Hormonal and Neurological Complexity in Traumatic Brain Injury Recovery for Women

Christine Greiss, DO

(Credit: Hackensack Meridian Health)

As clinicians’ understanding of traumatic brain injury (TBI) continues to evolve, there’s some growing attention is being paid to how sex-specific factors could influence patient recovery outcomes. Patients who are women, in particular, may experience distinct physiological and hormonal changes that can impact both the severity of injury and the course of rehabilitation. A recent review published review in Physical Medicine and Rehabilitation Clinics of North America shed more light on these complexities, suggesting the need for tailored approaches to care that address the unique challenges faced by women across different stages of life.^1,2

Conducted by lead author Christine Greiss, DO, medical director for the Center for Brain injuries and for the Concussion Program at JFK Johnson Rehabilitation Institute of Hackensack Meridian Health, and colleagues, the review highlighted having a comprehensive care that incorporates hormonal assessment, mental health support, and individualized care planning for women with TBI. The authors also called for an increase in awareness among clinicians about how hormonal fluctuations and life stage transitions can alter symptom presentation and recovery patterns. By integrating gender-specific considerations into clinical practice, providers can potentially better support functional recovery and long-term quality of life for their women patients with TBI.

Following the publication, Greiss sat down with NeurologyLive^® to discuss the multifaceted challenges of managing TBI in women. In the conversation, she emphasized the interplay between hormonal fluctuations and neurological recovery. Greiss, who also serves as a clinical associate professor at Hackensack School of Medicine as well as Robert Wood Johnson Medical School, explained how stages such as menstruation, pregnancy, and menopause can influence cognitive and emotional outcomes following brain injury. Overall, she underscored the importance of individualized rehabilitation programs that include early screening, hormonal monitoring, and lifestyle modifications tailored to postmenopausal patients.

NeurologyLive: How can clinicians better account for hormone fluctuations when managing TBI in patients who are women?

Christine Greiss, DO: We definitely should be able to dissect it a little bit further. Sometimes, when we're looking at brain injury, we have to ask ourselves: What level of brain injury does the woman patient in front of us have? Is it a mild TBI? Are they suffering from concussive symptoms? Is it a moderate TB, or is it a severe TBI? That will help guide our progress. It's always important to first look at what level of injury they're at and take it from there.

How is TBI tied to other neurological disorders such as stroke or even neurodegenerative diseases like Alzheimer disease?

TBI, at whatever level, usually will have some damage to the outlining of the nerve itself, and it will affect the electrical signals that are conducted by that nerve. It will also affect the chemical processes. So, because the brain cell isn't functioning properly—similar to other neurodegenerative diseases—but in this case, it's a result of brain trauma, what ends up happening is the cells themselves don't communicate properly. What we end up seeing, to whatever degree—if it's a mild degree—you may see that the patient's cognitive function or their endurance, or the duration for which they can maintain attention to a task, is affected.

In the moderate brain injury population, it may get a little bit worse, where it's affecting their word-finding, their vision, their balance. It may be affecting their mood and their sleep patterns. It’ll affect their overall awareness of their environment. And in the severe population— I mean, patients are more debilitated. For them, it's really affecting their ability to move, to speak, to walk, to even process the environment around them, to be aware of what time of day it is and who they are interacting with. In some cases, the patients can be almost in this vegetative state or a minimally conscious state.

What role do psychological and social factors play in the long-term recovery of women after TBI?

It's interesting, because when we look at hormonal fluctuations in women in general, for instance, if this is a woman who is still menstruating— we know very well that based on where they are in their cycle, they may exhibit certain changes in their mood. That is a result of hormones like progesterone and estrogen. That fluctuation in hormones can cause chemical shifts, can cause fluid shifts in the brain, and that translates clinically into the woman being a little bit more fatigued than usual. Hence, she'll be a little bit more irritable. She may be a little bit more temperamental. Her tolerance to basic things and her reaction to her environment is different than if she had that baseline energy reserve, right? And that's in the healthy individual.

Now imagine when the brain is already affected—because the chemical signals are already slower than normal, because the electrical transmission across the nerve cells, from nerve to nerve, is also slower. Now imagine coupling on top of that—when a woman, for instance, is going through premenstrual syndrome—you may see significant changes not just in mood and behavior patterns, but also in cognitive patterns. Some women, after a brain injury, for instance, when they become pregnant—that term “pregnancy brain?”—it may be exponentiated. They may have much worsening cognitive deficits, to the point where it can put them in danger. They may forget where they live. They may, for instance, leave the stove on or forget to lock their home. That becomes a safety issue. So those are degrees of how severe this can become.

Keep in mind also the recovery of the brain is determined a lot by its chemical environment. If the person, for instance, is a little bit perimenopausal at baseline and then suffers even a mild brain injury, that perimenopausal state is already a state of inflammation for the woman patient. Now imagine if they have an underlying brain injury— their symptoms will flare. They may experience symptoms of overall swelling, overall fatigue; their hot flashes may be worse. Their ability to maintain attention or regulate emotion is a lot worse than it was prior. Keep in mind, this could be in a person who, premorbidly—before the brain injury—didn't even have any underlying psychological disorder. We have to take those things into consideration.

In what ways should rehabilitation programs be adapted to address the unique risks and needs of postmenopausal women with TBI?

It's interesting to note—first off, in rehabilitation, one must be able to identify it. They have to have proper screening tools to identify patients who had brain injury and are postmenopausal. Then, based off that, determine where in their postmenopausal state they are. Have they already been stabilized? Are they 10 years postmenopausal, or is this a patient who's just one year postmenopausal? They must identify that.

The screening process initially is very important, because if a diagnosis isn't known or thought of, it’s a diagnosis not made. It's important for clinicians, all providers, to be aware and identify those patients—screening them early on. Because once we're aware of that, we can treat them better and offer them that unique care. Let's say we've identified those patients: the next step is usually we encourage them to follow up closely with their OB/GYN or their providers, simply because the gynecologist can really be on the lookout—trending these hormonal fluctuations and offering the proper treatment even more so than usual. And more readily, simply because they're the ones that are going to be more at risk. After the concomitant brain injury, they’re going to be more at risk for symptoms.

It's also important to treat neuropathic pain early in the women population, because they have more of a tendency to develop post traumatic headaches, post traumatic migraines. We may think that their migraine are, for instance, specifically because of the post-menopausal state, when in fact it could be a combination of the post-menopausal state as well as the TBI.

We also have to examine those patients properly, right? That examination can entail looking at their neck circumference, their neck mass, looking at their overall health. Encouraging healthy lifestyle changes early on. Less processed foods, not only because we're recommending that after brain injury, but particularly in the postmenopausal population because they are going to be more sensitive to specific diets that may be toxic. And so, the programs offering nutritional education, screening early on, and really raising awareness for all the providers in the program really helps these patients.

Transcript edited for clarity.

REFERENCES
1. Greiss C, Berkowitz A, Chan JP, Ferber A. Rehabilitation Considerations in Women with Traumatic Brain Injury. Phys Med Rehabil Clin N Am. 2025;36(2):239-251. doi:10.1016/j.pmr.2024.11.002
2. Hackensack Meridian JFK Johnson Brain Injury Expert Outlines Distinct Challenges Faced by Women with Concussion, Other Traumatic Brain Injuries. News Release. Published April 24, 2025. Accessed May 1, 2025. https://www.hackensackmeridianhealth.org/en/news/2025/04/24/hmh--jfk-johnson-brain-injury-expert-outlines-distinct-challenges-faced-by-women-with-concussion