Memory issues, fatigue, difficulty concentrating, difficulty sleeping…these are common complaints after a brain injury which are often attributed to the brain injury itself.  However, these identical symptoms can also be associated with reduced oestrogen, progesterone and/or testosterone levels in women, from either naturally-occurring menopause, or changes to the hypothalamic–pituitary–gonadal axis following a traumatic brain injury.1, 2  The prevalence of hypothalamic-pituitary dysfunction following a moderate-to-severe traumatic brain injury is between 25% and 70% (combined data from both genders). 3, 4  Sex hormone levels, cortisol, thyroid function and/or growth hormones, can all be negatively affected by this condition.3, 4, 5

The first indication of low female hormone levels is usually the absence of a regular menstrual cycle.  This of course assumes that there isn’t another explanation, such as pregnancy, surgical removal of the uterus, or the use of contraceptives known to affect the menstrual cycle. After a brain injury, 46% of pre-menopausal women become amenorrhoeic (when they stop having periods) and this can last for up to 5 years post-injury.6  Even if the brain injury hasn’t affected a woman’s hormone levels, each woman will also inevitably go through the menopause at some point in her life (often between the ages of 45-55 years).  This means everyone on the multi-disciplinary team needs to be aware of how changing hormone levels can affect a woman’s symptoms, and this needs to be reassessed at various times throughout her rehabilitation journey.

Is this a problem and what can you do?

Low female hormone levels (regardless of the reason) can negatively impact cognitive function, reduce bone mineral density and increase the risk of dementia, diabetes and cardiovascular disease.1, 7  Low female hormone levels can also cause a whole host of other symptoms, from depression, poor memory and poor sleep, to increased anxiety, hot flushes and muscle pain.1, 8  If clients are presenting with these symptoms, it’s worth exploring whether low female hormone levels are a contributing factor and if so, whether replacement hormones would help to reduce or eliminate some of these symptoms.

Here’s how to screen for, and act on, potential low female hormone levels:

Step 1

Ask female clients under ~60 years old whether they are having a regular menstrual cycle or not (and what was “normal” for them pre-injury).  If they aren’t having a regular menstrual cycle, investigate whether any of the following may explain the absence of their menstrual cycle: pregnancy, surgical removal of the uterus, using a form of contraception known to affect the menstrual cycle (e.g. Mirena coil), pre-injury menopause or extreme dieting, stress or extreme levels of physical activity.9  Keep in mind that a woman may have had the Mirena coil inserted pre-injury and may not always remember this post-injury.  It’s also worth considering that hormonal changes after a brain injury tend to be quite sudden, whereas naturally occurring hormonal changes (due to peri-menopause/menopause) tend to be more gradual and can happen over several years.

Step 2

If a women reports no menstrual cycle (or just spotting) for several months and there is no other explanation for this, then have the client score her symptoms using the free Balance app or click HERE for a pdf of the full questionnaire.

Step 3

Make sure the client’s GP, neurologist and rehab consultant are aware that the client is not having a regular menstrual cycle. Be sure to share the results from the menopause symptom questionnaire and then ask for the client to be referred to an endocrinologist for further investigation (if required).

Step 4

If menopause/low female hormone levels are diagnosed by one of the professionals above, then make sure that treatment options are also discussed with the client (e.g. the benefits and risks of using replacement oestrogen, progesterone, and/or testosterone).  If the GP is not familiar with all of the treatment options available, clients can be referred (or self-refer) to either an NHS or private endocrinologist or the private medical team at Newson Health.  In the case of a brain injury, the team at Newson Health want the correct investigations completed by an endocrinologist first.

What about hormone changes in men?

Dietitians can help identify clients who may be experiencing low hormone levels.  This article focused specifically on female hormones, as dietitians will often ask about a woman’s menstrual cycle during an assessment.  This is because female hormone levels can have a significant impact on nutrition and dietetic-related issues such as iron requirements, risk of iron deficiency, fertility, body composition and metabolic rate. However, it is also worth being aware that after a brain injury, up to 66% of men could have low testosterone levels, also due to changes to the hypothalamic–pituitary–gonadal axis.3  Low testosterone can also be a consequence of obesity, obstructive sleep apnoea, malnutrition, alcoholism, cirrhosis and/or the use of corticosteroids or opiates.10  Symptoms of low testosterone are slightly different to the above, and include decreased libido, erectile dysfunction, decreased bone density, decreased lean body mass, increased body fat, fatigue, weakness, increased anxiety, profuse sweating, and anaemia.10  These symptoms don’t always come up as part of a routine dietetic assessment and will likely be highlighted more during a discussion around sexual health that the case manager, GP or rehab consultant has with the client.

As always, the factors affecting recovery from a traumatic brain injury are extensive and varied.  However, the impact of low sex hormone levels on the rehabilitation process, particularly in women, is a fairly new area of research where we still have much to learn.

To refer a client for a comprehensive dietetic assessment (which includes a review of medical history and blood test results), please contact the team at Specialist Nutrition Rehab at info@specialistnutritionrehab.co.uk or 0121 384 7087.