services 401.863-3953
Located at the corner of Brown and Charlesfield streets.
Confidential information and care is available on a walk-in, or by scheduled appointment basis. Care is available for initial, current or past disordered eating patients. There are no fees for medical care at Health Services. However, there may be fees incurred if laboratory tests, medications, specialist or emergency hospital care is needed.

Counseling and Psychological Services 401.863-3476
Located on the fifth floor of J. Walter Wilson.
Confidential appointments are available at Counseling and Psychological Services for students concerned about their eating issues. Guidance is also available for those who are concerned about a friend, roommate, or teammates' eating. Services include crisis intervention, short-term psychotherapy and referrals. There are no fees for appointments at Counseling and Psychological Services.

Links you can use

NCAA Handbook: Managing the Female Athlete Triad

Body Positive    
This site looks at ways we can feel good in the bodies we have. One of their slogans: "Remember, your body hears everything you think." Other topics on the web site: Size Acceptance; What do you say when everyone around you is dieting? 200 Ways to Love the Body You Have; Dieting Detox; Evaluating Weight Loss Programs: What are the Red Flags? Free subscription to email newsletter "Body Positive Pages."

The American Dietetic Association
Articles from the ADA on eating disorders, including The Female Athlete, Compulsive Eating and Anorexia.

National Association of Anorexia Nervosa and Associated Disorders

National Eating Disorders Association
This site provides general information about eating disorders and body image concerns, tips for helping a friend and referral sources.

Gatorade Sports Science Institute 
Go to the Sports Science Center on this site for articles by experts in exercise science and sports nutrition. Topics include supplements, hydration and sports psychology.

The Physician and Sports Medicine Online
The Personal Health section of this website has information on fitness, nutrition, strengthening exercises, weight control and women's health.

Adapted from the Boston College Eating Awareness Team

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Disclaimer: BWell Health Promiotion is part of Health Services at Brown University. Health Promotion maintains this site as a resource for Brown students. This site is not intended to replace consultation with your medical providers. No site can replace real conversation. Health Promotion offers no endorsement of and assumes no liability for the currency, accuracy, or availability of the information on the sites we link to or the care provided by the resources listed. Health Services staff are available to treat and give medical advice to Brown University students only. If you are not a Brown student, but are in need of medical assistance please call your own health care provider or in case of an emergency, dial 911. Please contact us if you have comments, questions or suggestions.