March 14, 2023 – Jacqueline Theis, a Virginia-based optometrist, was an avid soccer player as a young person. Over the course of her athletic profession, she suffered several concussions that caused severe headaches when she read.
“I was told I had migraines and would 'get over it' and that I 'complained too much' – comments that women unfortunately hear all too often,” she says.
“After six years, I went to an optometrist who noticed that my eyes were no longer aligned properly and thought it was because of the concussions,” she says. “She prescribed glasses and vision therapy, and my headaches went away.”
Theis was offended that her headaches were downplayed and her vision problems ignored. “I had 100% vision and no one thought I might have eye problems,” she says.
“Invisible” and neglected
Katherine Snedaker, a licensed social employee, agrees that concussions in women are sometimes trivialized or ignored. She founded and directs PINK Concussions, a nonprofit group that focuses on concussions in women.
She says that just about all concussion studies up to now have used male lab animals and men as test subjects, although concussions are common in women as well. And while many individuals consider concussions in women as sports injuries, PINK Concussions' mission is to shine a highlight on accidents, military injuries and domestic violence.
Over the past five years, “we have been able to raise awareness of brain injuries among female athletes and veterans, but the far greater number of recurrent brain injuries remain hidden and endured by the invisible women who suffer domestic violence in every social and economic group in society,” she says.
“Concussions affect men and women differently, so it's important for doctors, parents and others to know how concussions can manifest in women and men,” says Snedaker, who has suffered several concussions herself, two of them in automotive accidents.
Hormonal connection?
David Wang, MD, chief team physician at Quinnipiac University in HamdenCT, says that men and women who compete in the identical sports suffer concussions more incessantly than men. Their symptoms also are inclined to be more severe and infrequently last more.
There are several theories about why women are more vulnerable to concussions and infrequently have more severe symptoms or worse prognoses, says Wang, director of Comprehensive Sports Medicine in Connecticut.
Some Studies suggest that female hormones may play a task. For example, one study found that ladies had worse symptoms during certain phases of their menstrual cycle after a concussion. And women often notice changes of their menstrual patterns after a concussion.
But Wang believes the difficulty is more complicated. “Concussions shock the pituitary gland, which is located in the head,” he says. “The pituitary gland is responsible for regulating certain aspects of female hormones. Stress on the pituitary gland – whether due to the mechanical injury of the concussion or due to the emotional stress that can follow a concussion – can affect the menstrual cycle.”
This is supported by a new study. Researchers examined 133 female athletes with a history of traumatic brain injury for hypopituitarism (low pituitary hormone production). They found that the vast majority of women (66.2%) had abnormal results on pituitary blood tests. Certain hormones were too high, others too low. Younger athletes and people with more symptoms had more pituitary hormone abnormalities.
Neck, eyes and brain
Wang shared several other theories regarding women's susceptibility to concussions.
“Women generally have weaker necks. And because the neck is weaker, the head accelerates more during an impact because the impact is more violent and severe,” he explains. Although this “is not the whole story, it is a contributing factor.”
Theis, who's affiliated with the Concussion Care Center of Virginia, says there's a “close relationship between eye movements, the brain stem and the neck; and because women have weaker necks compared to men, their eye movements are more vulnerable to neck injuries.”
She says eye problems are also a little-known complication of whiplash. “The connection is in the brain stem and the neck.”
She says that the neck doesn't necessarily hurt, but eye pain or headaches may be “referred” pain from the neck.
Other theories suggest that ladies even have different levels of inflammation in comparison with men, Wang says. And concussions often affect an area of the brain called the corpus callosum, which connects the appropriate and left hemispheres. “This area is the most stressed during a concussive blow, and it is used more in women than in men because women tend to use both hemispheres more than men.”
Myths about women
All experts agree that there are widespread myths concerning the higher incidence of concussions in women and the more severe symptoms.
“Some people believe that women suffer more concussions because they complain about the symptoms more often and are therefore diagnosed more often,” Wang says. “I don't like to hear that because it suggests that women are 'complainers' and that female athletes are less competitive than male athletes, which is simply not true.”
Wang and his colleagues studied athletes and located that ladies were no less than as likely as men to hide symptoms to avoid being taken out of the sport. “In fact, some of the most ambitious people I've ever met are female athletes,” he says.
Snedaker recommends that ladies take their symptoms seriously. “I've spoken to countless women who said their concussion symptoms were dismissed by their doctors or told they were just anxious,” she says.
So for those who've suffered a blow to the top and your doctor doesn't do a radical concussion evaluation, “it's time to look for another doctor,” Snedaker advises.
Different symptoms, different treatments?
Most of the symptoms of a concussion – other than menstrual irregularities – don't differ between the sexes, based on Wang. “It's not like a heart attack, where women often actually have different symptoms than men – like nausea instead of chest or jaw pain,” he says.
Typical symptoms of a concussion in men and girls include headache, dizziness, blurred vision or other visual disturbances, restlessness or cognitive changes, hypersensitivity to light and noise, disorientation, nausea or vomiting, or lightheadedness.
Because concussions can affect menstrual cycles, Snedaker recommends that healthcare professionals ask women who've suffered a concussion about their periods. “If there's a problem, follow up with an endocrine test,” she recommends. And for those who've had a concussion and spot changes in your period, you'll want to discuss with your doctor about it.
Men and girls have similar “milestones” and “rules” for returning to sports or other activities, akin to work or school. “We expect them to be symptom-free and gradually return them to activity,” Wang explains.
However, because symptoms last more in women than in men, “women need to be supported during this time,” Snedaker stresses. All too often, “women are labeled as 'malingerers' or 'mentally ill' when they don't recover as quickly as men.”