The “female athlete triad” sounds like an Olympic event, but it’s actually a sort of syndrome in which female athletes don’t get enough calories and nutrients to fuel their bodies. This deficiency isn’t just bad for their performance in sports; it can affect how their bones form and whether they get pregnant someday.
The triad is defined by at least one of three problems: not enough energy for your activity level, menstrual dysfunction and low bone density.
Original definitions of the triad included an eating disorder, but that’s no longer necessary for a diagnosis.
“It’s about being at any point on a spectrum, with or without an eating disorder,” says UNC Health sports medicine specialist Nailah Adams, MD. “At one end, you have optimal calorie intake, good bone health and regular menstruation. At the other end, there’s problematic low energy availability, osteoporosis and amenorrhea,” or missed periods.
Whether you’re the parent of a student athlete or in training yourself, Dr. Adams explains what you need to know about this triad.
Symptoms of the Female Athlete Triad
When your body doesn’t have enough calories to function, you don’t have enough energy. You or your athlete might be able to push through a game or race, but then you’ll feel tired, have trouble focusing or feel irritable.
“Sometimes, that’s just being a teenager, or some of these could be attributed to conditions like ADHD,” Dr. Adams says. “There can also be gastrointestinal issues, but those are also easily attributed to something else.”
Eventually, lack of calories impairs the body’s production of estrogen, and periods become irregular or stop. A missed period is usually the first symptom an athlete notices, Dr. Adams says, but for middle school and high school athletes who might not be familiar with their cycle yet, this symptom doesn’t always cause immediate alarm.
“When I’m doing an exam for a young athlete, I always ask if they’ve had their period yet, and if they have, if they’re having it every month,” Dr. Adams says. “It’s important to teach the concept that a period is healthy. Healthy periods equal healthy bone health.”
If lack of estrogen is affecting menstruation, it will start to affect your bones.
“Estrogen plays a role in bone strength, and women obtain their peak bone mass usually by the age of 20,” Dr. Adams says. “If a younger athlete can’t get to that peak bone mass because of the triad, they’re setting themselves up for thinner and more brittle bones.”
Lack of adequate calories also affects the bone’s ability to repair itself, so you may notice more injuries, such as shin splints or stress fractures.
It’s important to note that when male athletes don’t consume enough calories, their hormones are also affected, causing a decrease in testosterone and lack of sex drive (in an adolescent, this might mean loss of morning erections rather than loss of menstruation). With fewer calories, male athletes also will experience fatigue, irritability and trouble focusing, as well as increased risk for injury.
Relative Energy Deficiency in Sport (REDs) is a term that encompasses both male and female athletes who aren’t getting enough calories or nutrients for their activity level, and you may hear some providers use this term rather than female athlete triad.
Risk Factors for the Female Athlete Triad and REDs
Anyone, at any age, can experience the symptoms of REDs or the female athlete triad if they don’t consume the calories needed to fuel their activity level. If you’ve discovered a new love for lifting weights or long-distance running, be sure to talk to your primary care provider about your nutritional needs.
Certain athletes are at increased risk.
“If you wear a form-fitting outfit as part of your sport, like a leotard for gymnastics, you’re at higher risk for these types of symptoms,” Dr. Adams says. “These are what we call ‘lean sports,’ where there’s a perception that the less you weigh, the better you perform.”
Sports that require long periods of energy expenditure, such as cross country or soccer, also increase the risk of these symptoms, as does any sport where you compete by weight class, such as boxing, wrestling or rowing.
Some athletes who don’t eat enough calories have an eating disorder. Young athletes are at particular risk as concerns about body image start increasing in adolescence.
“There’s a lot of stress for a young person,” Dr. Adams says. “They’re dealing with social media, their peers, changes with their body. It’s part of what we’re screening for before they participate in sport.”
Treatment for the Female Athlete Triad and REDs
Because athletes can be at any point on this spectrum of symptoms, there’s no one way to diagnose this triad. Your provider may do other tests to rule out reasons for a missed period or weight loss, and blood work or a bone scan might reveal nutritional deficiencies, a body fat percentage that is unhealthily low or bone issues. Once it’s identified, the focus is on increasing your energy levels.
“You either increase the calories you take in or decrease the output of calories used, which might mean pulling them from the sport,” Dr. Adams says. “It’s also essential to address any disordered eating patterns or other underlying mental health conditions.”
This process requires a team approach—in addition to their primary care provider, an athlete may also need to see a sports nutritionist and a mental health professional—and it also requires coaches, athletic professionals and family members to understand the risks of performing without adequate energy. A female athlete may need to see a gynecologist or endocrinologist to address period problems.
The idea of increasing calories or taking a break is extremely challenging for some athletes, particularly young ones who may not grasp the long-term effects on their future fertility or bone health.
“It’s really important to get athlete buy-in for treatment and learn what their priorities are,” Dr. Adams says. “Are they hoping to get a scholarship or make this a profession? If so, we talk about balancing a short break now with lifelong performance. Do they want to have a family in the future? We help them see where that journey could be disrupted because of their current trajectory.”
Preventing the Female Athlete Triad and REDs
Talk to your child about their body so they will tell you when something isn’t right.
“Talk about which body changes are normal and which aren’t,” Dr. Adams says. “Be confident talking about periods, and how periods happen, with your child.”
As your child becomes more active in their sport, ask their doctor or a nutritionist about their macronutrient and micronutrient goals. Make sure they’re also hydrating and getting enough sleep.
“The ultimate goal is helping the athlete perform at their highest level without sacrificing their health and well-being,” Dr. Adams says.
Questions about nutrition or exercise? Talk to your doctor. If you need a doctor, find one near you.