The Effects of Sex Differences and Hormonal Contraception on Outcomes Following Collegiate Sports-Related Concussion

Gallagher V, Kramer N, Abbott K, Alexander J, Breiter H, Herrold A, Lindley T, Mjaanes J, & Reilly J. Journal of Neurotrauma. Ahead of Print. doi: 10.1089/neu.2017.5453.


Take Home Message: Male collegiate athletes may return to play sooner after a concussion than females. Females taking contraception may have less peak symptom severity than peers not taking contraception, but the days to return to play is likely similar.
There is inconclusive evidence to determine if a female is more likely to take more time to return to play following concussion than a male. Additionally, females may take hormonal contraception, but its influence on concussion recovery remains unknown. Hence, the authors’ performed a retrospective chart review to examine if peak concussion symptom severity and days to return to play differed by sex or hormonal contraception use among collegiate athletes. The authors performed a retrospective medical chart review on Division I collegiate athletes who had a physician-diagnosed concussion between 2011 and 2016. They included 40 males and 50 females (25 used hormonal contraception, 24 did not use hormonal contraception, and 1 was excluded from the contraception analysis). The study team grouped females by hormonal contraception use based on their recorded medication use at the time of injury and through an annual health questionnaire. Athletes went through a standardized stepwise return-to-play progression and the team physician cleared them for return to play. The authors used two outcome measures: peak symptom severity and length of recovery. Peak symptom severity was the max symptom severity total score from either the SCAT2 or SCAT3, which the athletes completed at least every 24 hours from immediately post-injury till full return to play. Length of recovery was the number of days between their clearance for return to play and the initial injury. The authors found that males and females had similar peak symptom severity (males ~26 and females ~22 out of 132 possible points), but males returned to play on average nine days quicker than females (males ~13 and females ~22 days). Regarding hormonal contraception use, females taking contraception experienced on average lower peak symptom severity (18) than females not taking contraception (26), but they did not differ in their days to return to play.
These findings provide further awareness on the possible sex differences in concussion recovery, with females potentially taking longer to return to play than males. A better understanding of “normal” recovery patterns and return to play timelines could aid clinicians in gauging where their patient falls regarding recovery, and help determine when a patient may need additional referrals and treatment. These findings may be clinically meaningful as men returned to play nine days earlier on average. But, it is important to note that there were large ranges in the length of recovery suggesting that a “normal” time range of recovery may not be so normal. Additionally, males and females reportedly differ in their symptom reporting behaviors due to factors such as “peer pressure”, which may influence when a male or female is cleared to return to play. Overall, females had similar time to return to play regardless of contraception use, but contraception users had less peak symptom severity. Although peak symptom severity is an important outcome measure, it would be interesting to see if these findings changed when using another clinically important outcome measure such as the number of days to symptom recovery. The authors’ findings are clinically important and are a great example of clinically-focused research; however, we should be cautious in applying and accepting these preliminary findings as being clinically applicable when treating concussed athletes. We as clinicians should realize that sex, contraception use, and many other reasons may influence our patient’s recovery, but there is no guarantee that one factor will make some slower to recover. We should be thoughtful to not tell patients they will have a prolonged recovery, but rather we should explain that it is relatively common if their recovery is delayed.
Questions for Discussion: If future research indicates hormonal contraception greatly reduced both concussion symptom severity and days to return to play, would you feel comfortable recommending female athletes be prescribed these medications? What do you think the potential positive and negative consequences are for informing athletes and coaches of “normal” concussion recovery timelines? In your clinical experience, do you see differences in symptom and recovery patterns between males and females?
Written by: Landon B. Lempke, MEd, LAT, ATC
Reviewed by: Jeffrey Driban
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