The Female Athlete Triad

The signs and symptoms of the Female Athlete Triad are broad, often mild and therefore miss-attributed to ‘thats just life’ events, often going unnoticed or ignored. But its important to be aware and catch this syndrome early to prevent potentially long term damage to health and training.

The triad refers to the association between the following three clinical conditions:

1.     Low energy availability (with or without an eating disorder)

2.     Menstrual dysfunction (amenorrhoea)

3.     Low bone mineral density (osteoporosis)


Low energy availability: This basically means that the woman is not eating enough to meet her daily requirements. It may be related to an ‘eating disorder’ or ‘disordered eating’ of some kind, especially for sports in which leanness and low body weight is encouraged, such as running, dancing, gymnastics or skating. This can then result in low body weight and a very low body fat percentage.

Menstrual dysfunction: The clinical end point of menstrual dysfunction is amenorrhoea (periods stopping for 3 or more months). In the case of low energy availability, menstrual cessation is a survival mechanism. When we have sufficient energy, the brain releases a hormone (gonadotrophin releasing hormone) which stimulates the ovaries to release oestrogen and progesterone, allowing for regular menstrual cycles with the goal of reproduction. But when there is a lack of energy availability or a low body fat percentage, the body wants to conserve its resources and the last thing the body needs is to spend energy and nutrients on making a baby! This means the brain stops producing hormones to promote secretion of reproductive hormones and menstruation eventually comes to a holt.

Low bone mineral density: The final condition in the triad is lowered bone mineral density, the clinical end point of which is osteoporosis. The key factor here is lack of oestrogen (due to the altered cycle of hormone production, as above), as oestrogen stimulates normal bone mineralisation in women. Other factors causing lowered bone mineral density can include lack of the necessary bone-supporting nutrients such as calcium, magnesium and fat-soluble vitamins A, D and K in the diet, and lowered oestrogen availability.


This is a progressive condition stemming from inadequate energy intake. Each component exists on a continuum between health and pathology. This means clinical symptoms of all three may not always be evident together. For example, periods may have changed in regularity or length rather than ceased, and bones may have begun to brittle but are not yet osteoporotic, and evidence of reduced bone mineral density is unlikely to be evident unless tested for or fractures have occurred. It’s important we try to catch this early to prevent any long term irreversible damage.

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Are you at risk?

The following are factors which may increase your risk:

  • Performing in a sport comprising of weight classifications e.g. rowing, weightlifting, boxing.

  • Sports which historically correlate low body mass and fat to success e.g. triathlons, long distance running, ballet, gymnastics, figure skating.

  • Simply being in an environment that idolises leanness and/or thinness as something to strive towards.

  • Current or history of an eating disorder


  • Low energy and general feelings of weakness and fatigue

  • Poor recovery and repair from training i.e. feeling sore and drained going into and during sessions

  • Plateau or reduced strength and/or muscle size

  • Catching coughs, colds and infections more often (decrease immune function)

  • Lack of sex drive

  • Depression

  • Irregular periods/ change in cycle or period length

  • Increase in injuries

  • Stress fractures

  • Restricting eating to certain food groups

  • Feelings of guilt after eating certain foods or missing training

Impact on health and performance

The ‘triad’ is how the condition is classified, with the health implications travelling along the pathological continuum towards infertility and osteoporosis. However, the implications and negative outcomes of the female athlete triad can be far-reaching, impacting not only day-to-day performance and wellbeing, but also long-term health. This is why the Female Athlete Triad has now been coined as Relative Energy Deficiency in Sport (RED-S).

RED-S Potential Performance Effects.png

Impact on performance:

  • Reduced aerobic capacity

  • Reduced anaerobic (sprinting) capacity

  • More missed training sessions due to illness

  • Reduced strength

  • Early onset fatigue in training sessions

  • Lack of drive to train

health effects RED-S.png

Impact on health:

  • Increased cardiovascular disease risk

  • Low thyroid function

  • Adrenal fatigue

  • Infertility

  • Stress fractures and osteoporosis

  • Mental health issues including: anxiety, depression, eating disorders

How to re-balance energy

Addressing low energy availability involves increasing energy intake, reduction in exercise or a combination of both until energy expenditure is met by energy intake.

Step 1: determine daily energy expenditure. This can be done using a simple calculator to establish a ballpark figure of requirement. Try using THIS calculator set to your level of training

Step 2: identify underlying causes of disordered eating. This could be that you don’t have a structure to when or what you eat and skipping meals. If you are struggling with disordered eating or want help/advice for yourself or someone you care about you suspect of suffering from an eating disorder, please get in contact and we will help guide you to the help and support you need.

Step 3: recruit support from friends and family. It can be both physically and psychologically challenging to change habits and identify and overcome barriers to increasing food intake or reducing training volume.

Step 4: address the underlying causes of the low energy availability to allow you to incrementally increase calorie intake per day and consider reducing training volume (i.e introducing a rest day/reducing double training days to single) until energy intake meets daily energy expenditure. These additional calories should come from high quality sources of protein and carbohydrates and be distributed predominantly around training.


Supporting menses (menstrual cycle) and bone health

To avoid menstrual disturbances it is key to ensure energy balance and healthy body fat percentage (this is vital for women to produce oestrogen). Consuming adequate quantities of quality carbohydrates (especially after training) will also aid in supporting proper hormonal regulation.

To maintain healthy bones we want to ensure we are consuming adequate amounts of calcium from food sources and should all be taking a Vitamin D supplement of 1000IU/day. This is especially important throughout the winter months.



If you are concerned that you or someone you know is showing signs or symptoms, please do not hesitate to get in touch and we will guide you to receive the help and support you need.



Keay, N. 2018 UPDATE: Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine Blog. May 2018

Statua, SM., Asif, IM., Drezner, JA. Relative energy deficiency in sport (RED-S). British Journal of Sports Medicine. November 2017 51(21).

Joy, E., De Souza, M., Nattiv, A. et al 2014 Female athlete triad coalition consensus statement on Treatment and return to play of the female athlete triad. August 2014 13(4).

Burke, L., Deakin, V. Clinical Sports Nutrition (fourth edition). Australia: McGraw-Hill; 2010.

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