REHABILITATION OF MODERATE TO SEVERE TBI: NEUROENDOCRINE DISORDERS: REPRODUCTIVE DISTURBANCES AND SEXUALITY  

  • Amenorrhea and menstrual irregularities are common, although the cycle usually returns within the first several months
    • Low-dose combined oral contraceptives may be indicated to restore the cycle
    • Beta human chorionic gonadotropin levels should be determined in all patients of child-bearing age

  • Sexual Dysfunction
    • Prevalance, Symptoms, and Causes
      • Decreased libido, decreased sexual performance and impotence, and decreased sexual drive and satisfaction/orgasm are the most common changes following TBI, although hypersexuality, specifically inappropriate sexual comments and gestures, and loss of secondary sex characteristics may also occur (Childers, et al 1998; Sandel, et al 1996; Britton, 1998), as a result of hypopituitarism and concomitant GH deficiency (Popovic, et al 2004) hypogonadism, lesions in the limbic system, or dysfunction of the hypothalamus and temporal lobe (Elliott and Beaver, 1996). Anterior pituitary dysfunction following TBI is common, but hypopituitarism is treatable (Agha, et al 2004).
      • Frontal lobe lesions and right hemisphere injuries are predictive of higher sexual satisfaction and functioning than other lesions, and patients with more recent injuries have reported greater levels of arousal than those less recently injured (Sandel, et al 1996). However, frontal or frontal-temporal injury can also produce sexual disinhibition and a total lack of interest as part of global amotivation (Elliott and Biever, 1996)
      • Other causes of posttraumatic sexual dysfunction include headaches, emotional lability/instability, dizziness, fatigue, anxiety/nervousness, depression, dependency, impulsivity, and cognitive changes, as well as stress which can cause hormonal and neurotransmitter changes , in the patient and in the sexual partner (Elliott and Beaver, 1996)
      • A high degree of physical independence and maintained sexual ability are among the most important predictors for sexual adjustment (Kreuter, et al 1998)

    • Medical Evaluation
      • History should focus on preinjury and postinjury medical and psychiatric problems, medications, preinjury and postinjury sexual functioning and relationships, birth control, and safe sex practices
      • Physical should focus on impairments that may influence communication, positioning, movement, oral ability, and sensory awareness and impairments
      • Medication review should focus on drugs that effect sexual function, such as antihypertensives, antipsychotics, antidepressanats, anxiolytics, and sedatives
      • Laboratory tests should be done for free testosterone levels, sperm count, LH and FSH, growth hormone, thyroxine or coritsol, low levels of which all indicate possible hypopituitarism and hypogonadism, the main cause of sexual dysfunction following TBI.

        TBI and subarachnoid hemorrhage are conditions associated with high risk of acquired hypopituitarism. The pituitary defect is often multiple and severe. GH deficiency is the most frequent defect. Thus neuroendocrine evaluations are always mandatory in patients after brain injuries (Aimaretti, et al 2004).

    • Therapeutic Interventions
      • The following interventions have recently been studied in TBI individuals:

      • The following interventions have only been studied in non-TBI individuals, but may have implications for the TBI population:
        • Human chorionic gonadotropin to treat erectile failure and/or increase sexual desire
        • Certain antidepressants, such as buproprion, trazodone, fenfluramine, to improve libido
        • Viagra or dopaminergic agents, such as apomorphine, to treat erectile dysfunction
        • Sexual therapy to improve sexual relationships

Based on information in Medical Rehabilitation of Traumatic Brain Injury, L.J. Horn and N.D. Zasler, eds. St. Louis, MO, Mosby, 1996, except for information where other papers are cited.