T.I.R.E.D.

The hypothalamic-pituitary-adrenal (HPA axis) is a part of our endocrine system. A series of hormonal glands that function as our central stress response system activating our instinctual fight, flight or freeze response. In terms of reproduction, the HPA axis mediates the function of the hypothalamic-adrenal-gonadal (HPG) axis responsible for the maturation of the reproductive organs (8) and overall reproductive function. Activation of the HPA axis during stress leads to the release of cortisol and can have detrimental effects on fertility (8). When on alert, this survival response stimulates the release of cortisol, shifting energy towards parts of the body that are needed for survival (brain, muscles, and limbs) and away from areas that are not immediately needed, (digestion and reproductive function). Cortisol mobilizes energy stores which facilitates increased arousal, vigilance, and attention. (5, 3). In this way, trauma and stress can directly affect reproduction. Childhood stressors and abuse have been associated with chronic HPA axis activation and (1) and physical brain alterations which have been widely associated with PTSD (10). "Trauma affects the entire human organism - body, mind, and brain. In PTSD the body continues to defend against a threat that belongs to the past" (22).

Located at the base of the limbic system deep in the temporal lobe, the amygdalae, a pair of almond shaped structures (17) play a very important role in storing emotional memories, specifically the processing of fear-provoking memories and threatening experiences. The amygdala discerns fears and initiates the fight, flight or freeze response (5,6,11). Amygdala hyper-activation is a common pathway for exaggerated anxiety and fear that is triggered by a specific stimuli like those associated with anxiety, panic disorders, phobias, and PTSD (18). Amygdala-based fear responses occur too quickly for the perception of danger to become concsious, rather the danger is detected neuroceptively, or through the neural processes that evaluate risk in the environment without our awareness (15,16). The amygdala reacts to perceptions of threat in moments and interactions as brief as 30 milliseconds (9). It is crucial that the doctor or medical professional entering the examination room is aware of their affect and is in a regulated self-state. Doctors must become attuned to the implicit communication which occurs during every interraction with their patients.

The hypolthalamus is important for reproduction and fertility. It regulates the activities of the pituitary gland and signals the endocrine glands to produce hormones (corticotropin releasing hormone, gonadotropin-releasing hormone (GnRH), and oxytosin, follicle stimulating hormone (FSH), and luteinizing hormone (LH)). Problems in this area can result in reproductive problems such as hypothalamic amenorrhea where menstruation stops for several months due to a number of factors. The hypothalamus is also the control center of two major stress response systems of the body, the sympathetic nervous system and the hypothalamus-pituitary-adrenal (HPA) axis. Also involved in controlling the energy levels of the body, (15) when prefrontal and limbic structures signal that a situation is threatening, the hypothalamus rapidly activates the sympathetic nervous system triggering - within seconds - the release of epinephrine and norepinephrine. (13). This stress response can directly affect fertility and reproduction. In the brain/body of a traumatized patient, this stress response can be triggered by any number or external stressors and/or triggers such as sight, sound, smell, touch, and taste.

In Reproductive Endocrinology, the hippocampus along with the prefrontal cortex and the amygdala, are important components of Hypothalamic-pituitary-adrenal axis (HPA axis) (23) regulating the release of hormones necessary for ovulation and reproduction. Chronic stress can have a significant impact on these areas of the brain. The hippocamous (memory) and amygdala (fear) work in a reciprocal way so that the hippocampus inhibits the amydala, while the amygdala's reactions also alert the hippocampus to what is important to remember (9). The hippocampus' main function is in mediating the recording and retrieval of explicit memories(9) and is very sensitive to stress (2).Under stress or after trauma, the ability to do this effectively may be disrupted. Because the hippocampus is meant to create a narrative that places events in the right time and place (5) those with PTSD may have difficulty piecing together memories chronologically. The trauma memory can contain a high degree of sensory detail, which contributes to a fragmented and disjointed story upon recall (19). CLICK FOR AUDIO

The insula is connected to the amygdala and regulates the nervous system. This part of the brain is responsible for integrating information from the five senses with the functioning of the ANS and HPA axis and thereby provides a physical (somatic) experience. The insula generates the visceral awareness of affect (internal state) and is essential to the felt sense of subjective experience (9). The insula is deactivated in dissociative states, contributing to the numbness and emotional detachment associated with them (9). It is important that medical providers are aware of their patient's somatic state and are able to determine if the patient is feeling disconnected from their body during an exam.

The anterior cingulate regulates aggression and affect arousal. Located in the prefrontal cortex, the anterior cingulate plays an important role in the appraisal and regulation of emotions. One of its jobs is to inhibit the amygdala's initial fear response by identifying the lack of danger where memory serves to provide a better understanding of the stimuli. When it becomes hypo-responsive, as a result of trauma, it fails to inhibit the amygdala allowing for an overactive fear response.

Located at the top outermost area of the limbic system (and developed last) The orbitofrontal cortex integrates all of the information received from the rest of the limbic system. Often thought of as the thinking part of the limbic system, this is where the complex integration of all of the above information occurs (9). As a medical practitioner working with A.R.T patients who have experienced trauma, it is important to understand that PTSD has resulted in actual structrural changes in the brain which impact the patient's ability to categorize or compartmentalize the trauma in a logical way. Patients who have experienced traumatic stress may experience the sensations of the trauma as though they are occurring in that moment. CLICK FOR AUDIO