From school tracks to elite arenas, women in Hong Kong are increasingly taking centre stage across a wide range of sports. While this growth in participation is a positive step forward, especially in a region where conversations about women's health in sport are still emerging, a lesser-known risk affecting many active women remains: the Female Athlete Triad.
Here at our PhysioCentral clinics, we’re passionate about supporting female athletes at every level - not just in improving performance, but in safeguarding their long-term health and well-being. This means recognising the unique physiological needs of women and identifying hidden risks that may be overlooked amidst demanding training, competition goals, or even well-intentioned routines.
The Female Athlete Triad is one such risk, and it’s more common than many realise, even here in Hong Kong. Here’s what you need to know.
What Is the Female Athlete Triad?
The Female Athlete Triad is a medical condition that involves three interrelated components:
- Low energy availability (with or without disordered eating)
- Menstrual dysfunction (such as irregular or absent periods)
- Decreased bone mineral density (leading to osteopenia or osteoporosis)
These components do not need to be present simultaneously to pose a risk. In fact, many active women may experience one or two elements, often unknowingly, while still performing well in sport. Left unaddressed, however, the triad can have serious long-term consequences on physical, hormonal and emotional health.
Note: Alongside the female athlete triad, the research and other online resources may also refer to the broader term RED-S (Relative Energy Deficiency in Sport). This is also widely used in sports medicine, which encompasses the triad but also considers other physiological functions affected by low energy, such as immune health, cardiovascular function, and metabolic rate.
How Does It Develop?
At the heart of the triad is low energy availability. This is where the energy a person takes in (via food) is insufficient to support both the demands of exercise and essential bodily functions. This can happen intentionally (through dieting or restrictive eating) or unintentionally (from not realising just how much fuel the body needs during high training loads).
Contributing factors to the development of the female athlete triad can include:
- Pressure to achieve a certain body type or weight
- Participation in appearance- or weight-sensitive sports (e.g. gymnastics, running, ballet, swimming)
- Intense training schedules with little recovery
- Misinformation around nutrition or calories
- Perfectionism, anxiety, or self-worth linked to performance
- Lack of education around female-specific physiology leading to misaligned advice and procedures
What starts as "pushing through tiredness" or trying to be disciplined can gradually progress into a pattern that affects hormone regulation and bone health.
Spotting the Signs: What to Look Out For
The triad tends to develop slowly over long periods of time, making it harder to catch early. Many women or their support teams often dismiss the signs as “just part of being tired” or the result of training hard. Common signs and symptoms include:
- Persistent fatigue or lack of energy
- Irregular or missed menstrual periods (amenorrhea)
- Frequent illness or low immunity
- Stress fractures or recurring injuries
- Weight loss or body composition changes
- Anxiety, irritability or low mood
- Disordered eating or excessive food control
- Delayed injury healing and longer recovery times
- Sleep disturbances
- Obsession with training, food, or body image
- Loss of endurance or performance decline
The risks are not only physical. Female athletes affected by the triad are more likely to experience burnout, depression, and disordered relationships with their sport and body.
Why It Matters: Long-Term Health Impacts
When oestrogen levels drop due to energy deficiency, this has a significant impact on bone mineral density. Women build most of their bone mass by their early 20s, meaning that disruptions in this window can have lifelong consequences, including a higher risk of fractures and early osteoporosis.
Menstrual irregularities are a key red flag, but not all women with low energy availability lose their menstruation, especially those on hormonal contraceptives, which can mask the absence of a natural cycle. That’s why a holistic assessment is so important. Other long-term risks include:
- Infertility or hormonal imbalances
- Chronic fatigue or burnout
- Increased risk of cardiovascular problems
- Poorer outcomes from musculoskeletal injuries
How Your Physiotherapist Can Help
Physiotherapists play a key role in early identification, management and recovery from the triad. While we don’t diagnose issues related to nutrition or prescribe nutrition plans (we can refer you to a nutritionist for this), we are often the first point of contact when injuries or performance issues arise, and we understand the broader picture.
Our physios take a comprehensive and supportive approach, including:
- Treating injuries such as stress fractures, tendinopathies and joint pain
- Identifying red flags for low energy availability or overtraining
- Collaborating with GPs, sports dietitians and mental health professionals
- Developing safe return-to-sport programs after injury or burnout
- Educating athletes on how to fuel for their sport and adapt training around their menstrual cycle
We also help coaches and families better understand what’s going on and how to best support the athlete.
Recovery Is Possible - And So Is Thriving In Sport
The promising news is that with the right care and a supportive team, athletes can recover fully from the effects of the triad and return to optimum performance. Recovery can involve:
- Restoring energy balance through proper fuelling (nutrition)
- Rebuilding bone density and strength (strength training, nutrition and supplements)
- Optimising strength and performance in a healthy way
Most importantly, it’s about cultivating sustainable habits that support long-term well-being and performance, rather than just achieving short-term success.
If you're an active woman, whether you're training for competition or just love to move, it's always important to understand how your body responds to stress, fuelling, and rest. If you’ve noticed a pattern of recurring injuries like stress fractures, don’t ignore it. These are signs that should be investigated, and we’re here to help.
Book your appointment with us online here or call us on +852 2801.4801