The Female Triad - Is your training damaging your body?

The female triad is not a gang of ninja women! It can be a serious consequence of overtraining, so how do you know if it's affecting you?

Some questions to ask yourself that might mean your current routine could be damaging your body:

  • Do you feel pressure to lose weight to improve performance even if you have a healthy BMI?

  • Do you see certain foods as forbidden?

  • Would you train even when sick or injured?

  • Do you still train when you’re exhausted?

  • Have you been experiencing irregular periods where you miss more than a month?

  • Have you had a stress fracture?

If you answered yes to any of these questions you may be at risk of developing the female triad. The female triad is a syndrome first described by the American College of Sports Medicine (ACSM) in 1992 in response to a large increase in the concurrent presentation of osteoporosis, amenorrhea (no or very infrequent periods) and disordered eating in female athletes. It is something often associated with elite athletes particularly in sports where a low body fat percentage is an advantage such as gymnastics and long distance running, but with the pressures in western society to be thin this pressure can be seen at all levels. The components of the triad are interrelated as outlined below:

Disordered Eating

If your calorie intake doesn’t match your energy expenditure the risk of the female triad increases. At one end of the spectrum this can be premeditated such as in cases of defined eating disorders such as anorexia and bulimia, placing a person at high medical risk. At the other end it can be unintentional, with a women eating regularly but not enough to meet energy demands. Many women practice disordered eating but do not meet diagnostic criteria for anorexia or bulimia. More commonly women are restricting calories from certain food groups with the intention of losing weight.

Disordered eating impairs performance and increases the risk of injury. The decreased calorie intake and subsequent electrolyte and fluid imbalances can cause decreased concentration, endurance, strength and speed. At the extreme end it can lead to stress fractures, syncope and arrhythmias of the heart.

Preventing disordered eating is largely down to education. At a junior level it’s the parents and coaches responsibility to foster a healthy training and nutritional environment without pressure on weight and image. At a non-elite level the key is making sure your diet is supporting the amount of training you are doing. Also appreciating recovery time has the same weighting as a training session to allow the body to adapt.

If you think you might be suffering with disordered eating a team approach is recommended so seeking help from a nutritionist, psychologist and sport doctor to cover all aspects.

Signs of disordered eating:

• Fatigue

• Depressed mood

• Decreased ability to concentrate

• Social withdrawal

• Cold intolerance

• Sore throat

• Abdominal pain and bloating

• Constipation

• Lightheadedness

• Irritability

• Insomnia

• Preoccupation with food

• Concerns about eating in public


Amenorrhea is the absence of a period for over 3 months or in the case of children, the delay of periods starting. Acute body weight loss and marked fluctuations in weight i.e. 4.5KG loss/regain can cause amenorrhea. The most prominent theory on why periods stop is based on the energy deficit caused by the disordered eating described above. Exercise alone has no disruptive effect on menstrual function, apart from causing an energy deficit.

The amenhorreic response seen in the triad is thought to be an energy conservation strategy. It has been suggested that the hormones that control menstruation cannot maintain normal concentrations when energy levels fall below 30kcal/kgFFM per day (calories/kg of free fat mass). Psychological stress is also thought to be a driver of amenorrhea due to the involvement of neurohormones (endorphins and catecholamine’s).

To prevent amenorrhea the initial strategy is the same as above to ensure the energy deficit does not take place by having a good nutrition plan to supplement training. In some cases a reduction in training intensity is necessary or an increased of 2-3% of body weight to try to restart menstruation. If that fails oestrogen replacement therapy is used to raise levels synthetically to prevent loss of bone mass as outlined below.


Osteoporosis translates to porous bones or ‘brittle’ bones. It refers to inadequate bone formation and loss of bone mass. The relationship between osteoporosis and the female triad is linked to the deficiency in oestrogen seen in amenorrhea. Oestrogen receptors have been seen on bone cells which indicated it is directly linked with bone function. It is thought that oestrogen blocks the calcium reabsorption, therefore low levels seen in amenorrhea can lead to bone loss.

A clinical diagnosis is a bone mineral density (BMD) score below 2.5 standard deviations from the normal bone mass for a person’s age. However it has been suggested that osteopenia (decreased bone density but less extreme than osteoporosis), is a more appropriate criteria for low BMD as in an athletic population it is more sensitive to issues early when looking for low BMD compared to osteoporosis. Women reach their peak bone density between 18-25 years old and then will have a steady decline at a rate of 0.3-0.5% per year. In osteoporotic athletes bone mass loss can be between 2-6% per year with the total bone mass loss reaching as much as 25% in some cases. This means women with this condition can have the bones of a 60 year old, meaning they are 3x more likely to get stress fractures.

The worrying finding with the loss of bone mass in the presence of amenorrhea is that it is partially irreversible. This is despite the resumption of periods, oestrogen replacement and calcium supplementation. Interestingly it has been seen that some sports are better at maintaining bone mass than others in the presence of amenorrhea. Gymnasts faired better than long distance runners, which is thought to be due to the increased strength and impact loading involved in gymnastics.

As these conditions are interlinked as described above prevention of osteoporosis/osteopenia relies on an adequate energy intake vs. energy expenditure. However in the case of osteoporosis there are some specific measures that can help. As mentioned previously, supplementing calcium (1200-1500mg per day) and when combined with amenorrhea supplementing 400mg of vitamin D can help restore some of the bone loss and prevent further deterioration. Weight bearing exercise in particular high impact work as seen in the gymnasts has been seen on multiple occasions to increase BMD. It would appear low impact exercises like walking will stop a decrease in BMD but won’t improve it, whereas strength training and high impact exercise such as squash, can reverse the BMD loss.


The female triad is a preventable syndrome. With smarter training and nutrition there should be no reason for a women to reach the osteoporotic stage. Whilst there are extreme cases which are triggered by eating disorders, there are times when this syndrome can be seen in seemingly ‘healthy’ women who just haven’t got their energy intake right for the amount of training they are doing, as in my case. Therefore the overall key points are:

  • Make sure your energy intake covers the exercise you are doing

  • If you have irregular periods or a stress fracture make sure your bone density and hormone profile are investigated

  • Include some strength training (preferably high intensity) in your routine



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