Hall of Fame – 2019
21st January 2019
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23rd June 2020

The Female Athlete Triad

What would you say if I told you that you had a >1 out of 3 chance of developing a medical condition that you currently knew nothing about, or how to prevent? Would you want to know more? Because I would. 

This isn’t an article that will excite you, inspire you or challenge you. This is an article that will teach you about your health and your body. Whilst providing you with the necessary information to protect yourself and others that participate in sports of any nature. 

Before I get into the nitty gritty of things, I’d like to briefly inform you of what the female athlete triad (FAT) is and how it affects our body. 

The FAT consists of 3 components:

  1. Low energy availability (EA) (with or without an eating disorder)
  2. Menstrual dysfunction
  3. Low bone mineral density (BMD)

Essentially, optimal energy availability is the key source for having regular menstruation (eumenorrhea) and optimal bone mineral density. When EA is poor, due to nutrient defects or disordered eating, this in return causes irregular menstruation (amenorrhea = 3+ without a period), thereby influencing BMD.

Low Energy Availability

Low EA is described as “The difference between energy intake and estimated energy expenditure.”

(standardised to kg of fat free mass (FFM)) 

For any coach out there, it’s vitally important to identify the nutritional status of your athlete, as well as any risk of undernutrition for prevention of low EA. For the coach and athlete, knowledge regarding the amount and type of foods that should be eaten is essential to support the training and exercise energy expenditure.  

It’s critical to remember that dieting and low EA can be intentional by the athlete due to a restriction in food to obtain a low body weight. Under these circumstances, a WHY needs to be established. Is an athlete deliberately obtaining a low body weight because they have a mental illness (anorexia)? Or are they obtaining a low body weight because they need to be leaner for their sport? I also want to emphasise on the NEED. Do they feel pressured to be at a certain weight due to criticising comments off coaches and parents? Or do they need to meet a certain weight class for their sport (for example, boxing)?

Literature states that athletes in lean sports (bodybuilders, gymnasts and dancers) exhibit more disordered eating behaviours and body dissatisfaction, than non-lean sport athletes, regardless of the competition level.  

They also have an increased risk of low EA, as well as: 

  • Changes in the endocrine system affecting energy expenditure and bone metabolism 
  • Changes in the cardiovascular and reproductive system  

Menstrual Dysfunction

Due to low EA – females may develop functional hypothalamic amenorrhea which is the absence of periods lasting for more than 3 months. Although athletes with oligomenorrhea or amenorrhea can be easy to identify, women can still develop luteal phase defects and anovulation based on an energy deficit. Throughout a long period of time this can cause infertility and early miscarriage within women. 

Bone Mineral Density 

Athletes with low EA or amenorrhea lasting for over 6 months should have their BMD measured by a DXA (dual-energy X-ray absorptiometry). A value of below -2.0 is considered osteoporosis with secondary clinical risk factors. 

Osteoporosis is a skeletal disorder characterised by compromised bone strength, predisposing a person to an increased risk of fracture. Bone strength and risk of fracture depend on the density and internal structure of bone mineral and quality of bone protein.

An athletes BMD reflects her cumulative history of EA and menstruation, as well as genetic endowment and exposure to nutrition and environmental factors. Amenorrhea does not cause osteoporosis immediately, but skeletal demineralization begins moving BMD in that direction. 

What are the risk factors associated with developing one of all 3 of the components? 

There are many factors that can influence an athlete and the decisions that they make. These factors will ultimately play a huge role in their health (body and mind) – so it’s necessary to be aware of any risk factors that could influence the athletes decisions, performance and health. 

Risk factors include:

An athlete’s history of:

  1. Menstrual irregularities and amenorrhea
  2. Stress fractures
  3. Critical comments about eating or weight from a parent, coach or team-mate
  4. Depression 
  5. Dieting

Intrinsic and Extrinsic Factors / Motivation

  1. Personality factors, such as perfectionism and obsessiveness
  2. Pressure to lose weight and/or frequent weight cycling
  3. Early start of sport-specific training
  4. Over training


  1. Recurrent and non-healing injuries 
  2. Inappropriate coaching behaviour

Whilst physical examination signs may be a symptom of an athlete already suffering from the FAT, these can also be used to prevent an athlete from developing the condition. These include:

  1. Low body mass index
  2. Weight loss
  3. Orthostatic hypotension (blood pressure falling significantly when you stand up)
  4. Lanugo (fine soft hair that covers the body, prevalent in anorexia)
  5. Hypercarotenaemia (yellow pigmentation of the skin and increased beta-carotene levels in the blood)
  6. Parotid gland swelling
  7. Callus on the proximal interphalangeal joints (also known as Russell’s sign)

In adolescent females, 90% of peak bone mass is attained by 18 years of age. Therefore, screening an athlete and taking action for early interventions will provide a window of opportunity for optimizing bone health.


Improving an athletes overall EA may be the key to reversing menstrual dysfunction and low BMD. However, the majority of active women are not willing to stop training or gain excessive amounts of weight to allow for regular menstruation. So, what’s the solution? 

Providing the athlete with an intervention plan that improves energy intake, reduces energy expenditure or both. 

I understand, being a bikini competitor myself and having many friends in the industry that it’s extremely hard for an athlete to reduce their energy expenditure, when they have a certain weight to meet and they need to be lean. However, the depletion in calorie intake and increased energy expenditure should never be that extreme that it’s causing the athletes menstruation to stop. This is highly dangerous.

Changing scenarios, 2 small pilot studies that were used to test increased daily energy intake (350kcal increase with 1 rest day a week) – resulted in a 1.0-2.7kg weight gain. 

For those suffering with a disordered eating, patients with anorexia nervosa have been shown to increase their BMD by 2-3% with an intervention plan. 

Research also stated that hormone replacement therapy has no benefit, whilst oral contraceptives reduce the likelihood of restoring menstrual cycles. 


Without trying to scare you, I hope that you can take this information and carry out your own research around the medical condition. 

Menstruation will always be a taboo topic. No one wants to talk about eating disorders in the sports world. And before this article, did anyone know that females are more at risk of developing osteoporosis than males? Because I didn’t. 

Let’s create awareness for the FAT and help our women to be as successful as they can be without causing damage to their body and health!

Author: Emily Singer

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