Female athlete triad and its components: toward improved screening and management

Mayo Clin Proc. 2013 Sep;88(9):996-1009. doi: 10.1016/j.mayocp.2013.07.001.


As female athletic participation has increased, the positive effects of exercise on health have become evident. However, with this growth in sports activity, a set of health problems unique to the female athlete has emerged. The female athlete triad as first described in 1992 by the American College of Sports Medicine consisted of disordered eating, amenorrhea, and osteoporosis; the definition was updated in 2007 to include a spectrum of dysfunction related to energy availability, menstrual function, and bone mineral density. For this review, a comprehensive search of databases-MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Scopus, from earliest inclusive dates to January 2013-was conducted by an experienced librarian with input from the authors. Controlled vocabulary supplemented with keywords such as female athlete triad, amenorrhea, oligomenorrhea, fracture, osteopenia, osteoporosis, bone disease, anorexia, bulimia, disordered eating, low energy availability was used to search for articles on female athlete triad. Articles addressing the prevalence, screening, and management of the female athlete triad were selected for inclusion in the review. This article reviews the current definitions of the triad components, epidemiology, pathophysiology, and recommended screening and management guidelines. The lack of efficacy of current screening of athletes is highlighted. Low energy availablity, from either dietary restriction or increased expenditure, plays a pivotal role in development of the triad. Athletes involved in "lean sports" (those that emphasize weight categories or aesthetics, such as ballet, gymnastics, or endurance running) are at highest risk. Treatment is centered on restoring energy availability to reverse adverse changes in the metabolic milieu. Prevention and early recognition of triad disorders are crucial to ensure timely intervention. Caregivers and physicians of female athletes must remain vigilant in education, recognition, and treatment of athletes at risk.

Keywords: AAP; ACSM; AN; American Academy of Pediatrics; American College of Sports Medicine; BMD; BMI; DXA; EEE; FFM; PPE; REE; anorexia nervosa; body mass index; bone mineral density; dual-energy x-ray absorptiometry; exercise energy expenditure; fat-free mass; preparticipation evaluation; resting energy expenditure.

Publication types

  • Review
  • Video-Audio Media

MeSH terms

  • Amenorrhea / diagnosis
  • Amenorrhea / etiology
  • Athletes
  • Bone Density
  • Female
  • Female Athlete Triad Syndrome / diagnosis*
  • Female Athlete Triad Syndrome / therapy
  • Humans
  • Medical History Taking
  • Risk Factors