Ask the expert: What is the female athlete triad and how can it be prevented?

Female athlete triad

The spring athletics season is in full swing and for those at the high school and college level, practices and game schedules can be intense. When you blend this physical commitment with the demands of a hectic academic schedule, sometimes maintaining healthy eating habits and positive energy balance can be challenging.

Dr. Kathryn Ackerman, medical director of Boston Children’s Female Athlete Program, shares important information about a condition called the female athlete triad and offers tools to keep young athletes healthy, energized and at the top of their game.

What is the female athlete triad? 

The female athlete triad is a condition of three intertwined health issues: (1) energy availability (caloric balance), (2) menstrual function and (3) bone health. In order to achieve a healthy balance and avoid the triad, Ackerman recommends female athletes follow these important guidelines:

•   take in enough quality calories to account for their energy expenditure from daily activities and exercise (energy availability)

•   monitor/maintain normal monthly menstrual cycles, and

•   through weight-bearing exercise, achieve bone density that is equal to or better than non-active adolescents and teens

“Most adolescents don’t care about their bone density until they start experiencing fractures,” says Ackerman, course director of Boston Children’s upcoming  Female Athlete Conference at Babson College. “But we know there can be health and performance consequences associated with triad even before fractures begin including immune dysfunction, iron deficiency, and more difficulty recovering from workouts.”

Defining the complications

Complications female athlete triad

1. Energy availability

In some cases, female athletes may be at risk for developing eating disorders because of pressures to maintain a low body weight, or because of poor guidance about nutrition and weight loss. This may lead to an energy deficiency.

“We need to be sending girls and women positive messages about strong, healthy bodies, and block the noise about an ‘ultra-thin ideal.’

Healthy dieting is considered a modest lowering of daily calories, while disordered eating includes harmful behaviors like skipping meals, using laxatives, bingeing and purging. Ideally, an athlete doesn’t “diet” at all, because she has the tools to keep a healthy body weight and has the energy her athletic body needs to perform and function properly.

Ackerman says it is important for girls to maintain healthful eating habits and a healthy mindset, and having a supportive network can help female athletes stay healthy.

“We need to be sending girls and women positive messages about strong, healthy bodies, and block the noise about an ‘ultra-thin ideal,'” Ackerman says. “Too often I see incredibly smart, talented, motivated female athletes who are so successful on and off the field, and yet they still have this drive to be thinner and harbor insecurities about their bodies.”

2. Menstrual function

Intense workout regimens and low caloric intake may lead to a decrease in hormones that regulate a girl’s menstrual cycle. According to Ackerman, women who participate in sports that emphasize leanness such as running, gymnastics, figure skating, and lightweight rowing, are much more likely to experience menstrual irregularities. But the triad can happen to any female athlete, she adds. Eating a healthful diet and being careful not to over-exercise can help prevent irregular periods.

“When an athlete stops getting her period, sometimes, it is due to over-exercising, experiencing extra stress and not getting enough good nutrition, which can reduce estrogen and other hormone levels in the body,” Ackerman says. “It is important to note that a missed period does not mean female athlete triad. There may be other reasons prompting menstrual irregularities that need to be explored.”

3. Bone health

Various hormones, including estrogen, are important for building and maintaining bone. According to Ackerman, girls accumulate 90 percent of peak bone mass by the age of 18, and regular physical activity helps maximize bone mass even into adulthood.

Athletes with the triad, however, can have reduced bone strength, which can cause stress fractures or even osteoporosis at a young age. “It’s important for female athletes to eat enough healthy calories because it gives them energy for exercise and growth and development, and helps maintain normal hormone levels,” she says.

Preventing the female athlete triad

At Boston Children’s, we have so many great resources for female athletes to get more informed about their health and performance.

To help female athletes stay at the top of their game, Ackerman suggests the following:

Be aware of your risk. If you compete in weight-class sports and aim to reduce your weight before a competition, or if your sport emphasizes leanness or aesthetics, like gymnastics, ballet, figure skating, lightweight rowing or running, you may be at a higher risk. But keep in mind that any female athlete may suffer from components of the triad.

Recognize pressures and reach out for support. If you feel pressured to reduce your weight for a sport or to use harmful dieting methods before a competition, ask your doctor for help communicating with your coach and other athletic community members to prioritize your health. Talk to your doctor about your weight, competitive pressures, menstrual cycle, stress fractures, exercise and eating habits and overall health.

Talking to your doctor. Even if you don’t think you are experiencing an element of the triad, it’s a good idea to talk to your doctor regularly about your exercise, eating and menstrual habits. Your pre-participation physical is a great opportunity to do this, since you may learn something new about yourself before your season begins.

“At Boston Children’s, we have so many great resources for female athletes to get more informed about their health and performance,” she adds. “I love seeing our patients taking advantage of these resources and feeling empowered as they become healthier and have more successful seasons.”

Learn more about the Female Athlete Triad and Boston Children’s Female Athlete Program.

Kathryn Ackerman, MD


Kathryn Ackerman, MD, MPH, is a Sports Medicine Physician, Director of Boston Children’s Female Athlete Program and Assistant Professor in Medicine at Harvard Medical School.