The Female Athlete Triad in Swimmers: a Review of Current Literature

Authors

  • Brienna K. Buchanan, BA Johns Hopkins University School of Medicine, Department of Physical Medicine and Rehabilitation, Baltimore, Maryland, U.S.A.
  • Victoria E. Bergstein, BA Johns Hopkins University School of Medicine, Department of Physical Medicine and Rehabilitation, Baltimore, Maryland, U.S.A.
  • Evin F. Rothschild, BS Victoria E. Bergstein, BA
  • Alexis Coslick, DO  Johns Hopkins University School of Medicine, Department of Physical Medicine and Rehabilitation, Baltimore, Maryland, U.S.A.

DOI:

https://doi.org/10.53646/ahq2qs39

Keywords:

amenorrhea, eating disorders, disordered eating, female athlete, female athlete triad, low energy availability, osteopenia, osteoporosis, REDs, swimming, swimmers

Abstract

BACKGROUND: The female athlete triad, including low energy availability, low bone mineral density, and menstrual dysfunction, has serious implications for female athletes, with extreme cases leading to potentially irreversible consequences. It is unclear how or if the female athlete triad uniquely affects swimmers, for whom weightbearing is not part of their sport. The goal of this systematic review was to analyze studies of the triad pertaining to female swimmers with an emphasis on the volume of literature and the prevalence of individual components of the triad.

METHODS: A literature search was conducted on November 8, 2023, through PubMed and Google Scholar using the terms “female athlete triad” and “swimmer” or “swimming.” Of the 259 studies extracted, 17 were selected for inclusion after abstract and full-text screening. Outcomes involving each component of the triad, as well as overall prevalence and risk of the triad, were aggregated to derive means. Quantitative reporting of triad components varied across studies; thus, reported mean percentages were calculated using only the studies that reported the relevant statistics. “Female” was defined in reference to cis-gender females based on self-identified gender identity.

RESULTS: The 17 studies varied widely in terms of reported metrics. The 11 studies that reported the number of female swimmers included a total of 478 female swimmers. Menstrual dysfunction was the most frequently documented symptom, with a mean of 41% of swimmers experiencing menstrual irregularity. A mean of nearly 12% of swimmers were found to have low bone mineral density, and 51% were found to have low energy availability. Overall, 41% of female swimmers were estimated to be at risk for the triad.

CONCLUSION: With an estimated 4 in 10 female swimmers at risk of the triad, early identification through screening, awareness, and special attention to the most reported symptom, menstrual irregularity, is key to maintaining health of athletes. The overall small number of studies on the triad/REDs in female swimmers, along with the wide heterogeneity of quantitative data point to the need for further research on the female athlete triad to better understand the interplay of each symptom in this unique athletic population.

References

1. Barrack MT, Ackerman KE, Gibbs JC. Update on the female athlete triad. Curr Rev Musculoskelet Med. 2013 Jun;6(2):195–204.

2. Biller BM, Saxe V, Herzog DB, Rosenthal DI, Holzman S, Klibanski A. Mechanisms of osteoporosis in adult and adolescent women with anorexia nervosa. J Clin Endocrinol Metab. 1989 Mar;68(3):548–54.

3. Dave SC, Fisher M. Relative energy deficiency in sport (RED - S). Curr Probl Pediatr Adolesc Health Care. 2022 Aug;52(8):101242.

4. Gomez-Bruton A, Montero-Marín J, González-Agüero A, García-Campayo J, Moreno LA, Casajús JA, et al. The effect of swimming during childhood and adolescence on bone mineral density: a systematic review and meta-analysis. Sports Med. 2016 Mar;46(3):365–79.

5. Hame SL, LaFemina JM, McAllister DR, Schaadt GW, Dorey FJ. Fractures in the collegiate athlete. Am J Sports Med. 2004 Mar;32(2):446–51.

6. Harel Z, Gold M, Cromer B, Bruner A, Stager M, Bachrach L, et al. Bone mineral density in postmenarchal adolescent girls in the United States: associated biopsychosocial variables and bone turnover markers. J Adolesc Health. 2007 Jan;40(1):44–53.

7. Soyka LA, Misra M, Frenchman A, Miller KK, Grinspoon S, Schoenfeld DA, et al. Abnormal bone mineral accrual in adolescent girls with anorexia nervosa. J Clin Endocrinol Metab. 2002 Sep;87(9):4177–85.

8. Tenforde AS, Carlson JL, Chang A, Sainani KL, Shultz R, Kim JH, et al. Association of the female athlete triad risk assessment stratification to the development of bone stress injuries in collegiate athletes. Am J Sports Med. 2017 Feb;45(2):302–10.

9. Thein-Nissenbaum J. Long term consequences of the female athlete triad. Maturitas. 2013 Jun;75(2):107–12.

10. Vicente-Rodríguez G. How does exercise affect bone development during growth? Sports Med. 2006;36(7):561–9.

11. Nose-Ogura S, Harada M, Hiraike O, Osuga Y, Fujii T. Management of the female athlete triad. J Obstet Gynaecol Res. 2018 Jun;44(6):1007–14.

12. Pfeifer S, Patrizio P. The female athlete: some gynecologic considerations. Sports Medicine and Arthroscopy Review. 2002 Mar 1;10:2–9.

13. Gimunová M, Paulínyová A, Bernaciková M, Paludo AC. The prevalence of menstrual cycle disorders in female athletes from different sports disciplines: a rapid review. Int J Environ Res Public Health. 2022 Oct 31;19(21):14243.

14. Schtscherbyna A, Soares EA, de Oliveira FP, Ribeiro BG. Female athlete triad in elite swimmers of the city of Rio de Janeiro, Brazil. Nutrition. 2009 Jun;25(6):634–9.

15. Witkoś J, Błażejewski G, Hagner-Derengowska M, Makulec K. The impact of competitive swimming on menstrual cycle disorders and subsequent sports injuries as related to the female athlete triad and on premenstrual syndrome symptoms. Int J Environ Res Public Health. 2022 Nov 28;19(23):15854.

16. Sawai A, Mathis BJ, Natsui H, Zaboronok A, Mitsuhashi R, Warashina Y, et al. Risk of female athlete triad development in Japanese collegiate athletes is related to sport type and competitive level. Int J Womens Health. 2018;10:671–87.

17. Mudd LM, Fornetti W, Pivarnik JM. Bone mineral density in collegiate remale athletes: comparisons among Sports. J Athl Train. 2007;42(3):403–8.

18. Scofield KL, Hecht S. Bone health in endurance athletes: runners, cyclists, and swimmers. Curr Sports Med Rep. 2012;11(6):328–34.

19. Tenforde AS, Carlson JL, Sainani KL, Chang AO, Kim JH, Golden NH, et al. Sport and triad risk factors influence bone mineral density in collegiate athletes. Med Sci Sports Exerc. 2018 Dec;50(12):2536–43.

20. da Costa NF, Schtscherbyna A, Soares EA, Ribeiro BG. Disordered eating among adolescent female swimmers: dietary, biochemical, and body composition factors. Nutrition. 2013 Jan;29(1):172–7.

21. Hoogenboom BJ, Morris J, Morris C, Schaefer K. Nutritional knowledge and eating behaviors of female, collegiate swimmers. N Am J Sports Phys Ther. 2009 Aug;4(3):139–48.

22. Klein DJ, McClain P, Montemorano V, Santacroce A. Pre-season nutritional intake and prevalence of low energy availability in NCAA Division III collegiate swimmers. Nutrients. 2023 Jun 21;15(13):2827.

23. Cabre H, Moore S, Smith-Ryan A, Hackney A. Relative energy deficiency in sport (RED-S): scientific, clinical, and practical implications for the female athlete. Dtsch Z Sportmed. 2022;73(7):225–34.

24. Maharam N, Shalan NAAM, Abdullah NF. Nutritional knowledge and calorie intake among university athlete with risk of female athlete triad. Jurnal Sains Sukan & Pendidikan Jasmani. 2022 Dec 27;11:82–7.

25. Robertson S, Mountjoy M. A review of prevention, diagnosis, and treatment of relative energy deficiency in sport in artistic (synchronized) swimming. Int J Sport Nutr Exerc Metab. 2018 Jul 1;28(4):375–84.

26. Melin A, Tornberg ÅB, Skouby S, Møller SS, Sundgot-Borgen J, Faber J, et al. Energy availability and the female athlete triad in elite endurance athletes. Scand J Med Sci Sports. 2015;25(5):610–22.

27. Yi J, Tenfelde S, Tell D, Brincat C, Fitzgerald C. Triathlete risk of pelvic floor disorders, pelvic girdle pain, and female athlete triad. Female Pelvic Med Reconstr Surg. 2016;22(5):373–6.

28. Almousa S, Bandín van Loon A. Female athlete triad epidemiology among adult athletes: a systematic review. Science & Sports. 2024 May 1;39(3):227–40.

29. Byrne S, McLean N. Elite athletes: effects of the pressure to be thin. J Sci Med Sport. 2002 Jun 1;5(2):80–94.

30. Shaw G, Boyd KT, Burke LM, Koivisto A. Nutrition for swimming. Int J Sport Nutr Exerc Metab. 2014 Aug;24(4):360–72.

31. Vanheest JL, Rodgers CD, Mahoney CE, De Souza MJ. Ovarian suppression impairs sport performance in junior elite female swimmers. Med Sci Sports Exerc. 2014 Jan;46(1):156–66.

32. Trappe TA, Gastaldelli A, Jozsi AC, Troup JP, Wolfe RR. Energy expenditure of swimmers during high volume training. Med Sci Sports Exerc. 1997 Jul;29(7):950–4.

33. Ackerman KE, Holtzman B, Cooper KM, Flynn EF, Bruinvels G, Tenforde AS, et al. Low energy availability surrogates correlate with health and performance consequences of relative energy deficiency in sport. Br J Sports Med. 2019 May 1;53(10):628–33.

34. Logue D, Madigan SM, Delahunt E, Heinen M, Mc Donnell SJ, Corish CA. Low energy availability in athletes: a review of prevalence, dietary patterns, physiological health, and sports performance. Sports Med. 2018 Jan;48(1):73–96.

35. Schaal K, Tiollier E, Le Meur Y, Casazza G, Hausswirth C. Elite synchronized swimmers display decreased energy availability during intensified training. Scand J Med Sci Sports. 2017 Sep;27(9):925–34.

36. Martinez GM. Trends and patterns in menarche in the United States: 1995 through 2013-2017. Natl Health Stat Report. 2020 Sep;(146):1–12.

37. Constantini NW, Warren MP. Menstrual dysfunction in swimmers: a distinct entity. J Clin Endocrinol Metab. 1995 Sep;80(9):2740–4.

38. Redman LM, Loucks AB. Menstrual disorders in athletes. Sports Med. 2005;35(9):747–55.

39. Noakes TD, van Gend M. Menstrual dysfunction in female athletes. A review for clinicians. S Afr Med J. 1988 Mar 19;73(6):350–5.

40. Schtscherbyna A, Barreto T, Oliveira FP de, Luiz RR, Soares E de A, Ribeiro BG. Age of onset training but not body composition is crucial in menstrual dysfunction in adolescent competitive swimmers. Rev Bras Med Esporte. 2012 Jun;18:161–3.

41. Bellew JW, Gehrig L. A comparison of bone mineral density in adolescent female swimmers, soccer players, and weight lifters. Pediatr Phys Ther. 2006;18(1):19–22.

42. Miller M, Kojetin S, Scibora L. Site-specific effects of swimming on bone density in female collegiate swimmers. Int J Exerc Sci. 2020 Feb 1;13(1):249–59.

43. Schipilow JD, Macdonald HM, Liphardt AM, Kan M, Boyd SK. Bone micro-architecture, estimated bone strength, and the muscle-bone interaction in elite athletes: an HR-pQCT study. Bone. 2013 Oct;56(2):281–9.

44. Vasiliadis AV, Lampridis V, Georgiannos D, Bisbinas I. Swimmers are at risk for stress fractures? A systematic review. Intl J Kinesiol Sports Sci. 2018 Jul 31;6(3):25–31.

45. Arendt E, Agel J, Heikes C, Griffiths H. Stress injuries to bone in college athletes: a retrospective review of experience at a single institution. Am J Sports Med. 2003;31(6):959–68.

46. Troy K, Hoch AZ, Stavrakos JE. Awareness and comfort in treating the female athlete triad: Are we failing our athletes? WMJ. 2006 Oct;105(7):21–4.

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Published

2025-04-25

Issue

Vol. 5 No. 1 (2025): Issue 11

Section

Review Article

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Copyright (c) 2025 Journal of Women's Sports Medicine

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How to Cite

The Female Athlete Triad in Swimmers: a Review of Current Literature. (2025). Journal of Women’s Sports Medicine, 5(1), 30-38. https://doi.org/10.53646/ahq2qs39

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