top of page

"The body of the traumatized individual

refuses to be ignored.

 - Babette Rothschild, MSW, The Body Remembers

FAQ
  • Hypothalamic-Pituitary-Adrenal Axis (HPA axis)
    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).
  • Amygdala
    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.
  • Hypothalamus
    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.
  • Hippocampus
    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
  • Insula
    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.
  • Anterior Cingulate
    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.
  • Medial Prefrontal Cortex
    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
Trauma, Physical Health & Fertility
Menstrual Cycle & Ovarian Function
Substance Use

Trauma, Physical Health, & Infertility

Physical changes to the body that may be the result of  PTSD are obesity and STDs,  both reported at higher rates in women with PTSD.

Obesity, Trauma & Infertility​

​

  • Because the brain and body are directly affected by stress and trauma, some physical health issues may appear in patients with PTSD. Two physical changes to the body that may be the result of  abuse are obesity and sexually transmitted disease which are both reported at higher rates in women with PTSD. (11)

​

  • Obesity falls in both physical and behavioral health categories of PTSD related issues. Physically, obesity may be the body’s reaction to stress. Physiologically, stress induces elevations in glucocorticoids (cortisol) which may promote food intake and obesity as well as hormone imbalance caused by elevated corticotropin-releasing hormone consistent with increased activity of the HPA axis in traumatized individuals. (3).

​

  • Obesity may affect infertility and reproduction in women by affecting ovulation and interfering with outcomes of A.R.T. Longer periods of ovarian stimulation and higher cancellation rates of follicular asynchrony have been found in obese patients undergoing IVF (14). Research into obesity and infertility reported menstrual disturbances were four times more common in obese women and it appears that even high normal to slightly overweight BMI levels have an effect on fertility (13).

​

Inflammation, Sexual Trauma & Infertility

​

  • Another common cause of infertility in women, tubal factor infertility (TFI) is due to an inflammation of the epithelial surfaces in the fallopian tubes and subsequent pelvic-perionatal adhesions. Several sexually transmitted diseases including Chlamydia Trachomatis and Neisseria Gonorrhea have been linked to this type of inflammation, both of which are most commonly caused by previous or persistent infections (18). Trichomoniasis, BV, Gonorrhea, and Chlamydia infection are the most frequently diagnosed infections among women who have been sexually assaulted (16).

​

  • While thorough screening for STD’s is conducted as part of A.R.T. practice, it is worth noting that the cause of the infection in some cases may suggest undisclosed past trauma. Reproductive endocrinologists and medical staff should be aware that more patients than they think may have a significant trauma history.   

Trauma, Menstrual Cycle & Ovarian Function

The connection between menstrual function and PTSD may be an important factor to assess for in reproductive endocrinology practice.

  • Exposure to childhood stressors is associated with diminished ovarian reserve and function as well as reported infertility and reduced probability of achieving pregnancy in one menstrual cycle (6).

​

​

  • Menstrual cycle is regulated by the hypothalamic gonadotropin-releasing hormone which may be inhibited by hormones released by the hypothalamic-pituitary-adrenal (HPA) axis in response to stress (6). 

​

  • Activation of the HPA axis during times of stress and/or fear increases survival processes (blood pressure, flow of blood to muscles, circulating levels of glucose) while decreasing processes related to nonessential functions to conserve energy (1) effecting reproduction via decreased ovarian function, and menstrual cycle irregularities.

​

  • One study (6) illustrated that as the number of adverse childhood experiences increased, the risk of fertility difficulties also increased.

​

  • Overall, the risk of fertility difficulties increased by 6% for each additional ACE experienced but specifically, sexual and physical abuse showed the strongest associations with fertility difficulties (6). 

​

  • Because abnormalities in menstrual cycle have been associated with various types of infertility, the connection between menstrual function and PTSD may be an important factor to assess for in reproductive endocrinology practice.

Trauma, Behavioral Health (Addiction) & Fertility

Some behavioral health co-morbidity factors include smoking, alcohol consumption, drug use, and eating disorders all of which can affect fertility in women.

PTSD has been linked with a variety of behavioral health risk factors.

​

  • Approximately one fifth of individuals with PTSD will use alcohol, drugs or both to reduce their symptoms (9).

​

  • People with PTSD are more likely to use substances in response to negative emotions and triggers. 

​

  • Some mental/behavioral health co-morbidity factors include smoking, alcohol consumption, drug use, and eating disorders) all of which can affect fertility in women.

​

  • Tobacco use, alcohol misuse, marijuana use, and opioid use and misuse can all affect the female reproductive system so while women with PTSD are more likely to use substances as a way of self-medicating or coping with stress and trauma, these same women are also more often seen by reproductive endocrinologists and may be more likely to have worse outcomes from fertility treatments than women without Substance Use Disorders (SUDs) (20).

​

Smoking has been found to significantly impact fertility (8)

​

  • Menopause occurs one to four years earlier in smoking women than in non-smokers.

  • Chemicals in cigarette smoke appear to accelerate follicular depletion and the loss of reproductive function. Mean gonadotropin dose requirements for smokers receiving stimulation for in-vitro fertilization (IVF) are higher when compared to those of non-smoking women

  • and overall the percentage of women who experience conception delay for over 12 months was found to be 54% higher for smokers than nonsmokers. (17).

​

Alcohol use even in moderation can effect fertility

​

  • Alcohol use disorders are associated with amenorrhea, anovulation, luteal phase disruption, hyperlactatemia, and increased risk of spontaneous miscarriage (20).

  • Alcohol disrupts normal menstrual cycling. Alcoholic women are known to have a variety of menstrual and reproductive disorders, from irregular menstrual cycles to complete cessation of menses, absence of ovulation and infertility (4).

  • Alcohol ingestion, even in small amounts can disrupt the delicate balance critical to maintaining human female reproductive hormonal cycles and result in infertility, anovulation which was associated with a reduced or absent pituitary LH secretion.

​

Marijuana use and fertility

​

  • Marijuana use has been shown to increase menstrual irregularity as well as decrease oocyte (egg) retrieval and opioids have a direct effect on the hypothalamic pituitary axis thus increasing the incidence of oligomenorrhea (frequent menstrual periods) and irregular menses.

​

Opiate use and fertility

​

  • Opioids have a direct effect on the hypothalamic-pituitary axis thus increasing the incidence of oligomenorrhea and irregular menses (20). 

Trauma & Behavioral Health (Eating Disorders)

Infertility may be the body’s response to weight gain or weight loss due to an eating disorder secondary to the patient’s experience of trauma.

  • Some forms of childhood trauma are significant predictors of eating psychopathology, specifically emotional abuse (7).

​

  • Sexual and emotional abuse may be a predictor for perfectionism, problems with impulse control and emotion dysregulation which may contribute to disordered eating.

​

Being underweight or overweight may affect fertility.

​

  • Eating Disorders typically affect women at peak age of reproductive functioning. Patients frequently present by means of physical sequalae, rather than the disorder itself. One study found 16% of patients in an infertility clinic had a primary, hidden eating disorder (10).

​

Menstrual cycle

​​

  • Primary or secondary amenorrhea results from hypogonadotropic hypogonadism in anorexia.

​

  • Anorexic patients present with a reduced response to LHRH, and clomiphene and menstrual abnormalities in anorexia reflect loss of body fat below the necessary threshold for fertility due to caloric restriction, excessive exercise or stress (10). 

​

Ovarian Function

​

  • Ovarian function is also down regulated in anorexic patients as there is a correlation between BMI and ovarian dysfunction high and low. Infertility may be the body’s response to weight gain or weight loss due to an eating disorder secondary to the patient’s experience of trauma (10). 

​

  • It is hypothesized that due to stress related hypothalamic–pituitary–adrenal (HPA) axis dysfunction, earlier victimization experiences recalibrate stress response systems and may contribute to sensation seeking and self-destructive behaviors explaining some of the behavioral changes in victims of abuse that increase the risk of substance use/abuse and the perpetuation of anorexia nervosa and binge-type behaviors (Bulimia Nervosa and Binge Eating Disorder) (2, 10, 7). 

ED & Fertility
QUIZ

Take the Quiz

bottom of page