Association of Concussion With Abnormal
Menstrual Patterns in Adolescent and Young Women

Snook ML, Henry LC, Sanfilippo JS, Zeleznik AJ,
Kontos AP. JAMA Pediatrics. 2017; ahead of print.

Take Home Message: Young
women may have an increased risk of multiple abnormal menstrual patterns after
a concussion.

experience higher rates of sport-related concussion and tend to have worse
concussion outcomes compared with male counterparts in similar sports. Concussions
may also disrupt the
neuroendocrine-pituitary-ovarian axis,
which manages the menstrual cycle, and lead to menstrual dysregulation such as
irregular bleeding habits. Early identification of menstrual irregularities is
vital due to the irreparable damage it can have on an athlete’s body (decreased
bone density). However, researchers and clinicians have yet to appreciate the
role of concussion on menstrual patterns. Therefore, the authors tested whether
menstrual patterns differed between 68 women who suffered a concussion (~16
years of age) and 61 women with an orthopedic injury (~17 years of age) for 120
days’ post injury. The athletes were included if they reported to an outpatient
sports medicine clinic between 2014 to 2015, were 2 years postmenarche and
reported regular menses for 2 years, no pregnancy, and did not use hormonal
contraception in the prior 6 months. Following confirmation of injury, the patients
completed a questionnaire, which included questions about their menstruation
and sexual history. Then, the authors sent weekly text messages for up to 120
days after the injury to answer 4 main questions: 1. Did they experienced any
bleeding episodes, and if so when did it begin, 2. Did they experience a new
injury, 3. Did they start or continue any hormonal contraception, and 4. Could
they be pregnant. The authors evaluated answers to define abnormal menstrual
patterns (short intermenstrual intervals of less than 21 days; long
intermenstrual intervals of 35 or more days, or bleeding less than 3 days or
more than 7 days). The authors found that 24% of athletes who had a concussion experienced
2 or more abnormal menstrual patterns during the study compared with only 5% of
athletes who had an orthopedic injury. Despite similar gynecologic age, body
mass index, and type of sports participation between groups, the risk of 2 or
more abnormal menstrual bleeding patterns after injury was almost 6 times higher
among athletes with concussion than among those with an orthopedic injury.

was the first study to prospectively characterize abnormal menstrual patterns
after concussion in young women. The authors found that a young woman with a concussion
is at greater risk of multiple abnormal menstrual patterns compared with an
athlete with an orthopedic injury. These results suggest that a concussion could
lead to a disruption of the neuroendocrine-pituitary-ovarian axis, which could
lead to problems later in life. It should be noted that none of the athletes
developed amenorrhea. It should also be noted that these menstrual cycles were
subjectively reported and there was no confirmation with hormone levels. The
authors also did not assess if there are long-term changes such as bone density
problems after this disruption. However, the authors noted that the American
Academy of Pediatrics and American College of Obstetricians and Gynecologists recommend
clinicians consider the menstrual cycle as a vital sign in adolescents because estrogen
is important in bone health and other tissues. Therefore, due to the ease and
low risk of subjectively assessing menstruation it may be beneficial for clinicians
to follow up with the athletes regarding their menstrual cycles. Additionally,
parents and athletes should be educated about these menstrual changes that
could arise following a concussion, so they may report any changes to their
athletic trainer. If clinicians detect these menstrual abnormalities and refer
the patient for evaluation and treatment it could have a major benefit to the patient’s
long-term health.

Question for
Discussion: Do you monitor menstrual cycles following an injury? Has an athlete
ever reported a change in menstruation due to an injury?

Written by: Jane McDevitt, PhD
by: Jeff Driban

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