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 80% and the condition can affect not just sex hormone levels, but also cortisol, thyroid hormones and/or growth hormones as well.3, 4

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.5  However, even if a woman’s hormone levels haven’t been affected by the brain injury itself, 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 after a brain injury.

The first indication of low hormone levels is usually the absence of a regular menstrual cycle, assuming there isn’t another explanation for this such as pregnancy, surgical removal of the uterus, or the use of contraceptives known to affect the menstrual cycle. After a traumatic brain injury, the change to hormone levels can be quite sudden, whereas naturally occurring hormonal changes (due to peri-menopause/menopause) tends to be more gradual and can happen over several years.

Is it 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, 6  Low female hormone levels can also cause a whole host of symptoms, from depression, poor memory and poor sleep, to increased anxiety, hot flushes and muscle pain.1, 7  If clients are presenting with these symptoms, it’s worth exploring whether low hormone levels are a contributing factor and if so, whether replacement hormones would help to reduce or eliminate some of these symptoms.

If you think low hormone levels may be an issue for one of your female clients, here’s what to do:

Step 1

Ask female clients whether they are having regular menstrual periods or not.  If not, 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) and/or extreme dieting, stress or extreme levels of physical activity.8  Keep in mind that a woman may have had the Mirena coil inserted pre-injury and may not always remember this post-injury.

Step 2

If no periods (or scant periods) and no other explanation for this, have clients score symptoms which could be due to low hormone levels, using the free Balance app or click HERE for a pdf of the full questionnaire.

Step 3

Flag the issue of no periods to the client’s GP, neurologist and rehab consultant and ask for the client to be referred to an endocrinologist for further investigation (if required).

Step 4

If menopause/low hormone levels are diagnosed by one of the professionals above, make sure they also discuss treatment options (e.g. using replacement oestrogen, progesterone, and/or testosterone).  If the low hormone levels are related to the menopause and the client prefers private input, clients can either be referred, or self-refer, to the medical team at Newson Health (although in the case of a brain injury, the team here 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 due to obesity, obstructive sleep apnoea, malnutrition, alcoholism, cirrhosis and/or the use of corticosteroids or opiates.9  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.9  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.