Intended for healthcare professionals

Clinical Review ABC of sports and exercise medicine

Female athlete triad

BMJ 2005; 330 doi: (Published 27 January 2005) Cite this as: BMJ 2005;330:244
  1. Karen Birch


The “female athlete triad” has long been recognised as a syndrome that has the potential to affect female athletes and consists of three inter-related disorders:

  • Osteoporosis

  • Disordered eating

  • Menstrual disorders.

The potential impact of each of, and the combination of, these disorders is detrimental to performance and to health. Certainly, the increased risk of infertility, stress fractures, eating disorders, and osteoporosis in later life is a high price to pay for involvement in an essentially healthy activity. This is especially true, as many of these factors can be prevented with careful management.

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The female athlete triad can affect performance and health but can be prevented with good management

Why are the three corners of the triad inter-related?

The three corners of the triad are inter-related through psychological and physiological mechanisms. The psychological pressures to perform to an optimal standard, and thus often a perceived requirement to maintain a low body mass, result in a high volume of training. The high volume of training and low energy intake, in addition to stress hormones produced by psychological stress, may lead to a physiological alteration in the endocrinological control of the menstrual cycle, which may ultimately lead to the athlete becoming amenorrhoeic (loss of cycle after menarche). The consequence of being amenorrhoeic through dysfunction of the hypothalamus and pituitary is a decreased production of oestrogen. This hormone has a huge role in maintaining adequate bone mineral density, and a hypo-oestrogenic state (low oestrogen) thus is associated with low bone mineral density and an increased risk of osteoporosis.

Menstrual disorders

The normal regular, healthy menstrual cycle (eumenorrhoea) is about 26-35 days, is controlled by the hypothalamus and pituitary glands, and is divided simplistically into two phases by the occurrence mid-cycle of ovulation. The first half of the cycle is the follicular phase and the second half the luteal phase. The follicular phase is characterised by …

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