GYRUS EDUCATIONAL SERIES:

Traumatic Brain Injury and Menopause: Overlapping Neuropsychiatric Challenges

Introduction

Traumatic brain injury (TBI) can leave survivors with persistent fatigue, mood swings and impairment of memory. Around mid-life, many women experience a similar symptom cluster as ovarian hormones wane. When the two events collide, questions quickly arise: can the blow to the head bring menopause forward, and how do we decide which condition is responsible for the ongoing cognitive and emotional fallout? We review the latest understanding in the field.

Can TBI Trigger Menopause?

Up to one-fifth of adults with moderate–severe TBI develop chronic pituitary hormone defects, most commonly growth-hormone loss but also low luteinising hormone (LH) and follicle-stimulating hormone (FSH) [1]. If LH/FSH stay suppressed, ovarian function falters and periods stop, mimicking premature menopause.

Even mild concussion can transiently affect the hypothalamic–pituitary–gonadal (HPG) axis. In a sports cohort young women were four times more likely to record abnormal cycles in the four months after concussion than after an orthopaedic injury [2]. In practice, however, a definite post-TBI reduction in sex hormones (effectively induced menopause) is uncommon, and most mid-life women who stop menstruating after a head injury are entering the natural menopausal transition anyway. A simple rule helps: high FSH suggests normal biological menopause; low or inappropriately normal FSH suggests a brain (pituitary) injury.

Menopausal Neuropsychiatric Symptoms

During perimenopause up to 60 % of women complain of “brain fog” or sluggish memory [3] and the odds of a first major depressive episode double [4]. Severe hot flushes, poor sleep and low mood go hand-in-hand with weaker performance on tests of attention and executive function [5]. Oestrogen replacement eases vasomotor and sleep symptoms, yet its effect on cognition is modest and variable. Longitudinal cohort work (e.g., SWAN and the Melbourne Women’s Midlife Health Project) shows that during late perimenopause women demonstrate modest but statistically significant drops—about 0.1–0.2 SD—in processing speed, verbal memory and working-memory tests, which tend to rebound after the final menstrual period.

Why the Pictures Overlap

TBI and menopause share a symptom catalogue: fatigue, short-term memory lapses, insomnia, irritability and headaches. Declining oestrogen may also remove a layer of neuro-protection, making the injured brain more vulnerable to secondary injury.

In TRACK-TBI, women aged 35–49—roughly the perimenopausal window—reported more persistent post-concussion symptoms than both younger and older women [6]. A 2024 Model Systems study compared menopause experiences in women with and without TBI; classical hot-flush scores were identical, but TBI survivors had consistently higher fatigue, sleep and cognitive scores across all menopausal stages (large effect size, p < 0.001), with fatigue rated as ‘severe’ by roughly twice as many women with TBI [7]. In other words, the brain injury sets a higher baseline to which menopausal complaints are simply added. Find more information here.

Clinical Vignette

History. Woman, 55, bicycle-car collision (February 2021). Imaging: left temporal contusion with subarachnoid haemorrhage, parietal and skull-base fractures, small right subdural haematoma. Already taking HRT for peri-menopausal symptoms.

Laboratory. October 2021: FSH 37 IU/L (post-menopausal range); morning cortisol normal. No indication of ACTH or GH deficiency.

Progress. HRT dose increased 2023. She still reports debilitating fatigue and memory trouble. 2024 CT shows focal atrophy in left dorsolateral prefrontal and anterior temporal cortex—regions critical for working memory and word retrieval.

Interpretation. The elevated FSH despite exogenous oestrogen confirms natural ovarian failure, not pituitary hypogonadism. Normal cortisol further argues against significant pituitary damage. The expert considered her ongoing neuro-fatigue and cognitive slowing to be better attributed to structural brain injury, with menopause acting as a background stressor rather than the primary cause.

Practical Take-aways

• Check pituitary panels in moderate–severe female TBI, but high FSH usually signals natural menopause.
• Expect symptom stacking: TBI sets the baseline; menopausal transition may add insomnia, mood lability and extra fatigue.
• Treat both: optimise HRT (or non-hormonal options) and provide cognitive rehabilitation, fatigue pacing and psychological support.
• In medicolegal work, causation is always complex and will be in the expertise of neurology and/or neuroendocrine experts. TBI severity and the temporal relationship to the index injury of the complaints are important.

References

1. Gasco V, Cambria V, Bioletto F, Ghigo E, Grottoli S. Traumatic brain injury as frequent cause of hypopituitarism and growth hormone deficiency: epidemiology, diagnosis, and treatment. Front Endocrinol. 2021;12:634415.
2. Snook ML, Henry LC, Sanfilippo JS, Zeleznik AJ, Kontos AP. Association of concussion with abnormal menstrual patterns in adolescent and young women. JAMA Pediatr. 2017;171(9):879-886.
3. Conde DM, Verdade RC, Valadares ALR, et al. Menopause and cognitive impairment: a narrative review of current knowledge. World J Psychiatry. 2021;11(8):412-428.
4. Freeman EW. Depression in the menopause transition: risks in the changing hormone milieu as observed in the general population. Women’s Midlife Health. 2015;1:2.
5. Calle A, Blümel JE, Chedraui P, et al. Severe menopausal symptoms linked to cognitive impairment: an exploratory study. Menopause. 2024;31(11):959-965.
6. Levin HS, McCauley SR, Boake C, et al. Association of sex and age with mild traumatic brain injury–related symptoms: a TRACK-TBI study. JAMA Netw Open. 2021;4(4):e213046.

Rapport LJ, Kalpakjian CZ, Sander AM, et al. Menopause and traumatic brain injury: a NIDILRR collaborative Traumatic Brain Injury Model Systems study. Arch Phys Med Rehabil. 2024;105(12):2253-2261.