Traumatic Brain Injury and Cases of Abnormal Menstrual Pattern To the Editor We read with interest the article1 on frequency of abnormal menstrual patterns in adolescents and young women after a sport-related concussion.1 Authors used self-reported menstrual bleeding patterns during the 120 days after injury as a proxy for hypothalamic-pituitary-ovarian axis function.1 This study follows an uncited position statement on concussion sequelae in both young and adult athletes,2 where words such as “hypopituitarism” or “menstrual disorders” are absent. Also uncited is a review on the hypothalamic-pituitary dysfunction resulting from mild to severe traumatic brain injury (TBI) in childhood and adolescence.3 This article3 cites 1 previous work of ours4 or some articles cited in our previous review.5 In the 19 cases reviewed (12 boys and 7 girls; age at injury, 0.1-16 years), the biochemically demonstrated leading pituitary deficiencies concerned somatototropin (85%) and gonadotropins (80%).3 Sport TBI (judo) was only involved in 1 of 19 cases (5%).3 Of 8 women with TBI-associated hypothalamic-pituitary dysfunction, the 3 with amenorrhea had TBI when aged 14 to 38 years.4 Of these, 1 diver had hit her head against the springboard. A similar incident occurred with an 18-year-old adolescent. At this age, another male patient had a mild TBI during motocross training.4 None of these sports applied to the population studied.1 Empty sella or diffuse pituitary hypodensities were observed at pituitary imaging in patients in our studies.4,5 Lack of pituitary imaging and hormone assays are obvious limitations of the study.1 As acknowledged in the Discussion, “concussions are known to be associated with emotional responses, including depression and anxiety, that may further exacerbate a psychological stress response.”1 Thus, menstrual irregularities associated with postconcussion acute hyperprolactinemia might have a merely dysfunctional rather than anatomopathological basis. However, stress and mood disorders were not evaluated, another limitation.1 Nevertheless, we l iked the strateg y of weekly testing, with a link to an online survey, and reasonable compensation.1 Indeed, this strategy permitted completing the study in approximately 98% of the enrolled adolescents. Considering that the aforementioned patients from our studies came to observation for reproductive issues many years after injury, we agree that “early identification of menstrual abnormalities and appropriate referral for further evaluation and treatment may improve potential health concerns in adulthood.”1 We hope that Snook et al1 will find a successful strategy to make both the study and control adolescents available for mediumto long-term follow-up with biochemical and imaging investigations. This would emphasize the predictive significance of their work.

中文翻译：

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外伤性脑损伤与月经不调病例

创伤性脑损伤和异常月经模式案例 致编辑 我们感兴趣地阅读了关于青少年和年轻女性在运动相关脑震荡后月经模式异常频率的文章 1。作者使用了自我报告的 120 天后月经出血模式损伤作为下丘脑 - 垂体 - 卵巢轴功能的代表。1 本研究遵循一项未引用的关于年轻和成年运动员脑震荡后遗症的立场声明，其中缺少“垂体功能减退”或“月经紊乱”等词。同样未被引用的还有一篇关于儿童和青春期轻度至重度创伤性脑损伤 (TBI) 导致的下丘脑-垂体功能障碍的综述。3 本文 3 引用了我们之前的 1 篇工作 4 或我们之前综述中引用的一些文章。 5 在 19 个案例中审查（12 个男孩和 7 个女孩；伤年龄，0.1-16 岁），生化显示的主要垂体缺乏与生长激素 (85%) 和促性腺激素 (80%) 有关。3 运动 TBI（柔道）仅涉及 19 例中的 1 例 (5%)。3 8 名患有 TBI 相关下丘脑-垂体功能障碍的女性，其中 3 名患有闭经的女性在 14 至 38 岁期间患有 TBI。4 其中，1 名潜水员的头部撞到了跳板。类似的事件发生在一名 18 岁的青少年身上。在这个年龄，另一名男性患者在越野摩托车训练期间出现轻度 TBI。4 这些运动均不适用于所研究的人群。1 在我们的研究中，在患者的垂体成像中观察到空蝶鞍或弥漫性垂体低密度。4,5 垂体缺乏成像和激素检测是该研究的明显局限性。 1 正如讨论中所承认的，“众所周知，脑震荡与情绪反应有关，包括抑郁和焦虑，这可能会进一步加剧心理压力反应。”1 因此，与脑震荡后急性高泌乳素血症相关的月经不规则可能仅具有功能障碍而不是解剖病理学基础。然而，没有评估压力和情绪障碍，这是另一个限制。1 然而，我们喜欢每周测试的策略，有一个在线调查的链接，以及合理的补偿。1 事实上，这个策略允许在大约 98已登记青少年的百分比。考虑到我们研究中的上述患者在受伤多年后才开始观察生殖问题，我们同意“及早发现月经异常并适当转诊以进行进一步评估和治疗可能会改善成年期潜在的健康问题。”1 我们希望 Snook 等人 1 将找到一种成功的策略，使研究和对照青少年都能在中长期内使用- 生化和成像研究的长期随访。这将强调他们工作的预测意义。