Authors: Mallory Johnson, Sarv Raafati, Meghan Etsey, Vaishnavi Patel, DO on behalf of the Gender Equity Task Force
Why do so many female athletes struggle to fully recover from a concussion? For many women, the answer is frustratingly complex. Post-concussion syndrome (PCS) doesn’t just linger, it often hits harder and lasts longer in female athletes than in men, affecting everything from daily life to peak athletic performance, and sometimes even preventing them from returning to their sport. Growing evidence suggests that a combination of biology, hormones, psychosocial factors, and biomechanics all play a role in why recovery can be slower for women. Understanding these differences isn’t just academic, it’s essential for safer, smarter, and more effective care for female athletes at all levels.
One of the most significant drivers of prolonged PCS in women is the interplay between biology and hormonal fluctuations. Studies consistently show that women, especially those aged 35 to 49, experience more severe and persistent PCS symptoms than men (Levin et al., 2021; Peacock et al., 2025; Mikolić et al., 2021; King, 2014). Hormones like estrogen and progesterone play unexpectedly complex roles in the brain’s response to injury. For instance, progesterone withdrawal during the luteal phase of the menstrual cycle has been linked to worse post-concussion outcomes, and hormone levels at the time of injury may even predict the severity of recovery (Carr & Fleddermann, 2025).
Although preclinical studies suggest that estrogen and progesterone are neuroprotective, these benefits haven’t consistently translated into better clinical outcomes for women with traumatic brain injuries (Levin et al., 2021; Peacock et al., 2025). In other words, the biological mechanisms that should protect women in theory don’t always play out as expected in real-life injuries, leaving many female athletes vulnerable to longer and more disruptive recoveries.
Biology isn’t the whole story. Psychosocial factors also contribute to prolonged recovery. Women tend to report their symptoms more openly and consistently, which can sometimes be misinterpreted as greater severity rather than more accurate reporting (Levin et al., 2021; Rowe et al., 2022). Additionally, pre-existing conditions such as anxiety or depression, more common in women, can further extend recovery timelines (Mikolić et al., 2021; King, 2014). These psychosocial dynamics highlight a key point: prolonged PCS isn’t “all in the head,” but the interaction between mental health and brain injury can shape both the perception and duration of symptoms. Awareness of these factors allows clinicians to support recovery in a more holistic and patient-centered way.
Female athletes also face unique biomechanical vulnerabilities. Research shows that women sustain concussions at higher rates than men in sports with comparable rules, often due to different mechanisms of injury, like contact with equipment rather than player-to-player collisions, which may produce different force patterns and injury severity (Medicine & Science in Sports and Exercise, 2018). Differences in neck strength, muscle mass, and cervical stiffness may also make women more susceptible to prolonged symptoms. These biomechanical disparities underscore why recovery protocols designed for men may not be fully effective for women. Tailoring training, prevention, and rehabilitation to account for sex-based anatomical and physiological differences could help shorten recovery times and prevent long-term complications.
Ultimately, PCS in female athletes reflects a convergence of hormonal, psychosocial, and biomechanical factors. No single intervention will address all of these challenges. Recognizing these differences is vital for developing individualized concussion management plans, from acute treatment to return-to-play decisions. Emerging research is beginning to explore whether hormonal interventions, such as timing injury assessments with menstrual cycles or using hormonal contraceptives, can influence recovery outcomes. While these strategies are still under investigation, they represent a promising new direction for improving care for women athletes. By understanding the multifaceted reasons behind prolonged PCS in female athletes, coaches, clinicians, sports organizations, and athletes can work together through better screening, sex-specific return-to-play protocols, and targeted education to improve safety and recovery. Awareness and sex-specific interventions are key to ensuring that female athletes achieve full recovery and a successful return to their sport.
References
Carr, G., & Fleddermann, M. T. (2025). The influence of menstrual cycle phases on postconcussion outcomes and symptom reporting: A scoping review. Scandinavian Journal of Medicine & Science in Sports, 35(7), e70093. https://doi.org/10.1111/sms.70093
King, N. S. (2014). A systematic review of age and gender factors in prolonged post-concussion symptoms after mild head injury. Brain Injury, 28(13-14), 1639–1645. https://doi.org/10.3109/02699052.2014.954271
Levin, H. S., Temkin, N. R., Barber, J., et al. (2021). Association of sex and age with mild traumatic brain injury–related symptoms: A TRACK-TBI study. JAMA Network Open, 4(4), e213046. https://doi.org/10.1001/jamanetworkopen.2021.3046
Mikolić, A., van Klaveren, D., Groeniger, J. O., et al. (2021). Differences between men and women in treatment and outcome after traumatic brain injury. Journal of Neurotrauma, 38(2), 235–251. https://doi.org/10.1089/neu.2020.7228
Peacock, W. F., Kuehl, D., Diaz-Arrastia, R., et al. (2025). Factors associated with persistent symptoms following mild traumatic brain injury. JAMA Network Open, 8(10), e2537729. https://doi.org/10.1001/jamanetworkopen.2025.37729
Rowe, B. H., Yang, E. H., Gaudet, L. A., et al. (2022). Sex-based differences in outcomes for adult patients presenting to the emergency department with a concussion. Journal of Neurosurgery, 136(1), 264–273. https://doi.org/10.3171/2021.1.JNS203753
Medicine and Science in Sports and Exercise. (2018). Female athlete issues for the team physician: A consensus statement—2017 update. Medicine and Science in Sports and Exercise, 50(5), 1113–1122. https://doi.org/10.1249/MSS.0000000000001603
About the Authors
Mallory Johnson, MS4
Mallory Johnson is a fourth-year medical student from St. George’s University. She holds a Bachelor of Science in Forensic Science and a Bachelor of Science in Chemistry from Tiffin University. She worked as an Analytical Chemist at P&G and KAO before medical school. She is passionate about giving back to vulnerable communities and providing equal access and opportunity to medical care. She is a member of the Domestic Violence and Music in Medicine Committees within the American Medical Women’s Association. When she’s not doing schoolwork, you can find her playing her cello, reading cozy mysteries, and playing with her poodles, Gertie and Maple.
Sarv Raafati MS3
Sarv Raafati is a third year medical student at St. George’s University. She completed her undergraduate at the University of Utah with a Bachelor of Science in Biomedical Engineering and a minor in Middle East Studies. She also holds a Bachelor of Medical Science from Northumbria University in England. During her time at SGU she was the lesson coordinator in STEMM, an organization committed to providing lessons to local classrooms in Science, Technology, Engineering, Math, and Medicine. When not focusing on medicine she can be found at your local rock climbing gym, reading, skiing, or just randomly exploring to find the best coffee shop to study at.
Meghan Etsey, MS4
Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.
Vaishnavi Patel, DO
Vaishnavi J. Patel, DO is an early career family medicine physician. She is passionate about Women’s Health and advocacy, serving on the Executive Board of the American Medical Women’s Association GETF and playing a crucial role in their initiatives to support women in medicine. Her research expertise includes scientific computation, data sciences, and analyzing methods to improve patient outcomes and women’s health. She is a dedicated volunteer for local free clinics and a speaker at various programs focused on patient education and advocacy. She serves as an ambassador of the Gold Humanism Honor Society and is a recipient of the Lifetime Presidential Volunteer Service Award and the Eliza Lo Chin Unsung Hero Award. In her spare time, she enjoys archery, reading, spending time with her family, and spoiling her pets. Her patients describe her as compassionate, thorough, and knowledgeable. Her classmates, coworkers, and mentors describe her as a genuine leader, hard-worker, and a valuable asset to the future of medicine.