Female Athlete Triad


Healthy weight is important for normal estrogen levels. When a female athlete's weight drops to an unhealthy level (i.e. when the percentage of body fat falls below 17 to 18%), either through disordered eating and/or intense training, menstruation may not start, may become irregular, or stop altogether. It is a myth that the absence of menses simply proves that a female athlete is training hard, and that amenorrhea is a positive adaptation of girls to exercise.

"Primary" and "Secondary" Amenorrhea

A girl is deemed to have "primary" amenorrhea if she has not begun to menstruate within 4.5 years after onset of breast development (menstruation usually begins between ages 12 and 15 for non-athletic females and 13 to 15 ½ for athletes). A girl who has not gotten her period for three to six months, menstruates irregularly or with very light flow, or at intervals longer than 35 days is considered to have "secondary" amenorrhea.

Affects All Female Athletes

Amenorrhea effects girls competing in all sports, but is most prevalent in competitive female gymnasts, ninety percent of whom get their periods a year or two late.

Because a female's body needs estrogen to absorb calcium for strong bones, not enough estrogen can cause bones to lose thickness and strength, resulting in a greater risk of stress fractures and osteoporosis. Research suggests that even minor forms of menstrual dysfunction may adversely effect bone density and lead to at least partially irreversible bone loss, although the silver lining to delayed menstruation is that it may lower a girl's risk of developing certain estrogen-related cancers.


A girl's teen years are a critical time for developing normal, strong bones as they are the years in which girls add half of their bone mass. Only ten percent of bone mass is added after age twenty. Too much exercise can cause effect bone mass and density, leaving a female athlete prone to increased risk of stress fractures if a girl is not having regular periods and does not have normal estrogen levels.


  • Balanced Diet. First, and foremost, a proper balance of exercise, body weight, calcium intake, Vitamin D (400 IU's daily) and estrogen is critical to prevent osteoporosis (1500 mg. of calcium if irregular menses, 1200 mg. if regular periods, either via 3 to 4 dairy products a day or supplements). If necessary, you should take your daughter to a dietician or nutritionist who works with adolescent athletes.
  • Screening. To screen for the triad, make sure your daughter undergo a pre-participation physical evaluation. It is essential that, in taking the medical history, your daughter's pediatrician asks questions about nutrition, menstruation, evidence of bone mineral loss (stress fractures; Dual Energy X-Ray Absorptiometry scan), and body image . Because athletes tend to be more honest about menstrual history and are typically dishonest about eating patterns, an abnormal menstrual history is a red flag for eating disorders and psychological issues (this is why your daughter should keep track of her periods).
  • No Pressure. As a parent you should avoid pressuring your daughter to achieve an unrealistically low body weight, such as by comments about appearance, good or bad foods, dieting and nutrition (this advice holds true for your sons as well, particularly swimmers and wrestlers) You should be wary of coaches who conduct out-of-competition weigh ins or measurement of body fat, especially public ones which can highlight for teenage girls the already sensitive issue of their weight (one prominent Southern California swim club that counts among its alumni numerous Olympic gold medal winners labeled members with what it deemed too high a body fat ratio as members of the "Blub Club"). One eating disorder specialist theorizes that a relationship exists between eating disorders and girls going through the natural separation in adolescence of girls from their fathers because they are particularly vulnerable during this time to viewing their coach as a substitute father figure. Because girls tend to internalize criticism more than boys, if the coach is critical of her weight, he or she can have a negative effect on a female athlete's self-esteem.
  • No Secrets. Fourth, if you suspect that your daughter exhibits symptoms of one or more elements of the triad, let her know that you want to help but that you can't keep the matter a secret, nor can you solve the problem on your own. If she is found to have disordered eating, experts recommend a multidisciplinary treatment approach (doctor, nutritionist, mental health professional).

Above all, be patient. Don't engage your daughter in a test of wills.