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Female Athlete Triad: A Primer for Parents

Warning signs: disordered eating, missed periods and repeated bone instability; early intervention and parental support key

Women with wrists bound by measuring tapeDisordered eating, skipped periods (amenorrhea) and repeated bone instability or fractures are the three signs of the athletic triad.

Unlike teens with anorexia nervosa or bulimia, teens are maintaining a low body weight because they exercise too much and don't eat enough to keep up with their activity. This can progress to intentional decreases in calories that leave them underweight.

The problem can occur in both boys and girls, but because of the initial definition being associated with skipped periods, it has been called the Female Athletic Triad.

1. Disordered Eating

For athletes, disordered eating usually means that they are not consuming enough calories, expending more energy than they are taking in through their diets and creating a dynamic deficiency in calories supplied to the body. The physiological effect is the same as in an anorexic who is malnourished:

  • Difficulty concentrating
  • Difficulty regulating body temperature
  • Fine hairs called lanugo on the arms, back or face; and
  • Irregular heartbeats and low blood pressure that can cause dizziness and fainting.

2. Amenorrhea

Even without an eating disorder from the female athletic triad, teenage girls can miss their periods for several months at a time. For some athletes, such as runners, their periods may stop as soon as the season starts, but if there are also ongoing eating issues a girl may miss her periods several months at a time beyond the end of the season or because she plays their sport all year long. Missing periods is a sign that the body does not have the required 17% body fat to maintain a regular menstrual cycle or period.

The significance of poor eating is that it leads to low levels of estrogen, which are an important for bone strength. As a result, periods missed due to malnutrition suggest low estrogen, and therefore a potential for poor bone growth, which, in turn, compromises bones and can lead to early hip fractures in a woman's 30s and to osteoporosis.

3. Repeated bone instability

Since these teen girls suffering from the female athlete triad do not get a period, which compromises their level of estrogen they are at higher risk of bone trauma, which can take the form of fractures or sprains or simply weak joints. This severely challenges their ability to play, increasing the risk of injury which may put them out of the game altogether.


Treating the female athlete triad depends on whether the teen has body image issues.

For a teen with no body image issues, treatment can be as simple as increasing her calories before and after they practice or play. Her diet can be monitored through weekly visits to the doctor, meeting with a nutritionist or registered dieticiain to become more educated about nutrition, and decreasing the number and intensity of practices until she is able to consume enough calories to support such level of activity. To be certain there are no issues with body image or depression that could be the cause of their poor eating.  To be certain there are no issues with body image or depression that could be the cause of their poor eating, athletes should be strongly encouraged to meet with a mental health professional.

A teen that has a combination of body image and anorexia with her athletic triad will require more intense treatment with her medical doctor, a nutritionist and a mental health professional. In such circumstances, the triad becomes a mental health issue, so a multi-disciplinary approach, with the medical clinician and nutritionist supporting the mental health professional, is important. Without good nutrition and medical stability, your teen will not be able to comprehend the changes required in order to become healthy.

Coping mechanism

Eating disorders are a way of coping. The athletic triad is unique in that it does not always stem from body image issues, but is usually caused by a desire to play more intensely, possibly prompted by pressure from a coach, parent, or peer but sometimes by the teen's own intense desire to compete and win.  That pressure can have a serious ripple effects on your teen's health, whether your teen is a girl or a boy.

Without the intervention, love and support of parents, teens can become so obsessed with the eating and exercising that they lose sight of who they are, or they begin to identify as someone with an eating disorder, turning into a person who you will not recognize as your teen. Early intervention is the key to prevention, and for that your teen needs your help.

Adekemi Oguntala, MD writes the blog TheTeenDoc. She is MomsTeam.com's pediatric and adolescent expert, an adolescent medicine physician, author, speaker and educator, and mom.  Dr. Oguntala lives in the San Francisco Bay area.

Created September 30, 2010