The Threat of the Female Athlete Triad

Dear Speed Lab,
My daughter, who is 16 years old, has just started to race in triathlons. I don't have any major concerns with her training and racing in all three events, but I have read that girls who compete at a young age are more likely to acquire a condition known as the female athlete triad. I am hoping you may be able to tell me what exactly makes up this condition and whether I should be concerned for my daughter's health while she's training for triathlons. She seems to be very committed to doing them.

Jennifer - San Antonio, TX

Dear Jennifer,
The female athlete triad refers to three interrelated conditions: disordered eating, amenorrhoea (or absence of menses) and osteopenia. Osteopenia is the term used to describe bones that have become less dense than normal; however, this condition is not as severe as its better-known cousin, osteoporosis. That said, a person with osteopenia is at risk for developing osteoporosis.

Sports physicians and scientists are becomingly increasingly concerned about the female triad, which occurs primarily in athletic young females. While the condition has only recently been described in medical literature, it has been silently observed by coaches, parents, team physicians and athletes for some time.

The female athlete, driven to excel in her sport or pressured to have a thin physique, may attempt to lose bodyweight or body fat by developing patterns of disordered eating. These patterns may lead to menstrual dysfunction and subsequent osteoporosis. Each portion of this triad can increase an athlete's health risks, but the dangers of the three together are synergistic.

Disordered Eating

A preoccupation with excessive thinness can precipitate a range of poor nutritional behaviours, including anorexia nervosa and bulimia nervosa. Food restriction, bingeing or purging, laxative or diuretic abuse and even excessive exercise are used to lose weight, ostensibly to improve performance. Pressure to be thin to win can come from the athlete, the coach and/or the parents and is often reinforced by cultural, societal and sport-specific expectations.

Very few studies have evaluated the prevalence of disordered eating among female athletes. Several small trials suggest that the prevalence may be as high as 62 percent in certain sports. According to the American College of Sports Medicine, females who participate in sports that emphasise low body weight are at the greatest risk for developing one or more of the components of the triad, including disordered eating.
Disordered eating may impair athletic performance and increase the risk of injury.
Decreased caloric intake, and the resulting fluid and electrolyte imbalances, can result in decreased endurance, strength, reaction time, speed and ability to concentrate. Food restriction and purging can result in menstrual dysfunction, irreversible bone loss and serious psychological and medical complications.

These complications are potentially fatal, as the death rate among non-athletes treated for eating disorders has been reported as high as 18 percent.


Disordered eating involving acute bodyweight loss and marked bodyweight fluctuations has been associated with amenorrhoea. A variety of menstrual disorders, including abnormal luteal phase, anovulation and amemorrhoea, are recognised as occurring more frequently in female athletes than in the general population.

Amenorrhoea is the absence of menstrual bleeding and can be classified as either primary or secondary. Primary amenorrhoea refers to a woman who has not had any menstrual bleeding by the age of 16 or is without sexual development by the age of 14.

Secondary amenorrhoea refers to a woman who has established menstrual cycles but then experiences an absence of menstrual bleeding for six months. The International Olympic Committee has defined amenorrhoea as one menstrual period or less per year in an attempt to standardize future reports.

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