The Female Athlete Triad

John Furia, MD


Medscape General Medicine. 1999;1(1) 

In This Article

Abstract and Introduction


Female Athlete Triad was identified in 1992 and is defined by disordered eating leading to amenorrhea and eventually osteoporosis. It most frequently affects those engaged in endurance sports, such as running and swimming, or activities where appearance is important, such as figure skating, diving, and gymnastics. Others prone to the Triad are athletes participating in sports with weight categories, such as horse racing, martial arts, and rowing, and athletes who participate in sports where subjective judging determines performance. Exercise-associated amenorrhea (EAA) is the most common cause of secondary amenorrhea in athletes. EAA is believed to be the result of a disorder in the hypothalamus and results in a hypo-estrogen state. Specifically, there is a decrease in the pulse frequency of gonadotrophic-releasing hormone from the hypothalamus. This results in a decrease in the frequency of luteinizing hormone from the pituitary. In time, low estrogen levels can result in diminished bone mineral density and osteoporosis.

Last night was another cool, crisp, autumn evening. I recently moved from Houston to central Pennsylvania, and have come to appreciate the beautiful rituals that occur in a small town. The event was the homecoming high school football game. The entire town had gathered to support the home team. As I sat in the stands, I could readily see the players, cheerleaders, and band members who help create the pageantry of homecoming.
Sitting next to me was the mother of a young women who I had operated on. The mother was the cheerleader coach and her daughter played soccer for the high school team. During the game, she and I reminisced of our own homecomings. We noted a striking difference between this event and homecomings 15 years ago: the number of cheerleaders had significantly decreased.
I remember there being at least a dozen cheerleaders at my high school football games; tonight there were six. The mother explained that the decrease has been coming on for years. She attributed the drop to the increased popularity in other kinds of athletics, citing her own daughter as an example.


As the number of women involved in athletics continues to rise, healthcare professionals are noticing an increase in several sports-related injuries and ailments. One recently recognized problem which is quite serious and exclusively affects women is the Female Athlete Triad.

First described at a meeting of the American College of Sports Medicine in 1992, the Triad consists of disordered eating, menstrual irregularities, and osteoporosis.[1] The components of the Triad are interrelated, with disordered eating leading to amenorrhea and eventually osteoporosis.[2]

Abnormal eating patterns can vary in severity. It is important to distinguish between the terms "disordered eating" and "eating disorder." An eating disorder is a psychiatric diagnosis such as anorexia nervosa or bulimia nervosa. As such, certain criteria as outlined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) must exist before the diagnosis is established.[3] In contrast, disordered eating entails sporadic eating, poor nutrition, unnecessary dieting, or occasional bingeing and purging.[1]

Although the Triad is recognized more frequently, it is poorly identified outside the university setting. Delays in diagnosis and inadequate treatment are still all too common. Scientists are beginning to understand the serious consequences of the Triad, because some of the manifestations may not be completely reversible.[4,5]