Why birth control pills help a concussion + Why you should care

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.

The Questions

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)?

• Men always naturally have low progesterone.
• Girls do before they get their first period.
• Women do, in later life, after their periods have ended.

Who has a high level of progesterone?

• Women of child-bearing years who progesterone levels rise and fall depending on the week of their cycle. 

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?"

• Women taking birth control do not experience a drop as the pill provides constant high levels of synthetic progestins.

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 Answers

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...

• Could this study be the starting point for a future hormone screening test - or even for a doctor to ask a simple question about when was an injured woman's last period?
• Could this simple screen alert doctors which women are more at risk and need more aggressive interventions?
• Could women in these risk groups based on their cycles be treated with progesterone after TBI?

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.

Why the fuss over Wambach's concussion?

Here are the issues why there is a fuss over Soccer's Abby Wambach's recent head injury and the ref's decision to stop the AT from examining her after she collapsed in the game. 1. Asking a concussed player if he/she is ok to play is like asking a drunk if he/she is ok to to drive. 2. Women are different than men when it comes to head injuries. 3. Children role model their play on how professional athletes play.

Concussed players are impaired and cannot make a determination if they are ok to play. This is one of the main the reasons that ATCs and other medical staff are present at games.

On the second point, we know women concuss at a higher rate then men but we are only at the point of guessing why due to neck strength, hormones, and/or genetic factors. And in general, women in general take longer to recover from concussions.

From American Medical Society for Sports Medicine Position Statement: Concussion in Sport 2012, page 6:

"Recent data suggest that in sports with similar rules female athletes sustain more concussions than their male counterparts.

- In addition, female athletes experience or report a higher number and severity of symptoms as well as a longer duration of recovery than male athletes in several studies."

And I am convinced that it is not because women being more honest, sensitive or fearful to return to sports. There is a real issue here. I recently presented in Washington, DC, at the Institute of Medicine (IOM)/National Research Council (NRC) workshop on sports-related concussions in youth where almost every presentation brought up the issue of women and concussions and the need for more studies. The most alarming moment was when Tim Kelly, Head ATC of West Point spoke of how he sees a longer recovery time needed for his female cadets athletes than his male cadets. If there ever was a cohort of similar males to females as far as physical strength, personal determination and fortitude, I think West Point Cadets is it. Women are not just more honest, sensitive or fearful to return to sports. There is a real issue here.

So the bottom line is we have to educate parents, girls, coaches, trainers and doctors about head injuries and the risks. I spent my days working on this issue but there is no funding and only a few select media moments where we can get the message out.

On Super Bowl Sunday 2013, JIm Nantz provided one moment when he stated on a pre-game show with Roger Goodell that “women’s soccer players are 2 1/2 times more likely to suffer a concussion than college football player." What Nantz meant to say was to compare women’s soccer to "men soccer", not to football players. This “misquote” caused controversy as press, and soccer-football fans alike scrambled to google the correct statistics. It also was the inspiration for our website www.PinkConcussions.com all about the issues of female concussions.

And on the last point, children are watching and do model their style of play on adults. How an athlete plays to how they celebrate a victory after a goal are all absorbed in by young players. Wambach's decision to play on and ref and trainer's response was a golden teachable moment. The medical staff, coaching staff and the ref had a chance to stop play and check her out which would have been following their own protocol. This did not happen and thus Stefan's article and the media response has been a windfall to spread concussion education to more people, parents and players.

Sports Culture will always be more powerful than any warning from a doctor or lecture from an educator... We are hoping to change the current sports culture about playing thru head injuries and making refs. coaches and ATCs more aware of the need to check out players right after the hit and not just after the game.