Female Athlete Triad: What You Need To Know.
Research: Ayrton Walshe - GMIT
Editor Marie Farag – Head Nutritionist Totum Sport (Cellnutrition Sport)

UP TO 60 percent of female athletes can experience some of the features of the Female Athlete Triad.

Only 63 percent of physicians could identify all features of The Triad while a mere 9 percent of physicians were comfortable in treating this detrimental condition.

What is the Female Athlete Triad?

The Triad is a phenomenon whereby a female athlete has a low availability of energy, menstrual dysfunction and complications with bone mineral density. Generally, this can occur through not eating enough calories, training excessively and inadequate recovery.

The challenge is that the Triad not only affects performance but can also cause major health concerns.

Menstrual Dysfunction

Female athletes can lose their menstrual functioning, also known as Amenorrhea or Oligomenorrhea. Oligomenorrhea is a menstrual cycle occurrence of more than 35 days while amenorrhea is a menstrual cycle of over 90 days. The natural cycle is 28-days.

Low Energy Availability

Low energy availability from high training load and an inadequate/insufficient calorie intake can lead to the female athlete having insufficient energy to support the reproductive system and overall full-body functioning. Some athletes may also have an associated eating disorder which will require medical or psychological support to resolve.

One nutritional consideration often overlooked in this scenario is the role of micro-nutrients, specifically Iron. A female athlete with inadequate food intake will likely be deficient in iron, and iron is a key component in red blood cells. Iron is essential to prevent anaemia, prevent declines in cognitive development, immunity and work capacity.

During menstrual cycles each month, female athletes iron stores are depleted, and if they are not meeting their nutrition requirements then stores are not replaced, and the athlete’s performance may decline also.

What happens during recovery?

During recovery from the triad, female athletes can struggle to regain their fertility. However, in other cases athletes may experience an unexpected pregnancy with unreliable birth control practices.

An example of this is US middle-distance runner Mary Cain, an athlete who became the World Junior Champion at 3000m in 2014 and was tipped for stardom on the international stage. Cain was enrolled in one of Nike’s prestigious running programs in Oregon due to her dominance as a freshman in high school. Cain’s coaches pushed the athlete to pursue a thinner and thinner physique in the belief that it would catapult her performance even further. This oversight for the potential consequences of such a strategy left Cain without her period for over THREE YEARS. Another consequence she faced is a reduction in bone mineral density, this may have had a role to play in Cain’s five broken bones she experienced during this time.

Bone Mineral Density

Bone density reductions can be caused once again by poor nutrition and also low oestrogen levels which affect bone formation and bone resorption. As a result, bone structure is compromised with athletes undergoing constant bone remodelling as they exercise regularly.

With the large forces exerted on female athletes during running and jumping manoeuvres, the importance to maintain bone mineral density can never be underestimated if looking to prevent injury.

What are the future consequences?

Females will naturally experience a decline in oestrogen post-menopause, with a natural decline in bone mineral density from this point onwards.

Therefore, if an athlete is already depleted prior to menopause they are far more likely to experience a condition such as osteoporosis. Osteoporosis is a severe fragility in bones making them susceptible to fractures. Once again, inadequate micro-nutrients in the diet further pre-dispose the female athlete to fractures, as Vitamin D and Calcium work synergistically to support our robust skeletal system.

Athletic performance is born from optimal training and optimal recovery, however in order to achieve this state the female athlete must be healthy. The triad can threaten an athlete’s health and lead to potentially detrimental injuries which can impact professional careers. Therefore, if you have any questions on this article please don’t hesitate to contact our team @ insert email address.

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(Troy et al., 2006; Ducher et al., 2011; Mountjoy et al., 2014; Reed et al., 2014; Petkus et al., 2017; Tenforde et al., 2017; Cain, 2020)


Cain, M. (2020). Opinion: I Was The Fastest Woman In America, Until I Joined Nike. The New York Times. [Online], 3rd February, 2020, 1.

Ducher, G., Turner, A.I., Kuku!an, S., Pantano, K.J., Carlson, J.L., Williams, N.I. and De Souza, M.J. (2011). Obstacles in the Optimization of Bone Health Outcomes in the Female Athlete Triad. Sports Medicine, 41 (7)587-607. 

Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K. and Budgett, R. (2014). The IOC consensus statement: beyond the female athlete triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med, 48 (7)491-497. 

Petkus, D.L., Murray-Kolb, L.E. and De Souza, M.J. (2017). The Unexplored Crossroads of the Female Athlete Triad and Iron Deficiency: A Narrative Review. Sports Medicine, 47 (9)2017/09/01, 1721-1737. 

Reed, J.L., De Souza, M.J., Kindler, J.M. and Williams, N.I. (2014). Nutritional practices associated with low energy availability in Division I female soccer players. Journal of Sports Sciences, 32 (16)1499-1509.



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  • Mar 13, 2020
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