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The female athlete triad: What it is, what causes it and the symptoms active women need to watch for


Active women try to do all the right things. Eat the right mix of foods, get the ideal amount of exercise or training for their favorite sports – all while keeping a healthy balance. But sometimes, what women think might be the best approach to health and fitness can end up having the opposite effect. In fact, it can cause a new set of issues affecting their lives beyond the gym.

We’re talking about the female athlete triad – a syndrome that might have some familiar symptoms. We’ll describe what they are and how to keep the female athlete triad from affecting your performance, and more importantly, your overall health.

What is the female athlete triad?

The female athlete triad is a group of three interrelated conditions experienced by active women:

  • Underfueling (taking in fewer calories than you need during the day)
  • Menstrual cycle irregularity
  • Low bone mineral density

The female athlete triad is more common than you think. Our sports-trained registered dietitian at TRIA sees these symptoms in women of all activity levels, from weekend warriors to competitive athletes. They tend to follow similar stories like this:

A few weeks into training for her first marathon, a patient starts to feel more tired during the day. At first, the problem doesn’t seem to be with her diet. In fact, it seems to be very healthy as it’s heavy on fruits, vegetables and lean proteins like chicken and fish.

However, she hasn’t increased the amount of food she’s eating to keep up with her new activity level. She figures the energy stored in her existing body fat will make up the difference, burning off as her training sessions become more and more rigorous.

Despite the lack of energy, she continues to push through her training and diet regimen. After a few months, her period becomes irregular. Then it stops completely. She also starts to feel pain in her lower leg – an ache that won’t go away. In addition, her energy levels are getting worse. Not only is she feeling sluggish, she also has a constant mental fog.

This is a classic example of someone experiencing the conditions of the female athlete triad.

What are the signs and symptoms of the female athlete triad?

Women experiencing the female athlete triad can feel a variety of symptoms, including:

  • Fatigue
  • A decrease in performance
  • Longer recovery after activity
  • An increase in injuries, especially stress fractures
  • Loss of muscle
  • Absent or abnormal periods
  • Increased depression and irritability
  • Decreased concentration and coordination
  • Impaired judgement

Left without treatment, the triad can lead to serious long-term problems:

  • Amenorrhea (a condition where your period stops completely)
  • Osteoporosis
  • Cardiovascular issues
  • Endocrine issues

Fortunately, with a little bit of knowledge and help from a TRIA dietitian, we can address the underlying causes to get you back on track.

Underfueling: The first leg of the female athlete triad

Remember when we mentioned the patient’s diet in the story above? She was eating a strict intake of fruits, vegetables and lean proteins that was calorically below what her body needed to fuel her training. Whether it’s “clean eating” or “just eating really healthy”, these descriptions from patients can be red flags. In these cases, they’re almost certainly underfueling.

Underfueling happens any time the energy you take in (through eating) is less than the energy you put out (through exercise). You can fall into this trap when you think that you can lose weight or achieve muscle tone with this approach. Add in eating only specific kinds of foods, and your diet likely can’t meet your body’s needs.

The tricky math of calories

Having the right nutrition is so important for active women.

When it comes to calories, your body does more than take in and burn out. When your body isn’t getting the fuel it needs from the outside, that doesn’t mean it’s going to immediately take the extra calories from fat. On the contrary, your body tends to preserve fat for protection. That means your body will aim to get calories from protein first – and your muscles make an excellent source.

Since different foods serve different functions, it’s never helpful to restrict entire food groups or calories. In fact, all foods can fit in a healthy diet.

The intersection with eating disorders

Most women don’t usually set out to underfuel their bodies. Often, it’s simply a result of not realizing how much energy she needs. However, intentional underfueling is very real, and can be an early sign of an eating disorder – along with:

  • Fasting or limiting food intake
  • Binge eating
  • Self-induced vomiting
  • Extreme exercise

When we see this situation, we can refer patients to the experts at Melrose Center to get the support they need. Paying attention to early signs of eating disorders is crucial in preventing them from developing into something more serious.

At Melrose Center, patients can find comprehensive treatment for eating disorders like anorexia, bulimia and binge eating disorder. Their compassionate care has resulted in over 30 years of many, many success stories.

Part two of the triad – menstrual cycle irregularity

As you can see, underfueling can cause big problems. When you don’t have enough fuel, your body starts to shut down systems that aren’t essential to your day-to-day survival.

Having a regular period is a good sign that you’re taking in enough energy to meet your body’s demands. And when that energy isn’t coming in from the outside, your reproductive system can be one of the first to get taken offline.

This is the second part of the triad: menstrual cycle irregularity or – in more serious instances – the complete stopping of your period, which is known as amenorrhea.

Triad part three – low bone mineral density

Finally, when you do not consume adequate energy, your bones don’t get the resources they need to recover from stress and damage. Your estrogen levels, which are essential for all women’s bone health, also become affected. It all adds up to the final part of the triad – low bone mineral density.

Over time, your bone density decreases, increasing your risk of injuries like stress fractures. Women are already more prone to certain injuries, and experiencing the female athlete triad can increase your level of risk. Over a long period of time, this can also lead to osteoporosis.

How to treat the female athlete triad

If you think the triad is affecting your health, getting in touch with a registered dietitian is key. Look for a dietitian who is part of a sports medicine team, like the Women’s Sports Medicine program at TRIA. This way, you’ll receive advice, treatment and planning that’s specifically designed with your lifestyle and goals in mind.

Anyone can make an appointment with a dietitian – you don’t need a referral from your personal physician. Plus, you don’t have to consider yourself an athlete to see a dietitian. We see all sorts of people who are active and want to live a long, healthy, happy life.

When patients see a dietitian, the session usually starts with questions about activity levels and relationships with food. Once the dietitian gets a good idea of what the patient’s current situation is, the dietitian works with the patient to target specific areas of their diet or eating patterns.

The dietitian will focus on things like eating consistently throughout the day, eating enough fat and carbohydrates, or responding to hunger cues. It’s all about paying less attention to things like calorie tracking apps, and more to your own body to better understand how much to eat.

Talking to an expert about the female athlete triad

Women of all activity levels – not just those who consider themselves athletes – can experience the female athlete triad. And if you’re noticing any of the symptoms, don’t ignore what you’re feeling. If not corrected, these issues can lead to serious long-term problems such as amenorrhea, osteoporosis, cardiovascular issues and endocrine issues.

Since underfueling is at the core of the female athlete triad, scheduling an appointment with a dietitian who specializes in women’s sports medicine should be your first step.

A dietitian can work with you to understand your symptoms and how your fueling habits may or may not be supporting your current exercise or training routine, and help you make a plan for getting your body what it needs to perform. 

To make an appointment with a dietitian or another expert from our Women’s Sports Medicine team, give us a call. To make an appointment with a sports medicine physician, call or make an orthopedic appointment online.

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