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Three factors for active women to watch out for

By Jillian Tholen, MS, RDN, LD

Whether you’re a weekend warrior or a competitive athlete, there are three conditions you should be aware of to make sure you stay healthy and active. The Female Athlete Triad is a group of three interrelated conditions experienced by active females, and it’s more common than most people think.

For example, a woman decides she wants to start jogging more often. She begins running regularly and enjoys the boost of energy and new routine in her life.

But after a couple of weeks, she starts feeling tired. Over the next few months, she also notices her period is not as regular or predictable. She has not increased the amount of food she is eating to keep up with her new activity level. She doesn’t realize this might be the cause of her new health issues.

Another woman wants to eat “healthier.” She starts by adding more fruits and vegetables into her diet. Soon she is eating only fruits, vegetables and lean proteins. She decides not to eat foods that have fat or a lot of carbohydrates because she thinks those foods are “unhealthy.”

She starts to notice her energy lagging while playing soccer. She continues to cut out different foods. She believes it might be the food she is eating that is causing her to get tired more quickly. After a few weeks, she notices pain in her lower leg. Her coach thinks it might be a stress fracture.

Female Athlete Triad

Both women in these scenarios are experiencing aspects of the Female Athlete Triad. This is also sometimes referred as RED-S (relative energy deficiency in sport) to expand on the term and include both sexes, not only females. The three aspects of the Female Athlete Triad are interrelated:

  • low energy availability (underfueling)
  • menstrual cycle irregularity
  • low bone mineral density

The Female Athlete Triad is not uncommon. Many active women can relate in some way to these stories. In fact, many active women experience issues related to the Female Athlete Triad unintentionally as they strive to maintain healthy, active lives.

As a sports-trained registered dietitian working at TRIA, I spend my days seeing patients and discussing nutrition-related issues. Many of my patients are women who don’t realize what type of fuel they need, how much they need, or when they need to be fueling in order to feel their best and stay healthy.

I help my patients correct any energy imbalances that might cause them to experience the Female Athlete Triad. I also educate my patients about the causes, starting with underfueling.


Underfueling is most common nutrition-related issue in female athletes. It is also the underlying cause of the Female Athlete Triad. Underfueling occurs any time energy output is greater than energy input.

Underfueling is not always intentional. It is usually a result of women simply not realizing how much their bodies need.

Sometimes people come in to see me and tell me they are using a calorie tracking app. The app tells them they are getting enough fuel. The problem is, these apps don’t know how much energy women actually need. The apps also teach us to rely on outside cues to decide how much to eat. I try to get my patients away from these apps as much as possible. I want to teach them how to fuel consistently throughout the day and listen to their bodies to better understand how much to eat.

Underfueling can be intentional as well. This often occurs with an effort to change body size or shape. Intentionally under-eating can lead to disordered eating, and can even result in a clinical eating disorder. In these cases, I am able to refer patients to Melrose Center to receive the support they need.

The highest risk of underfueling tends to occur in more aesthetic sports. These are activities with a focus on weight and image. Some examples include gymnastics, dance, figure skating, wrestling, running and rowing.

Menstrual Irregularities

The second condition in the Female Athlete Triad is irregularity in a woman’s period. High activity paired with a low energy availability can decrease the hormones that regulate a woman’s period. In short, if the body does not have enough energy for exercise and normal processes, it starts to shut down things that are not essential for survival. For women, one of these is the reproductive system. This can cause periods to become irregular. It can also cause them to stop altogether, which is called amenorrhea.

Bone Health

The third component of the Female Athlete Triad is impaired bone health. Without enough energy intake, bones do not receive the energy they need to regrow and remodel. Menstrual irregularities also impact estrogen levels, which are very important for bone health. As a woman’s bone density decreases, she is more likely to get injured. This can lead to osteoporosis if energy balance is low for a long period of time.

How a dietitian can help

I start by talking to my patients about food and activity levels. Some questions I might ask:

  • What is your activity level like?
  • What types of active things do you like to do?
  • What are your typical eating patterns like?
  • Are there specific foods you enjoy?
  • Are there foods you avoid?
  • How do you feel your relationship with food is?

I also look for the signs and symptoms of Female Athlete Triad, which include:

  • A decrease in performance
  • Fatigue
  • Longer recovery after activity
  • Increase in injuries
  • Menstrual irregularities

These issues can lead to serious long-term problems if not corrected. These include amenorrhea, osteoporosis, cardiovascular issues or endocrine issues. The sooner these issues are addressed, the easier it is to correct and avoid any long-term consequences.

I usually begin treatment by telling women about the Female Athlete Triad. Most of them have no idea what happens to their body if they underfuel.

I work with my patients to target specific areas of their diet or eating patterns. We focus on things like eating consistently throughout the day, eating enough fat and carbohydrates or responding to hunger cues.

Anyone can make an appointment to see a dietitian. Patients often see me before or after they have surgery. They also come to me after being diagnosed with a bone stress injury or after a physical therapist refers them. Other patients see me when they have specific nutrition-related questions or concerns. I help all of my patients with a plan on how to live a healthy and active live.

I see all sorts of people. You don’t have to think of yourself as an athlete. This is for anyone who is active and wants to have a long, healthy, happy life.

Our Women’s Sports Medicine program at TRIA brings together experts who treat active and athletic women of all ages and ability. Learn more here or call (952) 831-8742 to schedule an appointment.

About Jillian Tholen, MS, RDN, LD
Jillian Tholen is a registered dietitian nutritionist at TRIA  specializing in sports nutrition, women’s health and eating disorders. As part of Women’s Sports Medicine at TRIA, she helps female athletes with proper nutrition and sport-specific fueling needs. Her passion is helping her patients to explore and improve their relationship with food, and she is driven to increase awareness of disordered eating and underfueling in sport. As a lifelong athlete herself, Jillian enjoys helping women of all ages continue to be active and to live long, full and happy lives.

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