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The Female Athlete Triad

By Careen Joscelyn RN, MSN, CPT, GFI

You’re a runner and you heard or thought that if you lost a few pounds it could increase your speed, and as an athlete you know that a few seconds could mean the difference between winning or losing a race. Maybe you are a gymnast and thought you could flip higher or would look better in your leotard if you lost a few pounds.

These types of thoughts, favoring leanness to obtain a competitive edge or for appearances, can lead to a condition known as the female athlete triad. Let’s examine this more closely.

The Female Athlete Triad

According to Johns Hopkins Medicine, there are three intertwining medical conditions that make up the female athlete triad:

  • Inadequate energy intake

  • Menstrual cycle irregularities

  • Low bone density

Part One - Inadequate Energy Intake

The diet may present as low calorie intake, where the energy consumed does not meet the demands of the body. This restrictive eating, in conjunction with excessive exercise, results in decreased body fat.

Some levels of fat, also known as adipose tissue, are essential for healthy bodily functions. The essential needs vary between men and women, where the needs are as follows:

  • Men - 3-5%

  • Women - 12-14% (Fink & Mikesky, 2021)

For women, body fat levels beneath this range cause hormonal changes that interfere with normal menstrual cycles. This leads to the second phase of the triad.

Part Two - Menstrual Irregularities

Low levels of body fat triggers the body to cease ovulation. This leads to amenorrhea - an absence of a period or oligomenorrhea - menstrual irregularities resulting in approximately four to six cycles annually (Fink & Mikesky, 2021).

These cycle irregularities lead to hormonal imbalances, particularly decreased estrogen production. The consequence of this reduced hormone production is changes in bone mineral density (Fink & Mikesky, 2021), which leads to the third and final phase of the triad.

Part Three - Low Bone Density/Possible Osteoporosis

Decreased bone mineral density, due to hormonal changes brought on by low energy intake and subsequent low body fat levels, result in brittle bones and osteoporosis in some cases. This often presents as stress fractures, with 25-63% occurring in the tibia (the larger of the two lower leg bones).

In addition, restrictive diets can also be deficient in bone building minerals such as vitamin D, calcium, and magnesium (Fink & Mikesky, 2021). This further potentiates the problem.


We marvel at the athletic abilities and physiques of athletes. However, the ambition, competitive drive to win, pressure to be the best, and body appearance can lead the female athlete on a path toward the female athlete triad. Consuming insufficient calories that lead to decreased body fat, hormonal changes, and subsequent reductions in bone density are characteristic of the condition.

The purpose of this blog is to raise awareness of the complex condition, female athlete triad. If you think you may be at risk for or could possibly have this, please contact a medical provider for evaluation, diagnosis, and treatment.


Fink, H.H. & Mikesky, A.E. (2021). What is the female athlete triad? Practical Applications in Sports Nutrition, Sixth Edition. Pgs. 323-325

Nazem, T.G., & Ackerman, K.E. (2012). The Female Athlete Triad. Sports Health. Pgs 302-311.

OASH. (2021, February 22). Your Menstural Cycle and Your Health.

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