A pediatric/adolescent gynecologist explains female athlete triad: Improper eating, no or infrequent menstruation and low bone density

Published: December 6, 2018 | Updated: October 8, 2020

Girls who are exercising more and eating less — or at least not filling their bodies with the nutrients they need — may be putting themselves at risk for a health condition called female athlete triad.

“The female athlete triad has three parts: low energy availability, problems with menstruation and low bone density,” said S. Paige Hertweck, M.D., pediatric/adolescent gynecologist with Norton Children’s Gynecology. “A girl does not need to have all three at the same time and does not have to have an eating disorder.

“We see this happening frequently in girls who play field hockey or run cross country or track.”

Girls may not take in enough nutrition to account for how much energy they are burning through exercise. This has long-term implications for bone development. This is the time when the body builds up bone mass density needed to protect against osteoporosis and fractures throughout adulthood.

The lack of nutrition also affects whether the teen has a period. In the long term, it can affect heart health as well.

Being active and athletic has benefits, including self-esteem, weight management and good habits that can last a lifetime. The key is to balance the activity with good nutrition.

Related: What is a ‘normal’ period for a girl?

“This issue was once thought to be about eating disorders, but we know now that many female athletes simply aren’t eating enough or eating the right things,” Dr. Hertweck said. “If your daughter is athletic, is around 15 and hasn’t had her period yet, you may want to talk to a gynecologist.

“If she has had her first period and it has been three months since she’s had another one, that can be another cause for concern.”

Tips for overcoming female athlete triad

“Generally speaking, a pre-workout meal should consist of high carbohydrates and low fats,” said Nikki Boyd, health and wellness coordinator with Norton Children’s Prevention & Wellness and an American Council on Exercise fitness nutrition specialist. “Ultimately, the goal is to eat foods that fuel your body to make sure you have the energy and nutrients you need to perform well and to be healthy and safe.”

• Eat breakfast that has a good mix of protein, lighter fats and carbohydrates. Think nut butter on whole-grain toast or a multigrain English muffin with egg (not fried), some fruit and a glass of milk or some yogurt.
• Eat healthy snacks during the day — one in the morning and one in the afternoon at least 30 minutes before practice or a game. Good options are cereal, fruit, pretzels, nuts, a granola bar or a peanut butter (or other nut butter) sandwich on whole-grain bread.
• Don’t avoid carbohydrates — they provide longer-lasting energy throughout the day. Stick with whole-grain bread, crackers, cereal or pasta. Potatoes are good too — as long as they are not French fries!
• Add milk to help boost calcium intake — something critical for young female athletes because calcium helps muscles contract. Fat-free or low-fat milk are good options for protein and potassium, which helps keep body fluids balanced.
• Have protein throughout the day to repair muscles and help the body grow. Good proteins are eggs; low-sodium deli meat; low-fat meats such as chicken, turkey or fish; yogurt; tofu; or beans.
• Lower the fat, especially before practice or competition. High-fat foods slow digestion and can cause fatigue. These include fries, pizza and high-fat desserts.
• Drink plenty of water well before practice or a game, as well as during and after. Young athletes don’t need sports drinks unless they’ve been sweating heavily for over an hour. Less than an hour, stick to water.

“If your child has special nutritional needs due to issues such as diabetes or a gluten allergy, or she is vegan or vegetarian, be sure to talk to her physician,” Nikki said. “You may also consider a referral to a nutritionist.”