Menses and Sexual Changes in Women After Trauma

What is the endocrine system?

Your endocrine system includes glands and organs that make and release hormones, which are chemicals that help your body work properly. They control growth, sexual development, how your body uses and stores energy (metabolism), how it deals with illness, and more. You need proper types and amounts of hormones to feel well.

How can TBI affect the endocrine system?

Two important parts of the endocrine system—the pituitary gland and the hypothalamus—are located in or near the brain. The hypothalamus and the pituitary gland are like orchestra conductors. Their job is to tell other endocrine glands throughout the body to make the hormones that affect and protect every aspect of your health. TBI can injure them, causing hormone problems. A person with TBI may have hormone problems right away or months or even years after the injury.

Menses and Sexual Changes in Women After Brain Trauma

Repeated mild Traumatic Brain Injuries (TBI) occurring over an extended period of time can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.

After TBI, there may be some changes to the pituitary. The Pituitary is a pea-sized gland in your brain that makes hormones that help to keep your periods regular every month. When the pituitary makes low levels of certain hormones, this can mean having skipped or missed periods. Stress can cause your hormone levels to change. This can also change your periods. Certain medications can also cause changes to your periods. Ask your doctor about the side effects of the medications you are taking. endocrine3

Recent research indicates there is a higher incidence of hormone abnormalities in people who have sustained a brain injury. This is directly related to injury of the hypothalamus, and pituitary gland and all the hormones they produce or stimulate to produce, including thyroid hormone, growth hormone, cortisol, and the sex hormones (FSH, LH, Prolactin, estrogen, and testosterone). It is more common to see these abnormalities early on after a brain injury but they can come on as a long term consequence. The hypothalamus and/or pituitary gland, are small structures at the base of the brain responsible for regulating the body’s hormones. Damage to these areas can lead to insufficient or increased release of one or more hormones, which causes disruption of the body’s ability to maintain a stable internal environment (homeostasis). Damage to the pituitary gland leads to a reduction in hormone production resulting in a condition known as hypopituitarism. Medication and other medical illnesses should be ruled out as the cause of any hormone
abnormalities as well.

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Women experience greater cognitive decline, poorer reaction times, more headaches, extended periods of depression, longer hospital stays and delayed return-to-work compared to men following head injury. Such results are particularly pronounced in women of childbearing age; girls who have not started their period and post-menopausal women have outcomes similar to men.

At one year after injury, negative outcomes (persistent physical symptoms, requiring assistance with cognitive difficulties, social and occupational difficulties, reduced quality of life) were repeated more frequently by those who were female, older, and had received more severe injuries. However, among patient with mTBI injuries it has been identified that 24% of patients who suffered with persistent symptoms and significant life disruption at 3 months post injury were more likely to be young and female, had a prior head injury, neuro/psychiatric symptoms, or a TBI as a result of a motor vehicle accident.

Menstrual troubles such as amenorrhea, or the absence of a period, and irregular cycles are more common in women with TBI. The mean duration of amenorrhea was 6.5 months with a range of 1 – 60 months. There was one participant whose menses stopped at time of injury and had not returned by time of interview.

After a TBI you may have skipped or missed periods. You may also have more pain or notice more headaches during your periods. You may notice changes to your periods while in the hospital, rehabilitation or at home. These changes can happen in mild to more serious injuries. Still, absence of a menses is more likely to happen when the brain injury is serious. Skipping or missing your period can last from 1 month to many years. For many women, the changes to their periods get better with time, but not always.

Of 104 women with TBI (W-TBI), 46% experienced amenorrhea with duration of up to 60 months. Cycles became irregular for 68% of W-TBI after the injury. These findings were significantly different from those of controls. Among W-TBI, menstrual disturbances were associated with injury severity. No differences were shown between W-TBI and controls with respect to fertility, although significantly fewer W-TBI had one or more live births, and they reported more difficulties in the postpartum period than controls. W-TBI were less likely to have regular Pap smears and reported lower mental health, self-rated health, and function.

Significantly fewer (49%) reported changes in menstrual flow after injury compared with the control counterparts (64%). Matched case-control conditional regression analyses showed that W-TBI were 21 times more likely than controls to report amenorrhea after injury; for those with regular cycles, W-TBI were 6 times more likely to experience irregular cycles. Among W-TBI, amenorrhea was associated with lower GCS Scores, Higher ISS, and longer length of acute hospital stays. Irregular periods emerging after the injured were significantly associated with higher ISS only.

Pregnancy/Fertility – 28% of W-TBI indicated that they tried to conceive or became pregnant after their TBI vs. 35% of controls during a comparable time period. Hence, the subgroups for these analyses are smaller in size.

Changes in sexual functioning are common after TBI as well. Brain Injury can change the way a person expresses or experiences their sexuality. There are many reasons sexual problems happen after TBI. Some are directly related to damage to the brain. Others are related to physical problems or changes in thinking or relationships.

No significant group differences were found in terms of difficulty conceiving or difficulties during pregnancy after injury. Those who became pregnant however, significantly fewer W-TBI had one or more live births compared with controls. W-TBI were also more likely to report post pregnancy difficulties in the pregnancies that occurred after the brain injury compared with controls in the equivalent time period. The 12 women reported the following: Increased fatigue, pain, depression, mobility problems, inability to concentrate and lower extremity edema. Three women who did not report depression reported “feeling the blues” and 1 woman reported hip pain/headaches.

These findings inform prognosis after TBI for women and provide evidence for long-term monitoring of health outcomes and increased support after childbirth. More research is needed in this area, particularly with respect to the neuroendocrine system.

“I don’t think doctors consider menstrual history when evaluating a patient after a concussion, but maybe we should,” noted Bazarian, associate professor of Emergency Medicine at the University of Rochester School of Medicine and Dentistry who treats patients and conducts research on traumatic brain injury and long-term outcomes among athletes. “By taking into account the stage of their cycle at the time of injury we could better identify patients who might need more aggressive monitoring or treatment. It would also allow us to counsel women that they’re more – or less – likely to feel poorly because of their menstrual phase.”

Although media coverage tends to focus on concussions in male professional athletes, studies suggest that women have a higher incidence of head injuries than men playing sports with similar rules, such as ice hockey, soccer and basketball. Bazarian estimates that 70 percent of the patients he treats in the URMC Sport Concussion Clinic are young women. He believes the number is so high because they often need more follow-up care. In his experience, soccer is the most common sport leading to head injuries in women, but lacrosse, field hockey, cheerleading, volleyball and basketball can lead to injuries as well.

sex and tbi

Sex hormone levels often change after a head injury, as women who have suffered a concussion and subsequently missed one or more periods can attest. According to Kathleen M. Hoeger, M.D., M.P.H.,study co-author and professor of Obstetrics and Gynecology at the University of Rochester School of Medicine and Dentistry, any stressful event, like a hit to the head, can shut down the pituitary gland in the brain, which is the body’s hormone generator. If the pituitary doesn’t work, the level of estrogen and progesterone would drop quickly.

According to Bazarian, progesterone is known to have a calming effect on the brain and on mood. Knowing this, his team came up with the “withdrawal hypothesis”: If a woman suffers a concussion in the premenstrual phase when progesterone levels are naturally high, an abrupt drop in progesterone after injury produces a kind of withdrawal which either contributes to or worsens post concussive symptoms like headache, nausea, dizziness and trouble concentrating. This may be why women recover differently than men, who have low pre-injury levels of the hormone.

“If you get hit when progesterone is high and you experience a steep drop in the hormone, this is what makes you feel lousy and causes symptoms to linger,” said Bazarian. “But, if you are injured when progesterone is already low, a hit to the head can’t lower it any further, so there is less change in the way you feel.”

The team suspected that women taking birth control pills, which contain synthetic hormones that mimic the action of progesterone, would have similar outcomes to women injured in the low progesterone phase of their cycle. As expected, there was no clear difference between these groups, as women taking birth control pills have a constant stream of sex hormones and don’t experience a drop following a head hit, so long as they continue to take the pill.

“Women who are very athletic get several benefits from the pill; it protects their bones and keeps their periods predictable,” noted Hoeger. “If larger studies confirm our data, this could be one more way in which the pill is helpful in athletic women, especially women who participate in sports like soccer that present lots of opportunities for head injuries.”

In addition to determining menstrual cycle phase at the time of injury, Bazarian plans to scrutinize a woman’s cycles after injury to make sure they are not disrupted. If they are, the woman should make an appointment with her gynecologist to discuss the change.

How does a traumatic brain injury affect sexual functioning?

The following changes in sexual functioning can happen after TBI:

Decreased Desire: Many people may have less desire or interest in sex.
Increased Desire: Some people have increased interest in sex after TBI and may want to have sex more often than usual. Others may have difficulty controlling their sexual behavior. They may make sexual advances in inappropriate situations or make inappropriate sexual comments.
Decreased Arousal: Many people have difficulty becoming sexually aroused. This means that they may be interested in sex, but their bodies do not respond. Men may have difficulty getting or keeping an erection. Women may have decreased vaginal lubrication (moisture in the vagina).
Difficulty or Inability to Reach Orgasm/Climax: Both men and women may have difficulty reaching orgasm or climax. They may not feel physically satisfied after sexual activity.
Reproductive Changes: Women may experience irregular menstrual cycles or periods. Sometimes, periods may not occur for weeks or months after injury. They may also have trouble getting pregnant. Men may have decreased sperm production and may have difficulty getting a woman pregnant.

Possible causes of changes in sexual functioning after TBI include:

Damage to the Brain: Changes in sexual functioning may be caused by damage to the parts of the brain that control sexual functioning.
Hormonal Changes: Damage to the brain can affect the production of hormones, like testosterone, progesterone, and estrogen. These changes in hormones affect sexual functioning.
Medication Side Effects: Many medications commonly used after TBI have negative side effects on sexual functioning.
Fatigue/Tiredness: Many people with TBI tire very easily. Feeling tired, physically or mentally, can affect your interest in sex and your sexual activity.
Problems with Movement: Spasticity (tightness of muscles), physical pain, weakness, slowed or uncoordinated movements, and balance problems may make it difficult to have sex.
Self-Esteem Problems: Some people feel less confident about their attractiveness after TBI. This can affect their comfort with sexual activity.
Changes in Thinking Abilities: Difficulty with attention, memory, communication, planning ahead, reasoning, and imagining can also affect sexual functioning.
Emotional Changes: Individuals with TBI often feel sad, nervous, or irritable. These feelings may have a negative effect on their sexual functioning, especially their desire for sex.
Changes in Relationships and Social Activities: Some people lose relationships after TBI or may have trouble meeting new people. This makes it difficult to find a sexual partner.