External and internal pressures to win also may be a cause of the Triad. The chief cause of the amenorrhea component of the Triad is an energy imbalance brought on when athletes do not eat enough to balance the energy they expend in training. Teenage athletes in these sports, who also must cope with biological changes, peer pressure, society's glorification of thinness and the focus on body image that occur during puberty, are particularly at risk of suffering from the Triad. These characteristics, however, can also be the early warning signs of the Triad. Unusual food behaviors may be a sign of disordered eating.
Road trips are an especially good time to observe eating habits.
Coaches should also be aware of unusual mood patterns, sleep disturbances, and impaired concentration. Beyond amenorrhea, coaches must know that having irregular periods is unhealthy and is a warning sign. Osteoporosis may manifest itself in the form of stress fractures. Although not all stress fractures are the result of the Female Athlete Triad, one should certainly take a close look at the nutritional and training habits and menstrual history of any female athlete with a stress fracture. To recognize the Triad, coaches must also honestly evaluate their own beliefs, behavior and other external factors affecting their athletes.