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CAQ Review

The Female Athlete Triad

VanBaak, Karin MD; Olson, David MD, FACSM

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doi: 10.1249/JSR.0000000000000222
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The Female Athlete Triad was first described in 1992 as a syndrome seen in female athletes consisting of disordered eating, amenorrhea, and osteoporosis. Current understanding has expanded to include a spectrum of three components:

  • ◯ low energy availability (EA) with or without disordered eating/eating disorder
  • ◯ menstrual irregularities
  • ◯ low bone mineral density (BMD) (1,3,4)

Low EA (1,2>)

  • – Energy expenditure (kcal) = metabolic equivalent of a task × weight (kg) × duration of activity (h)
  • – Daily EA = energy intake (kcal) − energy expenditure (kcal)/fat free mass or lean body mass (kg)
  • – Low EA: <30 kcal·kg−1 fat-free mass (FFM) per day
  • – Optimal EA: 45 kcal·kg−1 FFM per day
  • – Low body mass index: <17.5 kg·m−2 or <85% of the expected body weight

Menstrual irregularity (2,4)

  • – Primary amenorrhea: absence of menarche by the age of 15 years
  • – Secondary amenorrhea: absence of three consecutive menstrual cycles in a previously menstruating woman
  • – Oligomenorrhea: cycle length >35 d or <9 cycles per year

Low BMD (1)

  • – Low BMD: Z-score less than −1.0 in female athletes in weight bearing sports
  • – Osteoporosis: Z-score −2.0 or less with one or more secondary risk factors for the fracture

Diagnosis: Low EA (1)

  • – Accurate assessment of dietary intake is difficult.
    • ◯ Consider 3- to 7-d dietary log, 24-h dietary recall, and food frequency questionnaire.
  • – Refer to the 2011 Compendium of Physical Activities for energy expenditure values.
  • – Markers of low EA include reduced resting metabolic rate, low fat mass, and low free T3.

Diagnosis: Amenorrhea/Oligomenorrhea (2)

  • – Functional hypothalamic amenorrhea.
  • – Workup should include a history, physical exam, and consideration of the following:
    • ◯ Human chorionic gonadotropin (Hcg), hemoglobin, luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin, estradiol, thyroid stimulating hormone (TSH), T4, androgen profile, and pelvic ultrasound as appropriate.

Diagnosis: Low BMD (1–4)

  • – Athletes in weight-bearing sports should have 5% to 15% higher BMD than nonathletes.
  • – Any Z-score less than −1.0 in an athlete should be investigated further.
  • – <20 years: dual-energy X-ray absorptiometry (DXA) should measure lumbar spine bone mineral content (BMC) and areal BMD as well as whole body less the head BMD and areal BMD.
  • – ≥20 years: DXA should measure the lumbar spine, total hip, and femoral neck.

Relative Energy Deficiency in Sport (2)

  • – The effects of low energy availability extend beyond these three components.
  • – Chronic low energy availability can have additional medical and physiological consequences such as:
    • ◯ Mental health issues such as depression.
    • ◯ Micronutrient deficiencies and consequences such as anemia.
    • ◯ Fatigue.
    • ◯ Increased risk of cardiovascular disease due in part to poor lipid profile and endothelial dysfunction.
    • ◯ Gastrointestinal consequences.
    • ◯ Decreased effectiveness of the immune system.
    • ◯ Deficiencies in growth and development due to slowed metabolic rate and decreased growth hormone production.
    • ◯ Negative impact on performance (1–4).

Screening and Risk Stratification (1,2,4)

  • – Early identification and intervention are essential.
  • – Two risk stratification tools have been published recently. Both stratify athletes into low, moderate, or high-risk categories so practitioners can tailor workup and clearance based on an individual’s risk.
  • – The Female Athlete Triad Coalition and IOC Consensus group both recommend screening as a part of the preparticipation examination to identify these evidence-based risk factors:
  • – The goal of screening should be to identify these evidence-based risk factors:
    •  ◯ dietary restriction
    •  ◯ current or history of disordered eating
    •  ◯ low body mass index or recent weight loss
    •  ◯ delayed menarche
    •  ◯ history of or current amenorrhea/oligomenorrhea
    •  ◯ history of stress fractures, including multiple low risk fractures or a single high-risk fracture
  • – Any athlete with one component of the triad should be evaluated for the other components.

Other Populations (2)

  • – Most data are from Caucasian women, but nonwhite and male athletes are susceptible to the same consequences from chronic low energy availability.
  • – African-American women have a lower risk of eating disorders, low BMD, and pathologic fractures compared with Caucasian women but can still experience the Triad.
  • – Male athletes are at lower risk of eating disorders and poor bone health than female athletes.
    • ◯ Functional suppression of the hypothalamic pituitary axis results in testosterone suppression, which has a negative impact on bone health.
    • ◯ Male runners and cyclists may be at higher risk of low BMD than other athletes.

Treatment (1,2,4)

  • – The goal of treatment is to increase EA utilizing a multidisciplinary team, which may include a sports physician, nutritionist, psychologist, therapist/athletic trainer, and physiologist.
  • – Energy intake should be increased by 300 to 600 kcal·d−1.
  • – Consider decreasing exercise in combination with increasing dietary intake.
  • – Athletes with DE/ED should be treated by a mental health professional who has experience with athletes.
  • – Oral contraceptives have not been shown to improve BMD independent of an increase in EA and are not recommended as a primary treatment for the Triad.
  • – Athletes with low BMD should participate in 2 to 3 d·wk−1 of high-impact loading and resistance training.
  • – Calcium intake of 1,000 to 1,500 mg·d−1 is recommended.
  • – Vitamin D 25, OH levels should be 32 to 50 ng·mL−1 with 1,500 to 2,000 IU·d−1 of vitamin D intake.
  • – Bisphosphonates, parathyroid hormone peptides, and calcitonin are not approved for premenopausal women.
  • – An individual’s prognosis depends largely on early identification and intervention.


1. De Sousa MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad. Br. J. Sports Med. 2014; 48: 289–309.
2. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad — relative energy deficiency in sport (RED-S). Br. J. Sports Med. 2014; 48: 491–7.
3. Nattiv A, Loucks AB, Manore MM, et al. The Female Athlete Triad. Med. Sci. Sports Exerc. 2007; 39: 1867–82.
4. Otis C, Drinkwater B, Johnson M, et al. ACSM Position Stand: the Female Athlete Triad. Med. Sci. Sports Exerc. 1997; 29: i–ix.
Copyright © 2016 by the American College of Sports Medicine.