Examining the Link Between Concussion and Abnormal Menstruation
A recently published study showed menstrual abnormalities in adolescent and young female patients who had sustained a sport-related concussion – which could have implications for future bone health. But with the study’s strict inclusion criteria, the findings may have limited applicability.
Elizabeth Barchi, MD, and Dennis Cardone, DO
Snook ML, Henry LC, Sanfilippo JS, Zeleznik AJ, Kontos AP. Association of concussion with abnormal menstrual patterns in adolescent and young women. JAMA Pediatrics. 2017 171 (9): 8790886. DOI: 10.1001/jamapediatrics.2017.1140
In a prospective cohort study, adolescent and young female patients diagnosed with a sport-related concussion had an increased risk of developing abnormal menstrual patterns compared with those diagnosed with a non-head sport-related orthopaedic injury.
The researchers enrolled patients between ages 12 and 21 who presented to a concussion or sports medicine clinic within 30 days of a closed head injury or non-head orthopaedic injury that occurred during a sport or recreational activity. Concussions were evaluated with a neurologic examination that included assessment of balance and cognitive, vestibular, and oculomotor function. For 120 days after injury, patients received weekly text messages with a link to complete a survey about their menstrual bleeding pattern in the previous week.
In total, 129 patients were enrolled in the study, 68 with a concussion and 61 with an orthopaedic injury. Three patients did not complete the 120 days of follow-up and 1 patient was excluded. The weekly response rate was 94.5% across all weeks.
The most common type of reported abnormality was prolonged intermenstrual interval. Patients in the concussion group were statistically younger than patients in the orthopaedic group. However, gynecologic age was not statistically different between groups. Body mass index, race/ethnicity, sport, and time from injury to enrollment also were not statistically different.
In the concussion group, 23.5% of patients had 2 or more irregular menstrual bleeding patterns, compared with 5% of patients in the orthopaedic group. There was no statistical difference between those who developed 2 or more abnormal menstrual patterns and those who did not in terms of prior concussion, number of prior concussions, or time to medical clearance. Patients with concussion were 5 times more likely to have short intermenstrual intervals (less than 21 days) compared with patients in the orthopaedic injury group.
The authors recognized that their study was limited in that subjective reporting of menstrual patterns does not confirm the quality of that menstrual cycle. Additionally, this study did not assess long-term menstrual status to determine effects of concussion on chronic end points, such as bone health.
A high incidence of functional disruption of the neuroendocrine hypothalamic-pituitary-ovarian (HPO) axis leading to menstrual irregularities has been demonstrated in adult women who sustained moderate to severe traumatic brain injury. Abnormal menstrual patterns, particularly oligomenorrhea and amenorrhea, are associated with hypoestrogenism and decreased bone mineral density.
This is the first prospective cohort study to characterize abnormal menstrual patterns after concussion in young women. The inclusion criteria were very specific – adolescent females who were at least 2 years post-menarche, did not have preexisting menstrual irregularities, and had not been previously diagnosed anxiety or depression. Because of these strict criteria, the study results do not apply to a large percentage of the menstruating population. Physical and psychological stressors have been known to affect menstrual patterns in adolescent females, and these effects may be compounded by concussion.
Continued research is required to further understand the effects of concussion on the HPO axis and the potential implications for menstrual patterns, estrogen production, and bone health. Monitoring of menstrual patterns after concussion can help identify patients who would benefit from referral and possible treatment of HPO axis disruption.
Elizabeth Barchi, MD, is a fellow at NYU Langone Health – Hospital for Joint Diseases, New York, New York. Dennis Cardone, DO, is an Associate Professor in the Department of Orthopaedic Surgery and an Associate Professor in the Department of Pediatrics at NYU Langone Health – Hospital for Joint Diseases, New York, New York.