The Female Athlete Triad: Understanding Secondary Health Consequences

By: Becky Sauceda, MS, RD, LD

The Female Athlete Triad is the interrelated relationship between low energy availability, impaired menstrual status, and decreased bone health, and has become an increasingly prevalent condition observed amongst the sports community. While significant strides have been made in education and care for Triad athletes, there are many secondary health consequences that are commonly overlooked and equally imperative to address.

The Three Components

Low energy availability (LEA) is the main component that drives the unfavorable health outcomes of the Triad. LEA is the direct result of insufficient energy to support normal physiological function after accounting for energy expended during exercise. Inadequate dietary energy can occur with or without the presence of an eating disorder or disordered eating behaviors. No matter, the current diet and body conscience culture puts athletes at a greater risk should they follow trends that support restricted dietary energy intake or participate in prolonged exercise periods. It’s also possible LEA can be completely unintentional, such as when an athlete struggles to consistently eat enough while juggling a demanding schedule for training and life, lacks the resources to adequately fuel, or chooses to begin a new diet pattern without strong guidance. As energy availability becomes suboptimal, the body begins to suppress reproductive function and bone remodeling to compensate for energy balance in an effort for survival.

In another means of suppression, significant LEA negatively impacts normal ovarian function resulting in functional hypothalamic amenorrhea, the second component of the Triad. Amenorrhea is defined as the lack of menstrual cycles for greater than three months. It can be caused by genetic abnormalities or stress in addition to energy deficiency, so it is pertinent that medical providers uncover the root cause. If menstrual function is suppressed for too long, irreversible bone demineralization can begin to occur.

The last component of the Triad is related to impaired bone health. As an athlete progresses through the Triad, they are at risk of decreased bone mineral density (BMD), bone injury, and developing osteoporosis. Bone strength and the elevated risk of fractures are both dependent upon the overall bone mineral structure, density and quality of bone protein. Since bone loss occurs over an extended period of time, the risk of osteoporosis is not always just due to deficits during adulthood, but also potentially from increased bone mineral loss experienced during childhood or adolescence.

Health Consequences

Let’s take a look at some of the secondary health consequences that should be considered when working with athletes who may be susceptible to the Triad.

Hormonal Changes

When chronic LEA is present, the luteinizing hormone rate associated with normal reproductive function decreases leading to hormone imbalance. The imbalance of reproductive hormones leads to low estrogen levels that increases the risk of infertility and impaired bone health. Triad athletes may be additionally at risk for endothelial dysfunction since estrogen is known to increase nitric oxide use, which plays a role in vascular health.

Bone Stress Injury

Bone stress injuries are common amongst athletes, and can vary in severity from swelling to visible fracture lines. Driven by LEA, healthy bone remodeling is suppressed leading to increased risk for future injuries and delayed recovery. Research has shown amenorrhoeic athletes with or without low BMD have stress fracture risks 2 to 4 times greater than those who are regularly menstruating. Additionally, if impaired menstrual cycles are not treated, amenorrhoeic females can suffer from 2-3% of bone mass loss per year.

Micronutrient Deficiencies

Physically active females who eliminate or restrict food groups or struggle to eat enough calories overall during their busy schedules are at a higher risk for micronutrient deficiencies. Calcium, vitamin D, and magnesium assist with bone formation and overall bone health. Folate, vitamin B12 and iron are essential for blood health. More specifically, iron is critical in oxygen transport, energy formation, and positive bone remodeling. When Triad athletes are iron deficient, oxygen is not effectively delivered to muscles, causing fatigue, lightheadedness, dizziness and poor athletic performance. These examples are just a few of many that indicate the severity of micronutrient deficiencies.

Immune Function

Normal immune function can be suppressed by a variety of factors such as inadequate nutrient intake, lack of sleep, stress, and extended exercise. However, amongst Triad athletes it is thought that immune function is diminished due to a lower catecholamine response rate.

Decreased Sports Performance

When energy availability is compromised, macronutrient intake is likely insufficient and inadequate to meet the demands of exercise. For example, when carbohydrate intake is consistently low, glycogen stores are unable to be adequately replenished during periods of prolonged high intensity training. This energy deprivation can hinder practices or workouts through decreased concentration, coordination, muscle strength and endurance, or training response. When protein consumption is compromised, the body is unable to effectively maintain, repair, and promote new skeletal muscle protein. Additionally if muscle glycogen is depleted and unable to be recovered prior to the next bout of exercise, the body may need to rely on fat sources that can be utilized as energy sources in unique situations.

Screening & Diagnosis

Promoting the health and safety of athletes should be the highest priority and guiding principle of healthcare and performance practitioners. Screening for the Triad during annual health screening and/or pre-participation physicals should be highly encouraged by the healthcare and multidisciplinary team or when an athlete presents with any of the clinical conditions associated with the Triad.

The Triad Cumulative Risk Assessment (De Souza et al., 2014) is one screening tool which uses a scoring system to assess the level of risk for safe participation in sport. One example element of the assessment is evaluating BMD through a DXA scan when deemed appropriate by a medical professional. A DXA scan is the gold standard to assess BMD, and the athlete’s z-score result would be assigned points for low, moderate, or high risk. Collectively, the Triad Cumulative Risk Assessment tool can be an objective piece of the puzzle of determining if increased monitoring, restriction, or disqualification from training or competition is in the best interest of the athlete’s overall well-being.


Educating both the athlete and support staff from all athlete-centered departments on the signs, symptoms, and secondary health consequences of the Triad is essential for prevention and management. Prevention and early treatment should involve a multidisciplinary team approach. Helpful approaches include instituting policies and procedures to discourage and eliminate harmful weight loss practices among female athletes, while creating environments that encourage positive fueling.

Health and performance issues seen in the Triad do not discriminate against sport, gender, or age. While those in weight class or body image centered sports may intentionally engage in suboptimal nutrition or exercise-related practices that perhaps temporarily modify body composition and / or image to encourage competitive success, Triad-related concerns should not just be expected from these athletes exclusively. Even though research is still limited on male athletes, there is emerging evidence that male athletes experience similar effects on hormonal function and bone health to those seen in the Female Athlete Triad. When continuous severe energy deficiency is present, male athletes have an elevated risk of developing bone stress injuries as well as suppressed reproductive function associated with infertility such as low testosterone, decreased sperm motility/quality, and low libido.

Sport RDs are integral to the Triad treatment program to reverse LEA and achieve positive energy balance. Athletes can be provided specific, individualized nutrition goals for sufficient caloric consumption, educated on essential micronutrient supplementation or specific food intake for adequate bone health, and guided in normalizing eating behaviors or negative food (eating) beliefs. It is imperative that screening be emphasized across all sports to ensure the safety and well-being of athletes for current high-level competition and optimal health for years after their athletic career.

This article was written by a Collegiate and Professional Sports Dietitian Association Registered Dietitian (RD).  To learn more about sports nutrition and CPSDA, go to


American College of Sports Medicine. (2007). The Female Athlete Triad Position Stand. Medicine & Science in Sports & Exercise, 1867-1882. doi:10.1249/mss.0b013e318149f111

De Souza, M. J., Koltun, K. J., & Williams, N. I. (2019). The Role of Energy Availability in Reproductive Function in the Female Athlete Triad and Extension of its Effects to Men: An Initial Working Model of a Similar Syndrome in Male Athletes. Sports Medicine, 49(S2), 125-137. doi:10.1007/s40279-019-01217-3

De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., Gibbs, J. C., Olmsted, M., Goolsby, M., Matheson, G. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. British Journal of Sports Medicine, 48(4), 289-289. doi:10.1136/bjsports-2013-093218

Holtzman, B., Tenforde, A. S., Parziale, A. L., & Ackerman, K. E. (2019). Characterization of Risk Quantification Differences Using Female Athlete Triad Cumulative Risk Assessment and Relative Energy Deficiency in Sport Clinical Assessment Tool. International Journal of Sport Nutrition and Exercise Metabolism, (29), 569-575. doi:

Joy, E. A., & Nattiv, A. (2017). Clearance and Return to Play for the Female Athlete Triad. Current Sports Medicine Reports, 16(6), 382-385. doi:10.1249/jsr.0000000000000423

Logue, D., Madigan, S. M., Delahunt, E., Heinen, M., McDonnell, S., & Corish, C. A. (2017). Low Energy Availability in Athletes: A Review of Prevalence, Dietary Patterns, Physiological Health, and Sports Performance. Sports Medicine, 1-27. doi:10.1007/s40279-017-0790-3

Manore, M. M., Kam, L. C., & Loucks, A. B. (2007). The female athlete triad: Components, nutrition issues, and health consequences. Journal of Sports Sciences, 25(S1), S61-S71. doi:10.1080/02640410701607320

Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., . . . Ljungqvist, A. (2014). The IOC consensus statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(7), 491-497. doi:10.1136/bjsports-2014-093502

Petkus, D. L., Murray-Kolb, L. E., & De Souza, M. J. (2017). The Unexplored Crossroads of the Female Athlete Triad and Iron Deficiency: A Narrative Review. Sports Medicine, 47(9), 1721-1737. doi:10.1007/s40279-017-0706-2

Rickenlund, A., Eriksson, M. J., Schenck-Gustafsson, K., & Hirschberg, A. L. (2005). Amenorrhea in Female Athletes Is Associated with Endothelial Dysfunction and Unfavorable Lipid Profile. The Journal of Clinical Endocrinology & Metabolism, 90(3), 1354-1359. doi:10.1210/jc.2004-1286

Tenforde, A. S., Barrack, M. T., Nattiv, A., & Fredericson, M. (2016). Parallels with the Female Athlete Triad in Male Athletes. Sports Medicine, 46, 171-182. doi:10.1007/s40279-015-0411-y


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