The female triad

Brent Grimsley

Director HGPhysio

Chief Physiotherapist

Prime Human Performance institute Durban


This syndrome is an interrelationship of menstrual dysfunction, low energy availability, and decreased bone mineral density in woman. A female can be diagnosed with this syndrome by having one, two, or all three parts of the triad in the absence of other diseases.

It is relatively common among young women participating in sports, but also possible in those who are sedentary and just recreationally active. Younger individuals are greatly impacted by the non-reversible, long-term consequences of this syndrome.

The International Olympic Committee (IOC) created an updated term for the triad, called the Relatively Energy Deficiency in Sport (RED-S).

The syndrome affects females involved in all types of sports; however, we see it more frequently in those participating in activities that emphasize leanness, such as running, athletics, gymnastics and dancing. Nearly three quarters of elite female athletes competing in sports are dieting and have some type of disordered eating pattern to help control weight.

Several health consequences occur in athletes with the triad:

Menstrual dysfunction may lead to infertility, miscarriage, or preterm birth. Low levels of Estrogen can cause cardiovascular disease and elevated low-density lipoprotein cholesterol levels.

Menstrual dysfunction in the female athlete includes a wide spectrum of disorders, with amenorrhea (absence of menses 3 months or more) most seen. Other types of menstrual irregularity include a delay in the age of menstruation, anovulation, luteal phase deficiency, and oligomenorrhea. Amenorrhea can be caused by energy deficiency from your diet and even stress.

Women with the triad also have decreased immune function and impaired skeletal muscle oxidative metabolism, thus struggle to get optimal muscle performance and recovery during sport. Many athletes with low bone density and/or menstrual irregularity suffer from stress fractures in their shins and low spine bone density, creating chronic back pain and disability for life.

Female athletes are at risk of developing eating disorders due to pressure to maintain a good-looking body along with poor guidance on performance nutrition and weight loss from peers. Decreased energy availability from their diets may have serious consequences.

Many of these athletes limit protein, carbohydrate, and fat intake in their diets which leads to nutritional deficits. Particularly reducing the intake of essential amino acids and fatty acids, can be detrimental to the body’s ability to build bone, maintain muscle mass, repair damaged tissue, and recover from injury.

Disordered eating associated with low energy levels also has serious psychological effects, including depression, low self-esteem, and various anxiety disorders in young girls.

In young female athletes with the syndrome, a decrease in bone strength, ranging from stress fractures to osteoporosis, may occur at a much younger age. Generally, young healthy women achieve most of their total body bone mineral content by the age of 18 years and maximal bone density by age 26. Bone loss usually occurs later with menopause and aging.

The Female athlete triad is a serious disorder and requires treatment from a multi-disciplinary team. The main goal of the treatment is to normalize the menstrual cycles, improve energy consumption vs expenditure and to increase bone density.

Currently, the best approach to the triad is early detection and prevention.

The RED-S Clinical Assessment tool can be readily accessed at the following link:

A Dietician would discuss the athletes eating and supplement habits and suggest changes to improve nutrition to meet sport requirements. Supplementing with an Immune booster, essential amino acids, L-Glutamine and protein could be beneficial. It is generally accepted that optimizing vitamin D and K and calcium intake in young women is important for bone health, especially since vitamin D levels are often found to be low in this age group.

A Physiotherapist can prescribe safe weightbearing exercise and high-impact physical activity program. This has a beneficial effect on bone density in women. Exercise can even cause a 4% to 5% gain in bone density in children.

A Doctor could prescribe Hormone intervention for these women to help restore menstruation or provide adequate hormonal supplementation.

For athletes who present with a clinical eating disorder, it is paramount to involve a mental healthcare professionals in their care.


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By Guest Blogger Brent Grimsley

HG Physio clinical Director and Sports Physio, Brent Grimsley currently works as Chief Physiotherapist at Prime Human Performance institute at Moses Mabidha stadium in Durban where he looks after Elite High-Performance athletes and various professional teams in multiple sporting codes.

With almost 20 years of experience in working with athletes from pros to weekend warriors and sporty children, he has developed a passion for teaching other medical professionals in injury management of muscle strains, ligament tears, taping and rehab prescription.

You can find out more about Brent and what he does here or  follow him on @hgphysio

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