Menstrual Phase as Predictor of Outcome After Mild Traumatic Brain Injury in Women
Wunderle K, Hoeger KM, Wasserman E, Bazarian JJ.J Head Trauma and Rehabil. 2013;
Take Home Message: Female patients who suffered a concussion during the luteal phase of their menstrual cycle, when progesterone levels are highest, reported lower quality of life scores one month after their concussion compared with those who did not suffer a concussion in the luteal phase.
Gender differences in concussion frequency and outcome have long been recognized, but the reasoning behind it is not fully understood. Women report more post-concussive symptoms and experience worse outcomes after a concussion (e.g., length of hospitalization stay, headaches, depression) compared with their male counterparts. Some studies suggest that sex hormones (e.g., progesterone, estrogen) may play a role as a predictor for concussion in women, but there is limited research in this area. Therefore, the authors assessed the relationship between menstrual cycle phase at the time of concussion and neurologic and quality of life outcomes 1-month post injury. One hundred and forty-four female patients (16-60 years of aged) who suffered a concussion that was diagnosed within 4 hours of injury participated in this study. The patients provided a serum sample to measure progesterone levels and answered health history questions by telephone (e.g., mechanism of injury, initial signs and symptoms, birth control medication, and last menstrual cycle). The authors divided the patients into three groups on the basis of birth control and progesterone levels: 1) synthetic progesterone (35 patients; consistent levels of progesterone), 2) follicular phase group (72 patients; < 2 ng/ml progesterone concentration), and 3) luteal phase group (37 patients; > 2 ng/ml progesterone concentration). One month after their injury the patients completed the Rivermead Post Concussion Quality of Life questionnaire (RPCQ; 16-question survey that assesses post concussive symptoms) and EuroQol/EQ5D (measures health outcome) by phone. The luteal phase group scored worse on the EuroQoL and general health rating compared with the synthetic group. The luteal phase group had approximately twice the odds of reporting worse on the EuroQol and reported the most symptoms on the RPCQ compared with the follicular or synthetic progesterone groups.
The theory of the “withdrawal process” postulates that a woman with a high progesterone concentration (luteal phase) who experiences a concussion injury will experience a sudden drop in progesterone levels and experience a worse outcome compared with men. These authors demonstrated that this theory could be correct. Women in the luteal phase, when progesterone is at its peak, reported worse outcomes following a concussion compared with those on synthetic progesterone (a steady level of progesterone) or in the follicular phase of their menstrual cycle (a low level of progesterone at time of the injury). These findings suggest that it might be worth exploring if women in the luteal phase of their menstrual cycle at the time of injury benefit from progesterone treatment. Furthermore, medical professionals may want to ask about the menstrual cycle – although this can be less accurate then measuring sex hormones – as part of a concussion evaluation because it may help determine if the athlete is at risk for more severe symptoms or a prolonged recovery. .
Questions for Discussion: Do you believe treatment with progesterone following a concussion could be beneficial for some women? Do you think being on synthetic progesterone could be protective against worse concussion outcomes?
Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban