Revista de Medicina Desportiva (English) September 2018 - Page 17

of menstrual cycles with failure to menstruate for 90 days or longer, which can be classified as primary or secondary). When we have amen- orrhea in the context of low EA and intense exercise practice should be a diagnosis of exclusion and is associ- ated to an inhibitory hypothalamic action over gonadotropin-releasing hormone neurons (GnRH) and, consequently, a disruption of the physiological pituitary LH pulsatility, hence be designated by hypotha- lamic or functional amenorrhea. 21 The association between hypotha- lamic dysfunction, hypoestrogenism and low levels of leptin on amenor- rhoeic female athletes was associ- ated with a 2-4-fold increased risk of stress fractures and lower bone min- eral density (BMD), which may not be retrievable after normalization of menstrual cycles throughout adult life. 21-23 Early low-BMD screening and diagnosis are severely important since up to 90 percent of peak bone mass is acquired by age 18. 24 Subsequently, the concept of low EA was directly related to deficit bone health independently of the coexistence of hypoestrogenism. This highlights the direct and independent impact of EA on bone structure regardless of menstrual dysfunction. 25-27 Especially in sports that have a weight-class requirement or for which a low body-weight or lean body is believed to give a competi- tive advantage (usually referred as lean sports – gymnastics, diving, row- ing, ballet, running, cycling, jockey- ing, wrestling, and martial arts), EA is often conditioned, with an increased likelihood of eating disor- ders in athletes of both sexes. 7,9,28 Since RED-S signs and symptoms are often subtle, it is mandatory to have a high clinical suspicion during the medical evaluation through a detailed medical history (including questioning of eating habits, the training program, gynecologic his- tory and previous history of infec- tions or stress fractures). Physical examination should include an eval- uation of the vital signs and of the anthropometric data. The presence of bradycardia, orthostatic hypoten- sion, BMI < 18.5 kg/m 2 on athletes older than 18 years of age, parotid hypertrophy or signs of peripheral HIGH RISK RED LIGHT No competion No trainning Use of written contract MODERATE RISK YELLOW LIGHT LOW RISK GREEN LIGHT May train as long as he/she is following the treatment plan Full sport participation May compete once medically cleared under supervision Figura 2 – Estratificação do atleta por categoria de risco de RED-S para decisão de retorno à competição, adaptado de Aspetar Sports Medicine Journal, 2018; (6):414-419. tissue hypoperfusion may raise sus- picion of an inadequate nutritional status and/or an eating disorder. 9 Additional diagnostic evaluation tools may be necessary in specific cases as Bone Densitometry Scan on female athletes with menstrual dysfunction, low BMI (< 17,5 kg/ m 2 ) or 10 percent reduction in body weight over a one-month period, past history of two stress fractures and/or presence of an eating dis- order. 7 It should be noted that on children, adolescents and premeno- pausal women, the diagnosis of low BMD should be based on Z-score (and not the T-Score). 6 Laboratory evalua- tion can include ionogram, complete blood cell count and full evaluation of integrity of the anterior hypo- thalamus-pituitary axis, including the thyroid stimulating hormone (TSH) and free thyroxine (T4), follicle stimulating hormone (FSH), LH and prolactin. 22 Although there is a growing awareness for the diagnosis and rec- ognition of the different components of the syndrome among athletes and their entourage, continuing training will be necessary for each member of the multidisciplinary sports team to warn about the negative impact of energy deficit besides gonadal dysfunction and bone health and, above all, to including female and male athletes in this nosological classification. 29-34 The qualification of these professionals is essential, allowing an early diagnosis and minimizing the negative impact on health and performance of the ath- lete of low EA. Using standard tools for periodic athlete evaluation is the correct strategy adopted to follow- up and surveillance. 9 To simplify and standardize the screening and follow-up of athletes, the IOC created in 2015 one clinical evaluation tool (RED-S CAT) to assist the professionals on the evaluation of the athlete. The screening may be included as part of the athlete’s annual health examination and/ or whenever there is evidence of an eating disorder (anorexia nervosa, bulimia, restrictive diet or extreme weight loss techniques), menstrual dysfunction (secondary amenorrhea over than six months or primary amenorrhea after 16 years of age), previous history of stress fracture, significant weight loss (over 5 to 10% reduction in body weight over one-month period), changes on tar- get height as predicted by parental height, the performance deficit or an obvious mood or behavior distur- bance. 9 The clinical tool proposed by IOC categorizes the athletes in three levels according to the RED-S risk level (red light – high risk; yellow light – moderate risk and green light – low risk) and integrates clinical and laboratory parameters eas- ily accessible during the clinical evaluation and athlete follow-up. This definition in categories will be also essential for stop-training and return to play decision by the medical team. Thus, the endpoints identi- fied, as high-risk category (red light) should not be cleared to take part in sport because of the inherent health risk associated to the practice and should receive adequate therapy to restore the EA focusing on treatment Disponibilidade energética (DE) Ingestão energética total diária – energia gasta exercício Massa livre de gordura corporal Figure 1 – Estimated energy availability calculation formula accor- ding to Loucks Et Al., 2011. Revista de Medicina Desportiva informa september 2018 · 15