Meet the Female Athlete Triad: The New Challenge for the Active Woman

By: William Felix MD, CAQSM

The participation of women between the ages of 35-50 in high-performance sport has grown exponentially in recent years. Probably, this increase reflects the many campaigns from multiple health-related organizations to encourage a more active lifestyle for women in this age range. Unfortunately, athletes who abuse physical activity thinking they will reach their physical goals faster by increasing the frequency of exercise can trigger medical complications typically only seen in adolescent girls and younger adults. These complications, known as “female athlete triad syndrome” include three common symptoms: loss of periods before menopause (amenorrhea), osteoporosis and eating disorders.


The stress related to excessive exercise affects the secretion of estrogen, the hormone responsible for regulating menstrual cycles. The irregularity in estrogen levels in turn affect its secondary function, the reabsorption of calcium in the bone. This alteration increases the risk of women to experience pathological fractures secondary to a weak and fragile bony structure (osteoporosis).

The root of this disorder is the result of excessive physical activity that is not compensated in proportion to the necessary caloric intake. Therefore, this triad is completed with the presentation of underweight women.


The female athlete triad is a challenge for the health care professional; diagnosis is difficult in the early stages. Multiple factors combine to complicate diagnosis, particularly the desire of the patient to continue with a rhythm of intense exercise driven mostly by psychological need to maintain the “perfect body” in response to the growing social pressure. Initially, this seems to be possible without apparent health consequences. New forms of exercise regimes that emphasize aerobic exercise, such as “Crossfit,” make this a very complex condition with an alarming increase of incidence. Patients usually present the doctor with unexplained symptoms or nonspecific pain. During the medical evaluation and analysis of patient records, the absence of menstrual periods before formally entering a period of perimenopause is often discovered.

Part of the assessment also includes documentation of weight and height. These two variables are used to calculate body mass index, which is regarded as normal parameter values between 20 and 25. Female athlete triad patients usually present with lower body mass index of 20.

A psychological evaluation is highly recommended due to the possibility of body dysmorphic disorder or exaggerated concern for any perceived defect in body image, whether real or imagined.


Fortunately, this triad can be solved without major implications as long as it is diagnosed early and various medical specialties are integrated as part of a collaborative effort. Exercise should be regulated and supervised by a certified fitness trainer, together with proportional physical activity and nutritional food intake. Exercise will always be beneficial at any age, as long as it is done moderately and not excessively.

William Felix, MD is a board certified physician in sports and emergency medicine; currently working at Florida Hospital Health Park Lake Nona and as medical consultant for the NBA. For more information, please call (407) 930-7800 or go to