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The recently published study, "Menstrual Phase as Predictor of Outcome After mTBI in Women" is so exciting because this study goes a step beyond confirming that women's concussions are different than men's. This research explored why in detail the differences occur within the subset of women themselves compared to men's experience of concussion. The authors of the study are Kathryn Wunderle, BA; Kathleen M. Hoeger, MD, MPH; Erin Wasserman, BA; Jeffrey J. Bazarian, MD, MPH, of The University of Rochester.
I will now offer my layman's view of this study; and as always, I encourage you to read the original study posted below. Please feel free to correct/comment on my thoughts and send me any questions you would like me to pass on to the research team who conducted the study. I will post questions and responses in my next blog.
Many of us who have experienced concussions or worked with women with mTBI have long felt there was a connection between concussion and a woman's cycle. In this study, researchers sought to prove the “Withdrawal Hypothesis,” which states that if a woman has a high level progesterone in her body at the time of an injury, she will experience sudden drop in progesterone. And that it is this decrease or "drop" that will cause worse concussion outcomes than a woman who had low level of progesterone at the time of injury and did not experience this "drop."
So who has a low level of progesterone (thought to be beneficial at the time of a concussion)?
Who has a high level of progesterone?
Researchers in this study hypothesized that women who experience mTBI during part of their cycles when progesterone is high, would have worse outcomes than women injured during time in their cycles when their progesterone is low.
Does anyone has level of progesterone which is resistant to this "drop?"
Remember in the case of this study, low progesterone levels at the time of concussion were predicted to be beneficial as they did not "drop" because they were low at the start. High levels which were subject to the "drop" were thought to predict poor outcomes.
The final results of this study support the researchers' prediction that women in their cycle where "progesterone is highest, had worse post-concussion symptoms" than women whose progesterone is initially low. Similarly, women who were taking synthetic progestin as birth control seemed to mirror the women who were in the low progesterone phases.
The authors of the study warn that their findings must be "considered preliminary." Yet, they believe if their conclusions are "confirmed by others, it has important implications for both treatment and prognosis."
My mind races with the possibilities...
As with every finding in the concussion field, more research needs to be done. But this study supports the hypothesis that the acute withdrawal of progesterone after mTBI may be the missing link (or one of the missing links) to why differences are seen in men and women's concussions. And in my opinion, this is a huge news for the concussion world - for men and women alike.
PDF of The Menstrual Phase as Predictor of Outcome After mTBI in Women Study
Objective: To determine whether menstrual cycle phase in women at the time of mild traumatic brain injury (mTBI) predicts 1-month outcomes.
Setting: Six emergency departments; 5 in Upstate New York, and 1 in Pennsylvania.
Participants: One hundred forty-four female participants (age, 16-60) who presented to participating emergency departments within 4 hours of mTBI.
Design: Nested cohort study with neurologic and quality-of-life outcome assessment, 1 month after enrollment. Female subjects aged 16 to 60 enrolled in the parent cohort study, with 1- month neurological determination data available, were classified into menstrual cycle groups by serum progesterone concentration and self-reported contraceptive use. Main Measures: Rivermead Post Concussion Questionnaire and EuroQoL/EQ5D.
Results: Women injured during the luteal phase of their menstrual cycle, when progesterone concentration is high, had significantly lower EuroQoL General Health Ratings and Index Scores than women injured during the follicular phase of their cycle or women taking oral contraceptives. Multivariate analysis confirmed a significant independent effect of menstrual cycle phase on EuroQoL Index Score and the Rivermead Post Concussion Questionnaire Somatic Subscore.
Conclusion: Menstrual cycle phase and progesterone concentration at the time of mTBI affect 1-month quality-of-life and neurologic outcomes. This association has important implications for treatment and prognosis after mTBI. Key words: brain concussion, brain injuries, follicular phase, luteal phase, menstrual cycle, postconcussion syndrome, progesterone, quality of life
PDF of The Menstrual Phase as Predictor of Outcome After mTBI in Women Study
Thank you to the authors - Kathryn Wunderle, BA; Kathleen M. Hoeger, MD, MPH; Erin Wasserman, BA; Jeffrey J. Bazarian, MD, MPH - and Leslie Orr of University of Rochester Medical Center - for allowing us to post this study.
Please direct questions to pricesned@gmail.com if you would like to take part in our exchange with the authors of the study.
There’s nothing like the pain of a concussion: a headache so bad, it’s vomit-inducing, and sensitivity to light and sound that can force isolation for weeks or months, sparking depression and anxiety.
Concussions have physical and emotional affects on all athletes, but Katherine Price Snedaker is spearheading research to look at female athletes’ experiences with concussions. She is hoping to use the research as a push for more education about head injuries in sports and a cultural change in the way concussed athletes are treated.
The study is an online survey for females 18+ who have had head injuries related to sports. Almost 350 women have already signed up to take the survey.
“I had concussions as a teenager, between sports and car accidents, and I was taken to the ER with headaches but nobody told me anything about concussions. I lived with that and in my 20′s, I noticed I kept getting concussions and when other (women around me) weren’t,” said Snedaker.
Then Snedaker’s son, who is in sixth grade, received a concussion during recess that kept him out of school for almost four months. But they didn’t stop – he received a number of additional concussions once returning to normal activities, and Snedaker became worried. His personality was flat, she said, and so she did research on the injury.
Snedaker, who has coached lacrosse and soccer, became passionate about concussion education and started clinics to teach parents, coaches and athletes about traumatic brain injuries.
In 2012, Snedaker who has a Masters Degree in Social Work, ran a post-concussion (support) group for teens through The Concussion Specialists of Connecticut. “In this group, 13 of 15 teens were girls,” she said. “And the the girls seemed much slower to heal, many had had repeat concussions, and all were isolated from their friends. Studies have shown girls take longer to recover from concussions. The dirty secret is some of us who get (concussions) as kids continue to have them throughout our adult lives. People have this fantasy that if they leave their sport, they don’t concuss anymore. It’s not always like that.”
So Snedaker launched PinkConcussions.com and consistently tried to update it with research relating to concussions in female athletes – except, there wasn’t much research being done.
She took to social media and connected with Dr. Jimmy Sanderson and Dr. Melinda Weathers, two researchers from Clemson University, and inquired about doing a study on the topic by posing questions to a general population of female athletes.
“The NFL is paying researchers to look at concussions (in football players), so that’s what researchers are doing,” she said. “There’s no money to be made in researching concussions in female athletes but we are hoping this will generate interest.”
Snedaker hopes to learn more about females’ experiences after being diagnosed with a concussion, reporting their concussions or playing through the pain. She also hopes to learn more about the emotional affects of the brain injury.
“There is new research being done with male football players and suicide relative to concussions, depression and alcohol,” she said. “We haven’t done the research to see how girls’ experience of concussion differs. I think girls are very social and struggle with the isolation. If they cannot text or go to the movies, school or their sport, it can be very depressing for many teenage girls recovering from concussions.”
In the future, Snedaker hopes to spearhead more research exploring many different aspects of concussions in female athletes. In the mean time, she will also continue to speak about the importance of education on the topic and implementing educational programs for coaches, parents and athletes.
“I would like concussion education to be like swimming lessons. We don’t call them drowning lessons…You reach a certain age and that’s just what you do. We don’t want you to drown. I think there should be an education piece as part of a curriculum in health where kids, parents and coaches learn about it, ” she said. “And it’s for every kid, not just athletes. Both active and non-active kids.”
Snedaker said she’s hoping the education can help people recognize concussions and learn how to manage them. She’d like to see more girls playing hockey, soccer, and other contact sports – with the right training on head injuries.
“I want more kids playing sports because when you have coaches and referees, you are more likely to get concussion care if you get hurt in a sporting event rather than in your back yard,” she said.
Snedaker also wants to help those who have felt isolated due to their concussions.
“People don’t know how to support people with head injuries, so I want to reach out and talk about how we can help these families as a community. That’s how I sell it to parents: someone’s kid is going to get a concussion; how can you help the person sitting next to you?”
The survey will be live through Oct. 31 and Snedaker hopes to reach at least 1,000 women. Women from any country can take the survey. Participants can also agree to stay in contact with the organization for future possible studies.
For more information on the survey and concussions in female athletes, click here.
