Neuroendocrine Risk for PTSD in Women

The LOW E2 STUDY- Neuroendocrine Risk Mechanisms for Post-traumatic Stress Disorder in Women

This study will test for effects of estradiol (E2) on PTSD symptoms and functional magnetic resonance imaging (fMRI) indicators of stress vulnerability, in naturally-cycling women who are not using hormonal birth control. Enrollment will be targeted to create three groups within two cohorts (early follicular phase and luteal phase):

1. PTSD: Women who meet Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD
2. Trauma-Exposed (TC): Women matched for age and trauma exposure severity but without PTSD
3. Healthy Control (HC): Women matched for age, but without trauma history or psychiatric disorder (self-reported)

Women will be recruited through Grady Trauma Project (GTP), a large longstanding study of civilian trauma and PTSD conducted at Grady Memorial Hospital in Atlanta, Georgia.

Study Overview

• Status: Completed
• Conditions: PTSD; Trauma
• Intervention / Treatment: Drug: Estradiol patch; Other: Placebo patch

Detailed Description

The majority of Americans will experience a traumatic event during their lifetimes. However, women are twice as likely as men to experience negative psychiatric outcomes following trauma, including post-traumatic stress disorder (PTSD) and depression. The reason for the increased prevalence in women is unclear, partially because of the historical lack of investigation of females in both human and pre-clinical animal research. The researchers propose to investigate the role of sex hormones in contributing to women's risk for PTSD. The study will investigate relationships between trauma exposure and women's menstrual cycle, examining key events in the cycle, including menstruation, ovulation, and mood changes. The study will then examine relationships between the level of naturally-cycling estradiol (E2; the primary female sex hormone), and brain-based measures of stress vulnerability. This includes amygdala hyper-reactivity to threat.

The trial will study if trauma-exposed women with lower E2 levels during the luteal phase will report greater PTSD symptoms, and show more stress-vulnerable patterns of brain function. It will also examine the effects of exogenous application of estrogen on PTSD symptoms.

Women will begin tracking their cycle using a free and widely-used cycle-tracking smartphone app "Clue" for one full menstrual cycle.

• For Study Aims 1 & 2 (N=120): Participants will be contacted on the first day of their menstrual period in the second cycle, and scheduled for an MRI with a 4-day window (early follicular phase). Participants will be randomized to begin with either the E2 or placebo patch. The will receive an E2 or placebo patch 1 day prior to the MRI visit, with a blood draw on the morning of the MRI visit (to assess hormone levels), 1 hour prior to scanning. On the first day of the third cycle (onset of menses), women will all be scheduled for their second MRI visit. Participants will experience the opposite condition from their first MRI scan. They will receive an E2 or placebo patch 1 day prior to the MRI visit in the afternoon, with a blood draw on the morning of the MRI visit, 1 hour prior to scanning.
• For Study Aim 3 (N=120): Participants will begin daily urine ovulation tests on Day 11 of their cycle, and will record the results in Clue. When participants record a positive ovulation test during the second month of cycle monitoring, they will be contacted to schedule their MRI visit 5-7 days following ovulation (during the luteal phase). The experimental protocol will otherwise be the same as in Aims 1 and 2, with participants randomized to either E2 or placebo at the first visit and returning the next month for the other condition.

The scientific premise of this study is that low E2 may contribute to stress vulnerability in women. Findings may aid in the development of treatments that will enhance women's mental health outcomes following trauma.

• Study Type: Interventional
• Enrollment (Actual): 127
• Phase: Early Phase 1

Contacts and Locations

Study Locations

• United States
  • Georgia
    • Atlanta, Georgia, United States, 30303
      • Grady Memorial Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 35 years (Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• African American women
• A menstrual period within the past 60 days
• Able and willing to give informed consent
• Must have a smart phone and willing to install the Clue app

Exclusion Criteria:

• Women currently taking any form of hormone-based birth control or other hormonal supplement
• Women who are pregnant or breastfeeding
• Current psychoactive medication use
• Nicotine use or smoking
• Hypercoagulable conditions
• History of embolism
• Current symptoms of psychosis or bipolar disorder
• History of major head injury or neurological disorder
• Weight >250lbs (a maximum weight to allow for participants to fit comfortably inside the bore of the MRI machine) and typical physical contraindications for MRI such as metal implants

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

12

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Cohort 1: PTSD Receiving Estradiol then Placebo; Participants with PTSD will record their first cycle with the Clue app. They will receive the estradiol patch during the second cycle, and the placebo patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Experimental: Cohort 1: PTSD Receiving Placebo then Estradiol; Participants with PTSD will record their first cycle with the Clue app. They will receive the placebo patch during the second cycle, and the estradiol patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 1: Trauma without PTSD Receiving Estradiol then Placebo; Participants with trauma exposure will record their first cycle with the Clue app. They will receive the estradiol patch during the second cycle, and the placebo patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 1: Trauma without PTSD Receiving Placebo then Estradiol; Participants with trauma exposure will record their first cycle with the Clue app. They will receive the placebo patch during the second cycle, and the estradiol patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 1: Healthy Controls Receiving Estradiol then Placebo; Participants without trauma history or psychiatric disorder will record their first cycle with the Clue app. They will receive the estradiol patch during the second cycle, and the placebo patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 1: Healthy Controls Receiving Placebo then Estradiol; Participants without trauma history or psychiatric disorder will will record their first cycle with the Clue app. They will receive the placebo patch during the second cycle, and the estradiol patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Experimental: Cohort 2: PTSD Receiving Estradiol then Placebo; Participants with PTSD will begin daily urine ovulation tests on Day 11 of their first cycle, and will record the results with the Clue app. During the second month of cycle monitoring, the MRI will be scheduled 5-7 days after they record a positive ovulation test (during luteal phase) and they will use the estradiol patch before getting the MRI. They will apply the placebo patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Experimental: Cohort 2: PTSD Receiving Placebo then Estradiol; Participants with PTSD will begin daily urine ovulation tests on Day 11 of their first cycle, and will record the results with the Clue app. During the second month of cycle monitoring, the MRI will be scheduled 5-7 days after they record a positive ovulation test (during luteal phase) and they will use the placebo patch before getting the MRI. They will apply the estradiol patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 2: Trauma Control Receiving Estradiol, then Placebo; Participants with trauma exposure will begin daily urine ovulation tests on Day 11 of their first cycle, and will record the results with the Clue app. During the second month of cycle monitoring, the MRI will be scheduled 5-7 days after they record a positive ovulation test (during luteal phase) and they will use the estradiol patch before getting the MRI. They will apply the placebo patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 2: Trauma Control Receiving Placebo then Estradiol; Participants with trauma exposure will begin daily urine ovulation tests on Day 11 of their first cycle, and will record the results with the Clue app. During the second month of cycle monitoring, the MRI will be scheduled 5-7 days after they record a positive ovulation test (during luteal phase) and they will use the placebo patch before getting the MRI. They will apply the estradiol patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 2: Healthy Control Receiving Estradiol then Placebo; Participants without trauma history or psychiatric disorder will begin daily urine ovulation tests on Day 11 of their first cycle, and will record the results with the Clue app. During the second month of cycle monitoring, the MRI will be scheduled 5-7 days after they record a positive ovulation test (during luteal phase) and they will use the estradiol patch before getting the MRI. They will apply the placebo patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.
Active Comparator: Cohort 2: Healthy Control Receiving Placebo then Estradiol; Participants without trauma history or psychiatric disorder will begin daily urine ovulation tests on Day 11 of their first cycle, and will record the results with the Clue app. During the second month of cycle monitoring, the MRI will be scheduled 5-7 days after they record a positive ovulation test (during luteal phase) and they will use the placebo patch before getting the MRI. They will apply the estradiol patch during the third cycle.	Drug: Estradiol patch; Estradiol (E2) patches at a dose of 100ug will be applied 24-48 hours before the MRI scan is performed.; Other: Placebo patch; Placebo patch identical to the estradiol patch will be applied 24-48 hours before the MRI scan is performed.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Amygdala Response to Fearful Faces Stimuli	Responses to threat cues are assessed by functional magnetic resonance imaging (fMRI) responses as participants view 15 blocks each of fearful face and neutral face stimuli, while amygdala reactivity is measured. The amygdala is separated in the right and left hemispheres, and subdivided into the basolateral amygdala and central amygdala. Across voxels in each region a contrast estimate of Fearful > Neutral faces was extracted. The contrast estimate is a standard reporting format for task-based fMRI data, and reflects the magnitude of blood oxygen level dependent (BOLD) activation difference between two experimental conditions. Contrast estimates are an arbitrary, unitless comparison of fMRI BOLD signal units of one experimental condition versus another (threat vs. neutral stimuli). Higher values indicate greater amygdala reactivity to threat cues (vs. neutral cues), a PTSD-linked response pattern. Negative values indicate stronger amygdala reactivity to neutral cues than threat cues.	Early-cycle for Cohort 1 (mean 4.5 (sd=1.5) days following onset of menstrual period) or Mid-cycle for cohort 2 (mean 5.5 (sd=1.4) days following a positive urine luteinizing hormone test) during cycles 2 and 3 (each cycle is an average of 28 days)
Amygdala Response to Fear Conditioning Task	Indicators of fear conditioning are assessed by fMRI during the fear conditioning tasks. Deficits in fear inhibition have been present in persons with PTSD and during phases of the ovarian cycle. The amygdala is subdivided into the basolateral amygdala and central amygdala. Across voxels in each region a contrast estimate of conditioned stimulation (CS)+ (conditioned threat cues) > CS- (conditioned safety cues) was extracted. The contrast estimate reflects the magnitude of BOLD activation difference between two experimental conditions. Contrast estimates are an arbitrary, unitless comparison of fMRI BOLD signal units of one experimental condition versus another. Positive values indicate strong responsivity to conditioned threats, which could indicate either fear- or memory-related responses. Strong positive values indicate high responsivity to the conditioned threat (CS+), a pattern often associated with PTSD. Negative values indicate greater responsivity to safety cues (CS-).	Early-cycle for Cohort 1 (mean 4.5 (sd=1.5) days following onset of menstrual period) or Mid-cycle for cohort 2 (mean 5.5 (sd=1.4) days following a positive urine luteinizing hormone test) during cycles 2 and 3 (each cycle is an average of 28 days)
Ventromedial Prefrontal Cortex (vmPFC) Activation During the Fear Extinction Task	Indicators of fear extinction are assessed by fMRI during the fear extinction tasks. Fear extinction is impaired in persons with PTSD and depends on the vmPFC and its inhibition of amygdala responses to threat stimuli. The vmPFC region is defined using the anatomical boundaries of Brodmann area 25 (BA25). Across voxels in this region, a mean contrast estimate of CS+ > CS- in late extinction was extracted. The contrast estimate reflects the magnitude of BOLD activation difference between experimental conditions. Contrast estimates are a unitless comparison of fMRI BOLD signal units of one experimental condition versus another. These values indicate responsivity to conditioned threats. For the vmPFC, a positive value often indicates regulation of emotion or fear now that the threat cues have been extinguished. Strong positive values indicate higher engagement of this region to the conditioned threat (CS+). Negative values indicate higher engagement of this region to safety cues (CS-).	Early-cycle for Cohort 1 (mean 4.5 (sd=1.5) days following onset of menstrual period) or Mid-cycle for cohort 2 (mean 5.5 (sd=1.4) days following a positive urine luteinizing hormone test) during cycles 2 and 3 (each cycle is an average of 28 days)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (PCL-5)	The severity of self-reported PTSD symptoms will be assessed with the PCL-5. The PCL-5 asks participants to recall the worst stressful event that is currently bothering them the most. Keeping this event in mind, participants respond to 20 questions indicating how bothered they have been by PTSD symptoms. Responses are on a 5-point scale, where 0 = not bothered at all and 4 = extremely bothered. Total raw scores range from 0 to 80 where higher scores indicate greater distress from PTSD symptoms.	Early-cycle for Cohort 1 (mean 4.5 (sd=1.5) days following onset of menstrual period) or Mid-cycle for cohort 2 (mean 5.5 (sd=1.4) days following a positive urine luteinizing hormone test) during cycles 2 and 3 (each cycle is an average of 28 days)
Beck Depression Inventory (BDI)	The BDI-II is a 21-item instrument assessing depression. Respondents indicate how severe their feelings of depression symptoms are on a scale of 0 (not present) to 3 (most severe). Total raw scores range from 0 to 63, with higher scores indicating greater severity of depression.	Early-cycle for Cohort 1 (mean 4.5 (sd=1.5) days following onset of menstrual period) or Mid-cycle for cohort 2 (mean 5.5 (sd=1.4) days following a positive urine luteinizing hormone test) during cycles 2 and 3 (each cycle is an average of 28 days)

Collaborators and Investigators

• Sponsor: Emory University
• Collaborators: National Institute of Mental Health (NIMH)
• Investigators: Principal Investigator: Jennifer Stevens, PhD, Emory University

Publications and helpful links

General Publications

• Hinojosa CA, DelRosario D, Davis M, Roeckner AR, Oliver KI, Taylor L, Santos JLC, Dahlgren K, Ely TD, Zeleke H, Murphy AR, Merrill NA, Young MR, Braden AL, van Rooij SJH, Wallen K, Michopoulos V, Powers A, Nugent NR, Stevens JS. Cyclical alcohol craving is linked with estradiol-based modulation of ventral tegmental area functional connectivity and is blunted by childhood maltreatment. Biol Psychiatry Cogn Neurosci Neuroimaging. 2026 Jun 22:S2451-9022(26)00179-5. doi: 10.1016/j.bpsc.2026.06.004. Online ahead of print.

Study record dates

Study Major Dates

• Study Start (Actual): November 11, 2019
• Primary Completion (Actual): April 30, 2025
• Study Completion (Actual): April 30, 2025

Study Registration Dates

• First Submitted: May 30, 2019
• First Submitted That Met QC Criteria: June 3, 2019
• First Posted (Actual): June 4, 2019

Study Record Updates

• Last Update Posted (Actual): July 22, 2026
• Last Update Submitted That Met QC Criteria: June 24, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: Estrogen; Stress Disorder
• Additional Relevant MeSH Terms: Trauma and Stressor Related Disorders; Mental Disorders; Wounds and Injuries; Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic; Physiological Effects of Drugs; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Estrogens; Ortho Evra
• Other Study ID Numbers: IRB00103595; 1R01MH117009-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: There is an agreement with the National Institute of Mental Health (NIMH) to share deidentified data with Research Domain Criteria (RDoC) database (a centralized NIH database). Raw neuroimaging data and behavioral data for the 3 tasks (Fearful Faces, Fear Conditioning, Fear Extinction), T1 structural brain images, non-identifying demographics, PTSD Checklist for DSM-5 (PCL-5), and Beck Depression Inventory (BDI) will be shared.
• IPD Sharing Time Frame: Data will be uploaded to the database every 6 months following the standard NIH schedule (Jan 15 and July 15 of each year of funding). Data will be released publicly within 4 months after submission.
• IPD Sharing Access Criteria: Data access requests will be submitted to RDoC database, and approved by NIH before data are shared. Only research investigators sponsored by an NIH recognized institution with federal wide assurance will receive access. Any analysis approved by NIH. Web-based access to the RDoC data archive.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No