When studies are released, there are often calls for additional research as well as recommendations. In my menstrual cycle survey report, I added quite a few recommendations. Some can be implemented immediately. Others address considerations for planning research. It’s based on what I’ve learned, what responses were to the survey, and more. Take a look at the recommendations included here. You’ll see that for many items, there’s no need to wait to get to work on this issue. There’s also a link to the full survey report at the end of the post.

Immediate Steps

These are some options that can be initiated and used immediately.

• At physician appointments, ask “have there been changes to your period after your concussion” in addition to “when was your last period” during patient intake. Ask about their period duration: has that lengthened or shortened? Don’t just ask for the start date of your last period. For those who are postmenopausal, ask if they’ve experienced issues with spotting or bleeding.

• Take menstrual cycle issues seriously. I’ve heard anecdotally that doctors do not consider concerns regarding menstrual cycles after concussion to be important. Also, a 2002 study found that over half of women with menstrual cycle issues in the study had to ask the same physician three separate times for testing, or had to visit three different physicians before their amenorrhea ovarian issues were diagnosed. [1]

• Have patients record their menstrual cycle over the course of their recovery. See Menstrual Cycles After Concussion (MCAC) form. [2]

• Screen for neuroendocrine disorder (NED) if concussion symptoms persist after three months. The Female Athlete Triad screens for endocrine issues at the start. [3]

• Expand concussion treatment teams to include endocrinologists and gynecologists.

• Screen for the Female Athlete Triad as well. If found to be an issue, review the RTP guideline for the triad and combine with RTP guidelines for concussion.

• Consult with Female Athlete Triad experts, as they have many years of data regarding menstrual cycles and physical activity.

• In preseason baseline tests or physician physical examination approval for sports participation, include information about an athlete’s menstrual cycle. Determine what phase her cycle is in at the time of testing, if it’s regular, and if there are any issues. Use the Female Concussion Baseline Record (FCBR). [4] After a concussion, compare the state of an athlete’s cycle with the baseline. If there is a change, incorporate the Female Athlete Triad RTP algorithm if there are issues with menstrual cycles. Continue to monitor and address cycle issues in the ensuing months.

• Consider reviewing progesterone levels to determine if a person is experiencing anovulatory cycles, not just go by the date of last menstrual cycle. You can have what seems to be a period but may actually be experiencing anovulatory cycles. Ovulation results in the production of progesterone.

Education

Because this topic isn’t discussed much, I think that education would be helpful.

• Develop educational materials for patients and parents regarding possible effects of menstrual cycles after a concussion. I’ve heard from individuals and parents that they often wonder if they or their daughters are the only ones with such issues.

• Share information with physicians treating females, as I’ve also heard that some doctors are dismissive of inquiries and insist that there is no connection between concussion and menstrual cycle issues that begin after the concussion. I’ve also heard that physicians are prescribing birth control pills to address menstrual issues after a concussion, not testing for endocrine issues, and that they don’t know what to do.

Studies

Based on my survey and what I found for others during my research, I have some recommendations for any future surveys or studies. To fully understand some of these recommendations, it’s best to also review the report in its entirety. A link is at the end of this post.

• Initiate a formal study to determine the types of menstrual cycle issues that females of all ages and life phases are experiencing following concussion. Ensure that it includes all mechanisms of injury such as motor vehicle accidents, falls, assault, and blast injuries in addition to sports.

• In future surveys and studies, specify vertigo as a symptom or item. Do not just use dizziness and balance.

• Ask for the current age and age at which the last concussion was sustained. A person might have had multiple concussions over an extended time period (years or decades, for instance).

• Ask for the mechanism of injury for each. Some respondents had multiple concussions, but from different sources.

• Cover a time span of at least three consecutive months. The De Souza et al., study found issues by looking at three months. The University at Buffalo BioCycle study included two months and found anovulatory and ovulatory issues. Researchers stated that it’s “one of a few” studies looking at more than one cycle. [5] Also, three months (90 days) is often a timeframe mentioned in guidelines and references. During perimenopause, one can also experience three months without a period.

• Study sedentary vs. physically active females as well as ovulatory status. Would that make a difference regarding concussions from motor vehicle accidents vs. sports-related concussion? Also, review team sports vs. recreational vs. sedentary females. Focus as well on all life phase age groups.

Download Full Survey Report

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[1] Alzubaidi NH, Chapin HL, Vanderhoof VH, Calis KA, Nelson LM “Meeting the needs of young women with secondary amenorrhea and spontaneous premature ovarian failure” Obstetrics & Gynecology 2002 May;99(5 Pt 1):720-5

[2] Norris J, “Menstrual Cycle After Concussion (MCAC)” herconcussion.com

[3] De Souza, MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, Giggs JC, Olmsted M, Goolsby M, Matheson G “2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad” British Journal of Sports Medicine 2014;48:289

[4] Norris J, “Female Concussion Baseline Record (FCBR)” herconcussion.com

[5] Hambridge HL, Mumford SL, Mattison DR, Ye A, Pollack AZ, Bloom MS, Mendola P, Lynch KL, Wactawski-Wende J, Schisterman EF “The influence of sporadic anovulation on hormone levels in ovulatory cycles” Human Reproduction 2013 Jun;28(6):1687-94.