Hormone Therapy

Overview

Hormone dysfunction can result from concussions due to disruptions to the endocrine system. Generally, patients suffering from dysregulation of hormones experience general symptoms like changes in weight, muscle aches, excessive thirst, anemia, headaches, and dizziness. Some women might experience disruptions to their menstrual cycle, and some men might experience erectile dysfunction. Hormone replacement may be very beneficial to individuals suffering from hormone deficiency following a concussion.

About TBI and endocrine dysfunction, from the VA website:

“The work at the VA Puget Sound Health Care System has demonstrated that Veterans with repetitive mTBI have a risk of developing growth hormone deficiency. Having growth hormone deficiency can lead to increased body mass index (BMI), fatigue, and symptoms of depression. These symptoms can then lead to decreases in sleep hygiene, self-esteem, psychological health, cognition, and quality of life. The Puget Sound investigators are in the process of proposing a multisite clinical trial that will investigate the efficacy of growth hormone replacement in those with TBI and growth hormone deficiency.”

Looking for a more comprehensive list of symptoms? Check out the Hormone Health Network.

What is an endocrinologist? 

Endocrinologists are health care providers that specialize in hormones. Often patients find that they might need extra help in addition to their primary healthcare provider when seeking treatments for hormone dysfunction. In this case, seeking out a neuroendocrinologist or endocrinologist is a great additive for patients seeking intervention.

Why should you get tested for hormone levels?

The effects of hormones within your body are integral and widespread. Because of this, a hormone deficiency could result in widespread impacts on your overall health. Hormone therapy helps replace deficiencies that could arise following a concussion; previous research has shown that hormone dysfunction may arise following mild to severe TBIs. Additionally, hormone therapy has been observed to improve the long-term effects of brain injuries. Scientists at the University of Texas Medical Branch at Galveston have demonstrated growth hormone (GH) treatment as an effective method of reducing long-term effects in patients suffering from a brain injury. It was reported that patients treated with GH experienced “reduced fatigue, anxiety, depression and sleep disturbance”.

More often, however, patients get hormones replaced based on individual deficiencies. Neuroendocrinologist Dr. Tamara Wexler explains that  “Once a deficiency is diagnosed, the deficient hormone can be replaced. If someone has more than one deficiency, it is important to replace them in a specific order”. Although not all hormone deficiencies require urgent care, deficiencies in cortisol--the “stress hormone”--could be very dangerous and thus requires rapid care. Often, hormone therapy comes in the forms of pills, injections, patches, or gels--the specifics depend largely on the type of hormone being replaced

How can I seek out help?

If you’re ready to seek out help or guidance, Dr. Tamara Wexler recommends going first to “somebody who has been overseeing [your] care, whether that be a primary care physician or a neurologist or a physical medicine and rehabilitation doctor”. She also suggests meeting with a neuroendocrinologist.

Although your healthcare provider might initiate hormone therapy, Dr. Wexler suggests it may be helpful to raise the topic with your doctor. A simple phrase like "A higher risk of hormone deficiencies has been described after a concussion, and I'm interested in pursuing that" could be a possible way to open up the conversation about getting tested for hormone dysfunction.

Testing

Testing mainly occurs for two reasons: initial diagnosis and treatment monitoring. Testing usually will not be recommended until at least three months after the initial injury because symptoms will improve many cases during the initial three months. Hormonal dysfunction usually occurs as a long-term issue and testing should only occur once symptoms have stabilized after three months. 

Example of a blood draw used for hormone testing.

If no hormonal changes are found after the initial test, but symptoms persist or worsen, additional testing can be done the following year. It should be noted, however, that even if no dysfunction is detected within the preliminary test, other hormonal dysfunctions can develop later. If it is decided that a form of intervention is necessary, additional testing will be used to determine if treatment is working to monitor individual hormone levels.

Hormonal testing is usually done early in the morning via blood draw. Some tests may require a medication to be taken before the test which will show how the hormone responds in certain circumstances. 

Since all healthcare providers can order the tests needed to screen for hormone deficiencies, it can be quite accessible to ask for a screening. Below are just some of the hormones that could be evaluated:

  • Growth Hormones: GH (in dynamic testing), IGF-1

  • Sex Hormones: FSH, LH

  • Male Specific: Testosterone/Sperm

  • Female Specific: Estrogen 

  • Stress Hormones: ACTH, Cortisol

  • Thyroid Hormones: TSH, free T4 (metabolic rate hormone)

The ranges and specifics of each hormone will vary with the time of day, the age, and the sex of the individual in question. It is very important for many of these tests to be administered early in the morning, with the appropriate tests ordered, and for the test to be read by a doctor familiar with reading hormone tests.

For Male Veterans

"A study in military veterans finds that explosive blast-related concussions frequently result in hormone changes leading to problems such as sleep disturbances, fatigue, depression and poor quality of life. The research, presented at the Endocrine Society's 98th annual meeting in Boston in April 2016, evaluated hormone levels in 41 male veterans who had been deployed to Iraq or Afghanistan.

'Some of these hormone deficiencies, which mimic some symptoms of post-traumatic stress disorder, may be treated successfully with hormone replacement if correctly diagnosed,' according to the study's leader, Charles Wilkinson, Ph.D., a researcher with the Veterans Affairs (VA) Puget Sound Health Care System, Seattle." See the article in ScienceDaily. 

Neuroendocrine Dysfunction in a Young Athlete With Concussion: A Case Report

11/1/2017 David M. Langelier; Gregory A. Kline; Chantel T. Debert

"An 18-year-old female ringette and basketball player presented to our sports concussion clinic 27 months after a concussion with fatigue, headache, exercise intolerance, polyuria, nocturia, and difficulties concentrating. Her history was remarkable for 4 previous concussions. Her neurologic examination was normal. Her neuroendocrine screen including thyroid function, morning cortisol, glucose, and insulin-like growth factor-1 (screening test for growth hormone deficiency) was normal. Further testing for growth hormone deficiency with an insulin hypoglycemia test revealed severe growth hormone deficiency. Urine and serum electrolytes were borderline normal, suggesting partial diabetes insipidus. Treatments with growth hormone replacement lead to complete recovery. This case highlights the importance of maintaining a high index of suspicion for neuroendocrine abnormalities in athletes with persistent symptoms after a sports concussion. Symptoms can be nonspecific and go undiagnosed for years, but appropriate recognition and treatment can restore function."

The neuroendocrine system 101

Basic Components


What are hormones?

Hormones are "chemical messenger" substances that stimulate bodily processes, such as metabolism, reproduction, energy regulation, and growth. By controlling these processes, hormones ultimately have a significant amount of influence over the body's organs. 

What are glands?

Glands are biological structures that create and release hormones, some of which are in the brain, but most of them are located in the rest of the body. 

What's the endocrine system?

The endocrine system is a group of glands that "produce and secrete" hormones for various bodily functions. These glands include the hypothalamus, pituitary gland, thyroid gland, parathyroid gland, pancreas, adrenal glands, pineal gland, ovaries, and testes. The bodily functions the endocrine system controls include respiration, metabolism, reproduction, sensory perception, movement, sexual development, and growth.


What's the hypothalamus?

The hypothalamus controls body temperature, hunger, mood, thirst, sleep, sex drive, and most importantly, "the release of hormones from other glands". It's located deep inside the brain, between the pituitary gland and thalamus.


What's the pituitary gland?

The pituitary gland is known as the "master control gland" in the body, as the hormones it produces induce the other endocrine glands to produce their own hormones. It's located at the brain's base or lowest part. According to Dr. Tamara Wexler, pituitary-related hormones are most-often deficient at higher rates after concussion.


What's the thyroid gland?

The thyroid gland produces hormones that help regulate the body's process of calorie burning, and it also helps control heart rate. It's located at the bottom of the neck, below the Adam's apple. 


What's the parathyroid gland?

The primary function of the parathyroid gland is to regulate how much calcium is in the body, which is a mineral that "helps form and maintain healthy teeth and bones". The gland is located in the neck. 


What's the pancreas?

The pancreas creates a hormone called insulin in order to manage blood sugar levels in the body. It's located "behind the stomach in the upper left abdomen" (Columbia University). 


What are the adrenal glands?

The adrenal glands make hormones that regulate sex drive and cortisol, which is the body's stress hormone. They're located on top of the body's kidneys. 


What's the pineal gland?

The pineal gland produces melatonin, which is a hormone that influences a person's sleep. It's located in the middle of the brain, where its two halves join.


What are the ovaries?

The ovaries are glands found only in women. They secrete estrogen, testosterone, and progesterone, which are female sex hormones. The ovaries are located in the lower abdomen.


What are the testes?

The testes are glands found only in men. They make testosterone—which is primarily the male sex hormone—and sperm. The testes are located in the male scrotum. 

The neuroendocrine system and its axes


What's the neuroendocrine system?

The neuroendocrine system is the system in which the hypothalamus and pituitary preserve homeostasis (i.e. equilibrium) in the body. The term 'endocrine system' merely refers to the group of glands in the body and the hormones they produce and secrete, while the term 'neuroendocrine system' emphasizes the relationship between the hypothalamus and the body's other glands. It also refers to the relationship between the pituitary gland and the other glands because―and as mentioned before―the pituitary gland is the master gland of the body. Consequently, it is the hypothalamus and pituitary gland that work together to power the neuroendocrine system. 


How is the neuroendocrine system organized?

The neuroendocrine system has five subsystems that help to regulate its processes. Together, these five subsystems are called the hypothalamic-pituitary axes, as the systems are ultimately under the control of the hypothalamus and pituitary gland. The axes include the: 

  • hypothalamic-pituitary-thyroid (HPT) axis

  • hypothalamic-pituitary-somatotropic (HPS) axis

  • hypothalamic-pituitary-adrenal (HPA) axis

  • hypothalamic-pituitary-gonadal (HPG) axis

These subsystems are called axes because each one is centered around a process known as a hormone cascade. A hormone cascade is when the production of one hormone induces the production of another hormone, creating a cascade of events. Despite their anatomic complexity, each axis's processes can simply be understood as a particular hormone cascade.

This video explains the different hormonal axes of the neuroendocrine system.