Episode 23: Hormonal Havoc: Imbalance after Injury with Dr. Tamara Wexler, Neuroendocrinologist
Surprise! Our brains control our bodies! While it’s common knowledge that our brains control thoughts, movements, and perception; did you ever think about it controlling your hormones? Hormonal imbalance may sound abstract but could be behind many persistent and chronic brain injury symptoms. Fatigue, brain fog, mood changes, not feeling like yourself, menstrual irregularities, changes in libido, and weight gain, among many others could be signs of hormone imbalance related to your brain injury. While hormone dysfunction may not be your answer; if it is, it is easily treatable and totally worth getting checked. Gain awareness and knowledge from our talk today with Dr. Tamara Wexler neuroendocrinologist.
Topics covered:
Neuroendocrinology
A specific set of hormones overseen by parts in your brain
Includes: thyroid hormones, sex hormones (testosterone, estrogen, prolactin- not necesarilly a sex hormone but does impact them), growth hormones, and stress hormones
Systems in the brain involved are the pituitary gland and hypothalamus--they affect end organs like the adrenal glands, ovaries, testes, the liver (not necessarily an end-organ, just what produces the IGF-1), and the thyroid
The end organ glands are in a feedback loop with the brain
The hormones carry the messages between the brain and the end organs
Awareness of hormone insufficiency post brain injury
There is under awareness of hormonal issues in brain injury
It is under diagnosed and under treated
You need testing to determine if there is pituitary deficiency. You can replace the deficient hormone and remove the symptoms associated with its insufficiency
Pituitary insufficiency is most researched in post concussion/TBI. There is some information about acquired brain injuries and hormonal deficiencies but the literature isn’t as broad
Common symptoms associated with hormonal insufficiency are vague and non-specific. Not all of these symptoms are caused by hormonal changes but without looking you do not know if they are. There is a higher rate of pituitary insufficiency after injury but it doesn’t mean every symptom is due to it. Treatment may not lead to a complete return to pre-injury self.
Fatigue
Mental fog
Not feeling like yourself
Changed menses and fertility
weight changes
exercise intolerance
Body composition changes
Slowed thinking
Poor tolerance of things you used to be able to handle
Mood changes
School performance
Behavior
Growth
If you don’t look for insufficiency, you can’t tell if it exists
How do you test?
Menstrual irregularities, absence of menses, or changes in libido that persist more than 3 months after a concussion can reflect a brain related hormonal change (pituitary damage)
If you are having regular periods without being on oral contraceptives you don’t need to be tested
Estradiol and FSH: if ovary insufficiency or menopause are causing the symptoms, the estrogen will be low and FSH will be high. The pituitary sends FSH to signal the ovaries. FSH is high if the ovaries are the problem
If the pituitary gland/brain is the problem the FSH will be normal or low. It is trying to mount a response but it can’t
You have to look at multiple hormones as they rely on each other to understand the cause of the problem (brain vs end organ)
Thyroid testing: TSH and Free T4 need to be measured together after brain injury to determine if there is a brain or organ problem
Testosterone deficiency in men post brain injury: needs two morning blood tests timed appropriately to catch insufficiencies
Hormone testing is done by a blood test timed appropriately with your cycles. If you are looking to see if something is low you need to test it when you expect it to be high.
Provocative testing is when you stimulate your body to mount a hormonal response and then test it
There are 4 systems monitored by the pituitary gland: stress hormone system, thyroid hormone system, sex hormone system, and the growth hormone system
There is a domino effect if any one of the systems monitored by the pituitary is affected
Thyroid hormone system. Symptoms indicating imbalances:
Metabolism
Mood
Thinking
Temperature sensation
Poorer school performance
Behavior
Growth
Menstrual changes
Weight gain
Sluggish
Skin and hair changes
All of these changes can also come from something else
Thyroid insufficiency because of pituitary damage is less common after brain injury than problems in the other systems
Sex hormone system (refer to the above notes for menstrual and reproductive irregularities)
Symptoms from testosterone insufficiency:
Changes to libido
Erectile dysfunction
Decrease in frequency of spontaneous erections
Changes in bone strength
Changes in muscle strength
Changes in red blood cells
In one study, researchers looked at people with brain injury and sexual side effects, irregular periods in women and sexual changes in men. There were higher rates of hypogonadism (decreased estrogen and testosterone due to the pituitary) but also higher rates of other pituitary issues. The symptoms may not be as specific to just one system as we thought.
Stress Hormone System
Cortisol supports our body and its blood pressure during times of stress.
Need to look for adrenal insufficiency acutely after injury (ACTH and cortisol system)--if you miss this issue it can be fatal. It is easily replaced
Among pituitary deficiencies, the most common are sex hormone or growth hormone defficiency
They all have to be tested because they have to be replaced in a specific order
First replace any stress hormone issues with cortisol, then replace thyroid, then sex hormone, then growth hormones. You can’t diagnose growth hormone insufficiencies without first treating sex hormone issues
Growth hormone system
It affects linear growth: in kids look for changes in growth patterns (a drop or change from their norm)
Symptoms of insufficiency:
Cognitive and mood effects
Cognitive slowing
Brain fog
Bone strength, more fragile bones
Body composition: harder time gaining muscle and will see more fat around the middle
Exercise intolerance and low energy
Fatigue
Cardiovascular health: too much hormone is bad and too little is bad
Blood glucose effects
When do you know when to screen for pituitary damage post brain injury?
If the symptoms are persistent and consistent beyond three months to a degree that is disturbing you, get hormonal screening
Symptoms can show up later (3, 6, 12 months and beyond) after TBI
You can’t tell if it is a pituitary problem without looking.
If symptoms are getting worse or new symptoms are showing up over time, it is worth getting rechecked
Finding help with hormones
Bring up with your provider that you have heard that there are increased rates of pituitary insufficiency after brain injury and ask how you can get that checked out
Some providers that may be able to help: a provider that knows you well (your PCP or NP), rehabilitation medicine physician or physiatrists, neurologists, neuroendocrinologists
Not brushing off symptoms
It is worth raising your questions even if you are unsure if it is related
Your “usual” may be ramped up. You may be in ‘fight or flight.’ It could be hormonal but it may not. It is always worth looking
It is worth going down different avenues until you find the reason for your symptom. Even if hormones isn’t the answer it is worth looking at and checking off the list
Acute hormone deficiencies do not predict later problems. There is a much higher rate of acute issues at time of injury. This doesn’t correlate with having or not having long term issues.
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