Triple threat: The lasting effects of the female athlete triad

This article was written by Carin Moonin and originally appeared in the Portland Monthly 2016 Kids’ Health Annual magazine.


The 1972 passage of Title IX, a federal law that prevents discrimination on the basis of sex in any federally funded education program or activity, dramatically increased the number of female athletes.

It also brought a new focus on issues specific to them. One was the female athlete triad, three disorders that tended to coincide in young women:

  • low energy with or without disordered eating,
  • irregular menstrual periods
  • decreased bone density

An unexplained rate of stress fractures occurring in girls participating in lean-body-focused sports, such as dance, gymnastics, figure skating and distance running, brought attention to this phenomenon. Today, health professionals have a better understanding of how these conditions are related and what can be done to treat the triad.

Historically, there was a stigma and misconception that psychiatric issues and more serious eating disorders such as anorexia or bulimia predisposed those girls to sustain fractures: In essence, they were starving themselves. However, eating disorders like these are very rare: Two to four percent of girls with female athlete triad. Health professionals now understand that much of this is unintentional and many of these young athletes are simply “underfueled.”

If a girl is training more than 90 minutes per day, she needs a bare minimum of 30 calories per kilogram of body weight per day in order for her brain to release leutinizing hormone. The hormone stimulates estrogen production and ovulation, helping to maintain bone density. For example, a 130-pound girl would need a minimum of 2,700 calories daily, with the recommended intake being 45 calories per kilogram – around 4,000 calories a day.

Adolescence is also a critical time for developing bone mass. Athletes may be getting plenty of exercise, which helps in the bone department, but they also need to eat plenty of calcium-rich foods paired with foods high in vitamin D.

“If you spend your adolescent years losing bone density instead of building it, there’ll be less bone in the bank when you’re older,” says Andrea Herzka, M.D., an orthopedic surgeon at OHSU. “It’s like spending from your savings account: Even if you restart deposits, the total is less than if there hadn’t been a hiatus.”

Education from parents and coaches is crucial. Adolescent athletes need to understand their body needs fuel just like a car. Running on empty can cause long-term health complications such as osteoporosis (brittle bones), cardiac problems, infertility or immune system problems.

Also, keeping track of a girl’s period, especially during training season, is important. If periods are irregular during training, check with your pediatrician, Dr. Herzka suggests; he or she is likely skilled in treating this disorder or, if not, can refer to adolescent health or sports medicine specialists to provide further education to both families and patients.

“Kids have a hard time thinking long-term,” Dr. Herzka says. “Explaining there could be premature osteoporosis may not motivate a teen, but explaining the immediate risks of possibly breaking your tibia, hip or foot can see more realistic.”

For more information about the female athlete triad, talk to your pediatrician or call OHSU Sports Medicine at (503) 494-4000. 


4 responses to “Triple threat: The lasting effects of the female athlete triad

    1. Thanks for your comment, Kristoffer! I am not the author of this post but speaking anecdotally as a woman who played high school sports, we’d often have 2-hour long practices – and sometimes twice a day. I don’t think that’s unusual but again, just my personal experience.

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