Menstrual Phase as Predictor
of Outcome After Mild Traumatic Brain Injury in Women

K, Hoeger KM, Wasserman E, Bazarian JJ.J Head Trauma and Rehabil.

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.

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.

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?

by: Jane McDevitt, PhD
by: Jeff Driban


Wunderle K, Hoeger KM, Wasserman E, & Bazarian JJ (2013). Menstrual Phase as Predictor of Outcome After Mild Traumatic Brain Injury in Women. The Journal of Head Trauma Rehabilitation PMID: 24220566