Endocrine Responses to Sport-Related Brain Injury in Female Athletes: A Narrative Review and a Call for Action
Abstract
:1. Introduction
2. The Need for Sex-Specific Brain Injury Research
3. Sex-Specific Differences in SRBI
4. Hypopituitarism
5. Progesterone
6. Estrogen
7. SRBI and the Menstrual Cycle
8. Future Directions: A Call to Action
- Repetitive head trauma, sometimes referred to as sub-concussive trauma, needs to be examined in female athletes in both the short and long term. Repetitive head trauma (or sub-concussive head trauma) does not result in diagnosable symptoms (i.e., dizziness, imbalance), making it extremely difficult to detect and diagnose. Researchers believe that longitudinal, repetitive head trauma can have serious, detrimental effects on physical and cognitive health [67,68,69,70]. Stern and colleagues at Boston University are extensively studying repetitive head trauma (sub-concussive trauma) in former male National Football League (NFL) players and have determined that repetitive head trauma from sport participation is a risk factor for later life neurocognitive and neuropsychiatric disease [67,68,69,70]. In the United States and around the world, female athletes are participating in sports where repetitive head trauma is a part of the sporting environment. Currently, in the United States, it is estimated that there are around 4000 female tackle football players, participating in two different leagues, where one league has a 10+ year participation history. The female tackle football players play by a mix of NFL and National Collegiate Athletic Association (NCAA) rules. Often, we are asked by female football players, “If I continue to play, will have the same issues as the former NFL players?”, to which we answer, “We do not know. Yet. We do not yet know if we will see the same prevalence and severity of head injuries in female football players as have previously been seen in the NFL.”
- Some research [11,12] suggests that there are immediate endocrine-based responses when a female athlete experiences a SRBI. In this review, we identified this concept as NED. Given the vast responsibilities of the pituitary gland and hypothalamus in the production and regulation of female sex hormones, it is critical that future research examines the acute changes in female sex hormones in response to SRBI. While this review has focused on estrogen and progesterone, it is critical to point out that there are several other important HPG axis hormones that are vital for the maintenance of proper menstrual cycle function and reproductive health (i.e., GnRH, LH, FSH) and little to no research exists on these other hormones. Thus, the menstrual cycle should be considered a vital sign for females [71] and abrupt changes in menstrual cycle function should never be ignored in female athletes.
- The ability to identify novel biomarkers that could be used to detect and/or diagnose pituitary hormone deficiencies that occur in the acute phase following SRBI requires studies to elucidate the nuanced changes that occur in both structure and function of various brain regions and the hormonal alterations that result from these changes. These novel biomarkers may also help to determine the time course of hormonal deficiencies that develop as the brain transitions from the acute to the chronic phase of SRBI. Ultimately, the culmination of these efforts would inform better rehabilitation and recovery interventions for female athletes.
- Longitudinal research is critical for understanding the chronic outcomes related to SRBI in female athletes. What we know about chronic outcomes for SRBI is based solely on the experiences of male athletes, specifically former NFL players and boxers, which is problematic given the sex-based differences outlined in this article. Therefore, it is critical that future research efforts not only track head injury exposure, but also the long-term physiological and psychological outcomes of such head injuries, which are likely to impact quality of life in these female athletes.
- Even though it is “messy,” the menstrual cycle must be accounted for in biologically based female athlete research. Research has highlighted that a SRBI disrupts the menstrual cycle and can lead to irregular menstrual cycles. Importantly, irregular menstruation can lead to an increased risk for chronic disease and premature mortality among females. Although the first steps forward in this relatively new area of research requires assessment of clinically overt impacts on menstrual cycle function, it is critical to point out that many disruptions in ‘normative’ menstrual cycle function are not clinically observable. For instance, normative menstrual cycles (i.e., occurring every 26–32 days), are not necessarily indicative of ovulatory cycles. Equally important is the notion that luteal phase defects can result in reproductive issues even when ovulatory cycles occur [72]. Nuanced changes in sex-steroid profiles over time may not produce overt menstrual cycle disruptions and thus, seemingly normal variations may obfuscate underlying reproductive issues.
- Given the acute, immediate hormonal response that occurs when a female athlete experiences a brain injury, future research should investigate how the hormonal response to brain injury may cause, contribute to, mask, or exacerbate other female-related performance disorders (i.e., the Female Athlete Triad, REDS).
9. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- National Federation of State High School Associations High School Athletics Participation Survey 2018–19. Available online: https://www.nfhs.org/media/1020412/2018-19_participation_survey.pdf (accessed on 25 March 2021).
- National College Athletic Association Sports Sponsorship and Particpation Rates Report 2018. Available online: https://ncaaorg.s3.amazonaws.com/research/sportpart/Oct2018RES_201718SportsSponsorshipParticipationRatesReport.pdf (accessed on 25 March 2021).
- Gessel, L.M.; Fields, S.K.; Collins, C.L.; Dick, R.W.; Comstock, R.D. Concussions Among United States High School and Collegiate Athletes. J. Athl. Train. 2007, 42, 495–503. [Google Scholar]
- Zuckerman, S.L.; Kerr, Z.Y.; Yengo-Kahn, A.; Wasserman, E.; Covassin, T.; Solomon, G.S. Epidemiology of Sports-Related Concussion in NCAA Athletes From 2009–2010 to 2013–2014: Incidence, Recurrence, and Mechanisms. Am. J. Sports Med. 2015, 43, 2654–2662. [Google Scholar] [CrossRef] [PubMed]
- Covassin, T.; Swanik, C.B.; Sachs, M.L. Sex Differences and the Incidence of Concussions Among Collegiate Athletes. J. Athl. Train. 2003, 38, 238–244. [Google Scholar]
- Dick, R.W. Is There a Gender Difference in Concussion Incidence and Outcomes? Br. J. Sports Med. 2009, 43, i46–i50. [Google Scholar] [CrossRef]
- Abdelmalik, P.A.; Draghic, N.; Ling, G.S.F. Management of Moderate and Severe Traumatic Brain Injury. Transfusion 2019, 59, 1529–1538. [Google Scholar] [CrossRef] [Green Version]
- Woolf, P.D. Hormonal Responses to Trauma. Crit. Care Med. 1992, 20, 216–226. [Google Scholar] [CrossRef]
- Center for Disease Control and Prevention (CDC). Available online: www.cdc.gov (accessed on 25 March 2021).
- Heidelbaugh, J. Endocrinology Update: Hypopituitarism. FP Essent. 2016, 451, 25–30. [Google Scholar]
- Di Battista, A.P.; Rhind, S.G.; Churchill, N.; Richards, D.; Lawrence, D.W.; Hutchison, M.G. Peripheral Blood Neuroendocrine Hormones Are Associated with Clinical Indices of Sport-Related Concussion. Sci. Rep. 2019, 9, 18605. [Google Scholar] [CrossRef]
- Molaie, A.M.; Maguire, J. Neuroendocrine Abnormalities Following Traumatic Brain Injury: An Important Contributor to Neuropsychiatric Sequelae. Front. Endocrinol. 2018, 9. [Google Scholar] [CrossRef] [PubMed]
- Pavlovic, D.; Pekic, S.; Stojanovic, M.; Popovic, V. Traumatic Brain Injury: Neuropathological, Neurocognitive and Neurobehavioral Sequelae. Pituitary 2019, 22, 270–282. [Google Scholar] [CrossRef] [PubMed]
- Mollayeva, T.; El-Khechen-Richandi, G.; Colantonio, A. Sex & Gender Considerations in Concussion Research. Concussion 2018, 3. [Google Scholar] [CrossRef] [Green Version]
- Resch, J.; Walton, S.; Broshek, D. Sport Concussion and the Female Athlete—Clinics in Sports Medicine. Clin. Sports Med. 2017, 36, 717–739. [Google Scholar] [CrossRef] [PubMed]
- Costello, J.T.; Bieuzen, F.; Bleakley, C.M. Where Are All the Female Participants in Sports and Exercise Medicine Research? Eur. J. Sport Sci. 2014, 14, 847–851. [Google Scholar] [CrossRef] [Green Version]
- Feuerstein, I.M.; Jenkins, M.R.; Kornstein, S.G.; Lauer, M.S.; Scott, P.E.; Raju, T.N.K.; Johnson, T.; Devaney, S.; Lolic, M.; Henderson, M.; et al. Working Together to Address Women’s Health in Research and Drug Development: Summary of the 2017 Women’s Health Congress Preconference Symposium. J. Women’s Health 2018, 27, 1195–1203. [Google Scholar] [CrossRef] [PubMed]
- Liu, K.A.; DiPietro Mager, N.A. Women’s Involvement in Clinical Trials: Historical Perspective and Future Implications. Pharm. Pract. 2016, 14, 708. [Google Scholar] [CrossRef] [Green Version]
- Mazure, C.M.; Jones, D.P. Twenty Years and Still Counting: Including Women as Participants and Studying Sex and Gender in Biomedical Research. BMC Women’s Health 2015, 15, 94. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Covassin, T.; Elbin, R.; Lipchik, A.; Kontos, A.P. Are There Differences in Neurocognitive Function and Symptoms Between Male and Female Soccer Players After Concussions? Am. J. Sports Med. 2013, 41, 2890–2895. [Google Scholar] [CrossRef] [PubMed]
- Cheng, J.; Ammerman, B.; Santiago, K.; Jivanelli, B.; Lin, E.; Casey, E.; Ling, D. Sex-Based Differences in the Incidence of Sports-Related Concussion: Systematic Review and Meta-Analysis. Sports Health 2019, 11, 486–491. [Google Scholar] [CrossRef]
- Howell, D.R.; Stracciolini, A.; Geminiani, E.; Meehan, W.P. Dual-Task Gait Differences in Female and Male Adolescents Following Sport-Related Concussion. Gait Posture 2017, 54, 284–289. [Google Scholar] [CrossRef]
- Ling, D.I.; Cheng, J.; Santiago, K.; Ammerman, B.; Jivanelli, B.; Hannafin, J.; Casey, E. Women Are at Higher Risk for Concussions Due to Ball or Equipment Contact in Soccer and Lacrosse. Clin. Orthop. Relat. Res. 2020, 478, 1469–1479. [Google Scholar] [CrossRef]
- Shansky, R.M.; Woolley, C.S. Considering Sex as a Biological Variable Will Be Valuable for Neuroscience Research. J. Neurosci. 2016, 36, 11817–11822. [Google Scholar] [CrossRef] [Green Version]
- Miller, L.R.; Marks, C.; Becker, J.B.; Hurn, P.D.; Chen, W.-J.; Woodruff, T.; McCarthy, M.M.; Sohrabji, F.; Schiebinger, L.; Wetherington, C.L.; et al. Considering Sex as a Biological Variable in Preclinical Research. FASEB J. 2017, 31, 29–34. [Google Scholar] [CrossRef] [Green Version]
- Clayton, J.A. Applying the New SABV (Sex as a Biological Variable) Policy to Research and Clinical Care. Physiol. Behav. 2018, 187, 2–5. [Google Scholar] [CrossRef] [PubMed]
- Merritt, V.; Padgett, C.; Jak, A. A Systematic Review of Sex Differences in Concussion Outcome: What Do We Know? Clin. Neuropsychol. 2019, 33, 1016–1043. [Google Scholar] [CrossRef] [PubMed]
- Broshek, D.K.; Kaushik, T.; Freeman, J.R.; Erlanger, D.; Webbe, F.; Barth, J.T. Sex Differences in Outcome Following Sports-Related Concussion. J. Neurosurg. 2005, 102, 856–863. [Google Scholar] [CrossRef]
- Bazarian, J.J.; Blyth, B.; Mookerjee, S.; He, H.; McDermott, M.P. Sex Differences in Outcome after Mild Traumatic Brain Injury. J. Neurotrauma 2010, 27, 527–539. [Google Scholar] [CrossRef] [Green Version]
- Iverson, G.L.; Gardner, A.J.; Terry, D.P.; Ponsford, J.L.; Sills, A.K.; Broshek, D.K.; Solomon, G.S. Predictors of Clinical Recovery from Concussion: A Systematic Review. Br. J. Sports Med. 2017, 51, 941–948. [Google Scholar] [CrossRef]
- Kostyun, R.O.; Hafeez, I. Protracted Recovery From a Concussion: A Focus on Gender and Treatment Interventions in an Adolescent Population. Sports Health 2015, 7, 52–57. [Google Scholar] [CrossRef] [Green Version]
- Scopaz, K.A.; Hatzenbuehler, J.R. Risk Modifiers for Concussion and Prolonged Recovery. Sports Health 2013, 5, 537–541. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Harmon, K.G.; Drezner, J.A.; Gammons, M.; Guskiewicz, K.M.; Halstead, M.; Herring, S.A.; Kutcher, J.S.; Pana, A.; Putukian, M.; Roberts, W.O. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Br. J. Sports Med. 2013, 47, 15–26. [Google Scholar] [CrossRef] [Green Version]
- McCrory, P.; Meeuwisse, W.; Dvořák, J.; Aubry, M.; Bailes, J.; Broglio, S.; Cantu, R.C.; Cassidy, D.; Echemendia, R.J.; Castellani, R.J.; et al. Consensus Statement on Concussion in Sport-the 5th International Conference on Concussion in Sport Held in Berlin, October 2016. Br. J. Sports Med. 2017, 51, 838–847. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Marshall, C.M. Sports-Related Concussion: A Narrative Review of the Literature. J. Can. Chiropr. Assoc. 2012, 56, 299. [Google Scholar]
- Solomito, M.J.; Reuman, H.; Wang, D.H. Sex Differences in Concussion: A Review of Brain Anatomy, Function, and Biomechanical Response to Impact. Brain Inj. 2019, 33, 105–110. [Google Scholar] [CrossRef]
- Tierney, R.T.; Sitler, M.R.; Swanik, C.B.; Swanik, K.A.; Higgins, M.; Torg, J. Gender Differences in Head-Neck Segment Dynamic Stabilization during Head Acceleration. Med. Sci. Sports Exerc. 2005, 37, 272–279. [Google Scholar] [CrossRef] [PubMed]
- Wallace, J.; Covassin, T.; Beidler, E. Sex Differences in High School Athletes’ Knowledge of Sport-Related Concussion Symptoms and Reporting Behaviors. J. Athl. Train. 2017, 52, 682–688. [Google Scholar] [CrossRef] [PubMed]
- Greco, T.; Ferguson, L.; Giza, C.; Prins, M.L. Mechanisms Underlying Vulnerabilities after Repeat Mild Traumatic Brain Injuries. Exp. Neurol. 2019, 317, 206–213. [Google Scholar] [CrossRef] [PubMed]
- Wunderle, M.K.; Hoeger, K.M.; Wasserman, M.E.; Bazarian, J.J. Menstrual Phase as Predictor of Outcome after Mild Traumatic Brain Injury in Women. J. Head Trauma Rehabil. 2014, 29, E1–E8. [Google Scholar] [CrossRef]
- Dorton, A. The Pituitary Gland: Embryology, Physiology, and Pathophysiology. Neonatal. Netw. 2000, 19, 9–17. [Google Scholar] [CrossRef] [PubMed]
- Benvenga, S.; CampennÍ, A.; Ruggeri, R.M.; Trimarchi, F. Hypopituitarism Secondary to Head Trauma. J. Clin. Endocrinol. Metab. 2000, 85, 1353–1361. [Google Scholar] [CrossRef] [PubMed]
- Dusick, J.R.; Wang, C.; Cohan, P.; Swerdloff, R.; Kelly, D.F. Chapter 1: Pathophysiology of Hypopituitarism in the Setting of Brain Injury. Pituitary 2012, 15, 2–9. [Google Scholar] [CrossRef] [Green Version]
- Tanriverdi, F.; Senyurek, H.; Unluhizarci, K.; Selcuklu, A.; Casanueva, F.F.; Kelestimur, F. High Risk of Hypopituitarism after Traumatic Brain Injury: A Prospective Investigation of Anterior Pituitary Function in the Acute Phase and 12 Months after Trauma. J. Clin. Endocrinol. Metab. 2006, 91, 2105–2111. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Gray, S.; Bilski, T.; Dieudonne, B.; Saeed, S. Hypopituitarism after Traumatic Brain Injury. Cureus 2019, 11, e4163. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Javed, Z.; Qamar, U.; Sathyapalan, T. Pituitary and/or Hypothalamic Dysfunction Following Moderate to Severe Traumatic Brain Injury: Current Perspectives. Indian J. Endocrinol. Metab. 2015, 19, 753–763. [Google Scholar] [CrossRef]
- Kaulfers, A.-M.D.; Backeljauw, P.F.; Reifschneider, K.; Blum, S.; Michaud, L.; Weiss, M.; Rose, S.R. Endocrine Dysfunction Following Traumatic Brain Injury in Children. J. Pediatrics 2010, 157, 894–899. [Google Scholar] [CrossRef]
- Yang, L.; Guo, Y.; Wen, D.; Yang, L.; Chen, Y.; Zhang, G.; Fan, Z. Bone Fracture Enhances Trauma Brain Injury. Scand. J. Immunol. 2016, 83, 26–32. [Google Scholar] [CrossRef] [Green Version]
- Covassin, T.; Elbin, R.J. The Cognitive Effects and Decrements Following Concussion. Open Access J. Sports Med. 2010, 1, 55–61. [Google Scholar] [CrossRef] [Green Version]
- DeMayo, F.J.; Zhao, B.; Takamoto, N.; Tsai, S.Y. Mechanisms of Action of Estrogen and Progesterone. Ann. N. Y. Acad. Sci. 2002, 955, 48–59. [Google Scholar] [CrossRef]
- Moreno, M.A. New Updates on Concussions in Girls and Menstrual Patterns. JAMA Pediatr. 2017, 171, 924. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Oyola, M.G.; Handa, R.J. Hypothalamic-Pituitary-Adrenal and Hypothalamic-Pituitary-Gonadal Axes: Sex Differences in Regulation of Stress Responsivity. Stress 2017, 20, 476–494. [Google Scholar] [CrossRef] [PubMed]
- Snook, M.L.; Henry, L.C.; Sanfilippo, J.S.; Zeleznik, A.J.; Kontos, A.P. Association of Concussion with Abnormal Menstrual Patterns in Adolescent and Young Women. JAMA Pediatr. 2017, 171, 879–886. [Google Scholar] [CrossRef] [PubMed]
- Northam, W.T.; Alexander, A.; Carneiro, K. Sport-Related Concussion Preceding Adrenal Insufficiency and Hypopituitarism. Curr. Sports Med. Rep. 2020, 19, 8–10. [Google Scholar] [CrossRef]
- Bollerslev, J.; Klibanski, A.; Tritos, N. Traumatic Brain Injury: Effects on the Endocrine System. J. Clin. Endocrinol. Metab. 2013, 98, 27A–28A. [Google Scholar] [CrossRef] [Green Version]
- Agha, A.; Thompson, C.J. Anterior Pituitary Dysfunction Following Traumatic Brain Injury (TBI). Clin. Endocrinol. 2006, 64, 481–488. [Google Scholar] [CrossRef] [PubMed]
- Barbieri, R.L. The Endocrinology of the Menstrual Cycle. In Human Fertility: Methods and Protocols; Rosenwaks, Z., Wassarman, P.M., Eds.; Springer: New York, NY, USA, 2014; pp. 145–169. ISBN 978-1-4939-0659-8. [Google Scholar]
- Charkoudian, N.; Stachenfeld, N.S. Reproductive Hormone Influences on Thermoregulation in Women. In Comprehensive Physiology; American Cancer Society, Ed.; John Wiley & Sons: Hoboken, NJ, USA, 2014; pp. 793–804. ISBN 978-0-470-65071-4. [Google Scholar]
- McEwen, B.S.; Akama, K.T.; Spencer-Segal, J.L.; Milner, T.A.; Waters, E.M. Estrogen Effects on the Brain: Actions beyond the Hypothalamus via Novel Mechanisms. Behav. Neurosci. 2012, 126, 4–16. [Google Scholar] [CrossRef] [Green Version]
- Mumford, S.L.; Steiner, A.Z.; Pollack, A.Z.; Perkins, N.J.; Filiberto, A.C.; Albert, P.S.; Mattison, D.R.; Wactawski-Wende, J.; Schisterman, E.F. The Utility of Menstrual Cycle Length as an Indicator of Cumulative Hormonal Exposure. J. Clin. Endocrinol. Metab. 2012, 97, E1871–E1879. [Google Scholar] [CrossRef] [PubMed]
- Seifert-Klauss, V.; Prior, J.C. Progesterone and Bone: Actions Promoting Bone Health in Women. J. Osteoporos. 2010, 2010, e845180. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Ripley, D.L.; Harrison-Felix, C.; Sendroy-Terrill, M.; Cusick, C.P.; Dannels-McClure, A.; Morey, C. The Impact of Female Reproductive Function on Outcomes after Traumatic Brain Injury. Arch. Phys. Med. Rehabil. 2008, 89, 1090–1096. [Google Scholar] [CrossRef]
- Henderson, V.W. Progesterone and Human Cognition. Climacteric 2018, 21, 333–340. [Google Scholar] [CrossRef]
- Tanriverdi, F.; Schneider, H.; Aimaretti, G.; Masel, B.; Casanueva, F.F.; Kelestimur, F. Pituitary Dysfunction After Traumatic Brain Injury: A Clinical and Pathophysiological Approach. Endocr. Rev. 2015, 36, 305–342. [Google Scholar] [CrossRef] [Green Version]
- Brotfain, E.; Gruenbaum, S.E.; Boyko, M.; Kutz, R.; Zlotnik, A.; Klein, M. Neuroprotection by Estrogen and Progesterone in Traumatic Brain Injury and Spinal Cord Injury. Curr. Neuropharmacol. 2016, 14, 641–653. [Google Scholar] [CrossRef] [Green Version]
- Gallagher, V.; Kramer, N.; Abbott, K.; Alexander, J.; Breiter, H.; Herrold, A.; Lindley, T.; Mjaanes, J.; Reilly, J. The Effects of Sex Differences and Hormonal Contraception on Outcomes after Collegiate Sports-Related Concussion. J. Neurotrauma 2018, 35, 1242–1247. [Google Scholar] [CrossRef] [PubMed]
- Adams, J.W.; Alvarez, V.E.; Mez, J.; Huber, B.R.; Tripodis, Y.; Xia, W.; Meng, G.; Kubilus, C.A.; Cormier, K.; Kiernan, P.T.; et al. Lewy Body Pathology and Chronic Traumatic Encephalopathy Associated with Contact Sports. J. Neuropathol. Exp. Neurol. 2018, 77, 757–768. [Google Scholar] [CrossRef]
- Alosco, M.L.; Mez, J.; Kowall, N.W.; Stein, T.D.; Goldstein, L.E.; Cantu, R.C.; Katz, D.I.; Solomon, T.M.; Kiernan, P.T.; Murphy, L.; et al. Cognitive Reserve as a Modifier of Clinical Expression in Chronic Traumatic Encephalopathy: A Preliminary Examination. JNP 2016, 29, 6–12. [Google Scholar] [CrossRef] [PubMed]
- Alosco, M.L.; Mez, J.; Kowall, N.W. Age of First Exposure to Tackle Football and Chronic Traumatic Encephalopathy. Ann. Neurol. 2018, 83, 886–901. [Google Scholar] [CrossRef] [PubMed]
- Mez, J.; Daneshvar, D.H.; Abdolmohammadi, B.; Chua, A.S.; Alosco, M.L.; Kiernan, P.T.; Evers, L.; Marshall, L.; Martin, B.M.; Palmisano, J.N.; et al. Duration of American Football Play and Chronic Traumatic Encephalopathy. Ann. Neurol. 2020, 87, 116–131. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hillard, P.J.A. Menstruation in Adolescents: What Do We Know? And What Do We Do with the Information. J. Pediatr. Adolesc. Gynecol. 2014, 27, 309–319. [Google Scholar] [CrossRef] [PubMed]
- De Souza, M.J. Menstrual Disturbances in Athletes: A Focus on Luteal Phase Defects. Med. Sci. Sports Exerc. 2003, 35, 1553–1563. [Google Scholar] [CrossRef] [PubMed] [Green Version]
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Duffy, D.; Elliott-Sale, K.J.; Gardner, H.; Goldenstein, S.; Wideman, L. Endocrine Responses to Sport-Related Brain Injury in Female Athletes: A Narrative Review and a Call for Action. Endocrines 2021, 2, 99-108. https://doi.org/10.3390/endocrines2020010
Duffy D, Elliott-Sale KJ, Gardner H, Goldenstein S, Wideman L. Endocrine Responses to Sport-Related Brain Injury in Female Athletes: A Narrative Review and a Call for Action. Endocrines. 2021; 2(2):99-108. https://doi.org/10.3390/endocrines2020010
Chicago/Turabian StyleDuffy, Donna, Kirsty J. Elliott-Sale, Hanna Gardner, Samantha Goldenstein, and Laurie Wideman. 2021. "Endocrine Responses to Sport-Related Brain Injury in Female Athletes: A Narrative Review and a Call for Action" Endocrines 2, no. 2: 99-108. https://doi.org/10.3390/endocrines2020010