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Recent evidence exploring the associations between physical activity and menopausal symptoms in midlife women: perceived risks and possible health benefits
Women's Midlife Health volume 1, Article number: 1 (2015)
Although the health benefits of physical activity are well established, the prevalence of midlife women accumulating sufficient physical activity to meet current physical activity guidelines is strikingly low, as shown in United States (U.S.) based surveillance systems that utilize either (or both) participant-reported and device-based (i.e., accelerometers) measures of activity. For midlife women, these low prevalence estimates may be due, in part, to a general lack of time given more pressing work commitments and family obligations. Further, the benefits or “reward” of allocating limited time to physical activity may be perceived, by some, as too distant for immediate action or attention. However, shifting the health promotion message from the long term benefits of physical activity to the more short-term, acute benefits may encourage midlife women to engage in more regular physical activity. In this article, we review the latest evidence (i.e., past 5 years) regarding the impact of physical activity on menopausal symptoms. Recent studies provide strong support for the absence of an effect of physical activity on vasomotor symptoms; evidence is still inconclusive regarding the role of physical activity on urogenital symptoms (vaginal dryness, urinary incontinence) and sleep, but consistently suggestive of a positive impact on mood and weight control. To further advance this field, we also propose additional considerations and future research directions.
The aging of the baby boomer cohort, born in the United States (U.S.) between mid-1946 and mid-1964 , has resulted in increased interest in strategies to optimize the health and well-being of midlife adults (ages 45 to 64 years). Indeed, research efforts specifically targeting midlife women, in particular, has increased exponentially in recent years. This interest may be due, in part, to the relatively recent recognition that sex differences exist, not only with regards to the incidence and/or prevalence of various health outcomes, but also with the prevalence of health behaviors (e.g., not meeting physical activity guidelines) that increase one’s disease and/or mortality risk.
Physical activity is a viable strategy to reduce the burden of chronic disease and disability. Strategies to increase physical activity at the individual- and population- level are particularly appealing given the strong evidence demonstrating the multiplicity of health benefits, including reduced risk of premature death, coronary heart disease (CHD), stroke, hypertension, hyperlipidemia, type 2 diabetes, metabolic syndrome, breast and colon cancer, and depression . Further, since physical activity is a behavior and, thus, is modifiable, it is an excellent target for health promotion interventions focused on prevention.
Yet, despite the well-established health benefits of regular, habitual physical activity, few midlife women are accumulating sufficient levels to meet physical activity guidelines. Current U.S. based aerobic guidelines encourage: (1) ≥150 min per week of moderate intensity physical activity, (2) ≥75 min per week of vigorous intensity physical activity or (3) an equivalent combination of moderate and vigorous intensity physical activity (MVPA) . The guidelines also recommend that adults participate in muscle-strengthening activities, across all major muscle groups, on ≥2 days per week. Based on 2013 Behavioral Risk Factor Surveillance System (BRFSS) data , 28.2 % (Standard Error (SE) ± 0.41) of women aged 45 to 54 years met the aerobic physical activity guidelines only, 6.0 % (SE ± 0.20) met muscle-strengthening guidelines only, and 14.8 % (SE ± 0.30) met both the aerobic and muscle-strengthening guidelines. Among women aged 55 to 64 years, the prevalence estimates for meeting guidelines were similar: 28.5 % (SE ± 0.37), 5.6 % (SE ± 0.19), and 13.7 % (SE ± 0.26) met aerobic guidelines only, muscle-strengthening guidelines only, or met both guidelines, respectively . In the 2003–04 and 2005–06 cycles of the National Health and Nutrition Examination Survey (NHANES) , physical activity levels of a U.S. representative sample were also directly measured via accelerometers. The prevalence estimates for meeting physical activity guidelines were strikingly lower than those obtained in BRFSS using self-reported methods (as reported above). Using NHANES 2003–06 accelerometer data, only 26.7 % (SE ± 2.4) and 18.0 % (SE ± 2.6) of midlife women, aged 45–54 and 55 to 56 years, respectively, met aerobic guidelines. To be consistent with the wording of the 2008 Physical Activity Guidelines for Americans , meeting physical activity guidelines was defined as any accumulated time (minutes per day) spent above the moderate- intensity threshold (1952 counts per minute ), and did not necessarily occur in prolonged activity bouts. It is important to note that these low prevalence estimates may be due, in part, to functional limitations that emerge during midlife. Previous studies have found that 20–40 % of midlife women reported moderate to severe physical limitations [7, 8], which could serve as a significant barrier to engaging in sufficient, higher intensity physical activity to meet current physical activity guidelines.
Previous studies have suggested that another barrier to engaging in sufficient physical activity is a “lack of time” [9–11]. This is certainly a tangible barrier for midlife women given that during this stage of adulthood, women often find themselves “sandwiched” between caring for both dependent children and aging parents . In addition, many midlife women are working outside the home; according to 2013 BRFSS data , 56.6 % (SE ± 0.46) and 43.1 % (SE ± 0.41) women aged 45 to 54 and 55 to 64 years, respectively, reported being employed for wages. Additionally, self-employment was reported in 8.6 % (SE ± 0.28) and 7.1 % (SE ± 0.21) of women aged 45 to 54 years and 55 to 64 years, respectively. Work demands and family obligations, therefore, frequently compete with the desire for leisure time activities such as physical activity, given the limited amount of time (i.e., leisure time) available during a day.
Principles of behavioral economics posit that decisions about being physically active involve trade-offs relative to fixed resources . Thus, allocating time to recreational physical activity, given other competing demands, may be perceived as a “risk” for midlife women. However, individuals may undertake this risk, if the perceived “rewards” are sufficiently adequate and/or valued. The risk of developing the top three leading causes of death in women (i.e., coronary heart disease, cancer, and stroke)  increases with age, with risk escalating after age 65 [15, 16]. While midlife women are at immediate risk for developing these conditions, they may not perceive that a reduction in disease risk, that may be manifested in the future, is an adequate reward given the immediate risk of needing to allocate ≥ 30 min per day for physical activity in their already full schedules.
One potential strategy to alter the risk/benefit ratio and increase the prevalence of midlife women meeting physical activity guidelines may be to target health promotion messages centered on the benefit of physical activity for more acute health outcomes or concerns, such as a reduction in- or relief from- menopausal symptoms. A 2005 review paper by Woods and Mitchell  summarized the prevalence of menopausal symptoms from published community-based longitudinal studies of the menopausal transition by Staging Reproductive Aging Workshop (STRAW) criteria, whenever possible. The prevalence of reported vasomotor symptoms ranged from 6 to 13 % in the late reproductive phase to as high as 79 % among postmenopausal women. The prevalence of reported vaginal dryness ranged from 3 % of women in the reproductive stage to 47 % among women who were 3 years postmenopausal. According to data from the Study of Women’s Health Across the Nation (SWAN), Sampselle et al.  found that 57 % of study participants reported urinary incontinence with 15 % reporting it as moderate and 10 % as severe. The prevalence of reported sleep disturbances ranged from 31 % of women in the reproductive phase to 45 % among women who are 3 years postmenopausal. With regards to reported depressed mood symptoms, the prevalence estimates ranged from 19 to 29 %. Several other longitudinal investigations have reported significant increases in mean body weight and other markers of adiposity (e.g., waist circumference and fat mass) during the menopausal transition [19–22]. In addition to the moderate to high prevalence of reported menopausal symptoms in mid-life women, other studies [23, 24] suggest that these symptoms may persist for a substantial portion of the menopausal transition. For example, a recent (2015) longitudinal SWAN analysis found that vasomotor symptoms persisted for a median duration of 7.4 years , and even longer among some demographic groups such as Black women.
Therefore, if women were convinced that physical activity would improve their most salient and disturbing symptoms, they might accept the “risk” of allocating valuable time to be physically active in exchange for the “reward” of symptom relief. They would also, as a secondary, longer-term reward, gain additional benefit in relation to chronic disease and disability prevention. The purpose of this paper is to evaluate whether this health promotion message is tenable by reviewing the recent literature (i.e., past 5 years) reporting on the effect of physical activity on menopausal symptoms. The selection of menopausal symptoms included in this review were based on the prevalence estimates reported by Woods et al.  We also provide commentary on the strengths and limitations of the existing research, and propose future research directions.
The recent literature, published with the past 5 years (i.e., January 01, 2010 to February 28, 2015), exploring the association of physical activity with menopausal symptoms that are frequently reported by midlife women was reviewed and summarized . Menopausal symptoms targeted in this literature review include those related specifically to hormonal changes that characterize the menopausal transition (i.e., vasomotor symptoms, including hot flashes and night sweats, and vaginal dryness) and more general symptoms that are characteristic of midlife and/or the normal aging process (i.e., urinary incontinence, sleep quality and/or sleep disturbances, psychological distress, and weight gain). While all selected studies for this review are included in the summary tables, investigations utilizing prospective cohort-, quasi-experimental-, or experimental- study designs are highlighted in the text. Studies were not included in this review if more general symptom categories (e.g., urogenital symptoms versus urinary incontinence) were ascertained and/or reported by study investigators. This literature review summarizes the major findings from 14 cross-sectional studies [27–40], 2 longitudinal studies [41, 42], 7 prospective cohort studies [43–49], 1 non-randomized intervention studies , and 9 randomized controlled trials (RCT) [51–59] (see Tables 1, 2, 3, 4, 5 and 6).
Potential biological mechanisms: physical activity and menopausal symptoms
Physical activity has both acute and chronic physiological and psychological effects, many of which could help to alleviate menopausal symptoms and other complaints of midlife women. Even though the specific etiology of vasomotor symptoms remains unclear, hot flashes and night sweats are the result of neuroendocrine processes at the level of the hypothalamus . One hypothesis for how physical activity might alleviate vasomotor symptoms is through the impact of physical activity on neurotransmitters (e.g., β-endorphins) which regulate thermoregulation . Similarly, physical activity, which increases sympathetic nervous system activity, could alleviate the vaginal dryness which results from the declines in circulating estrogen characteristic of menopause  by increasing sexual arousal and lubrication . However, it is unclear if this is an acute effect of physical activity or if the increased lubrication persists at rest. The benefit of physical activity for reduced risk of urinary incontinence is likely mediated through obesity. Previous studies have indicated that obesity is a risk factor for urinary incontinence and studies have shown that weight loss can result in urinary incontinence remission . The mechanisms by which physical activity may improve sleep quality include associated reductions in anxiety and depression. More directly, physical activity has been shown to promote increases in slow wave sleep, which is indicative of good sleep quality. Physical activity may also impact sleep through favorable influences on circadian functioning . As reported by Dugan et al., the proposed biological mechanisms supporting the beneficial role of physical activity for preventing or reducing depression include: reduced inflammation, increased neurotransmitter (i.e., dopamine and serotonin) levels, and increased endorphin secretion . Finally, physical activity contributes to prevention of weight gain and promotion of weight loss and reduces risk of adiposity-related outcomes because physical activity is a key component of total energy expenditure (i.e., ~20 % of total energy expenditure) .
Physical activity and vasomotor symptoms
Table 1 summarizes the recent evidence examining the association between physical activity and vasomotor symptoms, including hot flashes and night sweats. In a 15-day longitudinal study, Elavsky et al.  found an acute bout of exercise (30 min of moderate intensity exercise) decreased subjective and objectively determined hot flashes, but had no impact on night sweats. Also, daily physical activity estimates (detected via accelerometry during the 15-day observation period) were not associated with reported hot flash frequency, although less fit participants reported more hot flashes on days when they engaged in more activity than usual. In another longitudinal study by Elavsky and colleagues , participants concurrently wore an accelerometer and reported daily hot flashes via an electronic personal digital assistant for 30 consecutive days. Statistically significant same-day and cross-lagged (previous day’s physical activity compared to hot flashes the next day) associations were highly variable in both magnitude and direction. Three recent prospective cohort studies have also been conducted, including one showing a null association , another showing an increased risk of hot flashes among women classified as active , and the third reporting significantly fewer hot flashes in women classified in the highest active group (i.e., maintained or increased to >60 min per day over 12-weeks) . A non-randomized intervention study also reported a significant decrease in reported hot flashes and night sweats following a 6-month aerobic program , and the same general finding was seen in a small randomized control trial of Turkish women (n = 42) .
In contrast, the evidence from the majority of randomized controlled trials, including results from the 2 × 3 Factorial Menopause Strategies: Finding Lasting Answers for Symptoms & Health (MsFLASH) Study, shows no association between physical activity and vasomotor symptoms [54, 56]. For MsFLASH, women were recruited from three sites: Indianapolis, IN, Oakland, CA, and Seattle, WA and were randomized (3:3:4) to 12 weeks of exercise, yoga, or usual activity and further randomized to (1:1) to omega-3 fish oil or a placebo. Women in the yoga group performed one, 90 min session of supervised yoga per week and 20 min of unsupervised yoga on all other days. The exercise group participated in an individualized, supervised aerobic program (3 times per week, 40–60 min per session) with a progressively increasing energy expenditure goal. During month 1, the prescribed workload was 50–60 % of heart rate reserve. In months 2 and 3, heart rate reserve was increased to 60–70 % heart rate reserve . Activity modes included: treadmill, elliptical trainer, or stationary bike. Heart rate and perceived exertion was recorded every 5–10 min by trained supervisors . The usual activity group were instructed to follow their usual activity patterns and were asked to not begin a yoga or new exercise program [55, 56]. Reed et al.  reported that after the 12-week program, the yoga group had significant improvements in reported vasomotor symptoms, obtained via the 29-item Menopausal Quality of Life Questionnaire (MENQOL), when compared to the usual activity group. However, when the frequency and intensity of vasomotor systems were obtained using more sophisticated daily diaries, yoga had no effect on the vasomotor symptoms when compared to the usual activity group . This null association was also found when comparing the reported frequency and burden of vasomotor symptoms via daily diaries between the exercise and usual activity groups . This evidence from the more rigorous RCT studies largely supports the 2014 Cochrane Report by Daley et al. , which concluded there was insufficient evidence to demonstrate that physical activity is an effective treatment for management of vasomotor symptoms.
Physical activity and vaginal dryness
As shown in Table 2, the recent evidence from cross-sectional studies examining the association between physical activity and vaginal dryness is mixed [33, 34], while a prospective cohort study  of Brazilian women by de Azevedo Guimaraes and colleagues found no association between habitual physical activity and vaginal dryness. Similarly, a non-randomized intervention study found no pre- to post- exercise program difference in vaginal dryness after 6-months . Yet, in a randomized controlled trial of Finnish women  the prevalence of vaginal dryness decreased pre- to post intervention following a 6-month, unsupervised aerobic training program (4 times per week, 50 min per session at 64–80 % of maximal heart rate) in the treatment group versus control.
Table 3 presents the evidence regarding the association between physical activity and urinary symptoms, including incontinence. In the prospective cohort study of Brazilian women by de Azevedo Guimaraes et al., women classified in the highest active group (maintained or increased to >60 min per day), reported less instances of leaking urine than those classified as low or moderately active at the 12-week follow-up , and in the non-randomized intervention study by Karacan , there was a reduction in urinary symptoms following a 6-month aerobic exercise program. However, in the Finnish randomized controlled study, there was no change in urinary symptoms as a result of a 6-month aerobic exercise program . When interpreting these findings it is important to note that associations were not adjusted for change in body weight, which is unfortunate given the proposed underlying biological mechanism between physical activity and urinary incontinence.
Sleep quality and disturbances
Cross-sectional studies have generally shown better sleep quality and/or fewer sleep disturbances among physically active women (Table 4); this association was also shown in the non-randomized intervention study by Karacan  and has been largely confirmed in recent evidence from randomized controlled trials. Utilizing data from the Dose–response to Exercise in postmenopausal Women (DREW) Study , participants randomized to any of the three exercise groups reported improvements in sleep quality when compared to the control group. Further, a dose–response effect was shown with reported sleep quality across the exercise groups, with the magnitude of the effect increasing with each increase in exercise dose. The exercise intervention arms were designed specifically to reflect 50 %, 100 % or 150 % of the National Institutes of Health (NIH) Consensus Panel physical activity recommendations . Further, the odds of reporting a significant sleep disturbance were also lower with a dose response relation in all exercise groups compared to the controls. The beneficial effect of physical activity on sleep quality was also shown in two additional randomized control studies, including the Finnish study  and the MsFLASH trial . The Advisory Committee for the development of the 2008 Physical Activity Guidelines for Americans , concluded that the evidence supporting the benefit of physical activity for improved sleep quality was moderate. These findings will likely provide additional support for the next iteration of the Guidelines.
Psychological distress: depression and anxiety
As shown in Table 5, the majority of the recent evidence in midlife women supports an inverse association between physical activity and depressive symptoms, including anxiety. Indeed of six recent cross-sectional studies [27, 30, 31, 35–37], only one study  found no difference in depressive symptoms by regular exercise status (≥3 times per week). In the prospective cohort study of Brazilian women, de Azevedo Guimaraes et al. , found improved psychological symptoms after 12-weeks in the high active group. This was also shown in an analysis of SWAN participants. Here, those classified as meeting physical activity guidelines had a lower odds of depression than inactive participants and this finding persisted over 10 years . Karacan  also reported a reduction in psychological symptoms, including depressive mood, irritability, and anxiety after 3 and 6 months of participation in an aerobic exercise program. There was also a statistically significant reduction in exhaustion from baseline to 3 and 6 months. Of the four studies detailing findings from randomized controlled studies, all demonstrated a beneficial effect of physical activity for psychological symptoms including depressive symptoms [51, 56, 57], mood swings , and anxiety symptoms  when compared to a control [51, 53, 57] or usual activity group . However, the impact of the physical activity intervention on depressive symptoms did not reach statistical significance in the MsFLASH Study  due to a more conservative alpha level to account for multiple comparisons (α = p < 0.028). These findings generally support the conclusions of the 2008 Physical Activity Guidelines for Americans  Advisory Committee that rated the evidence pertaining to the benefit of physical activity for reduced risk of depression as strong.
Table 6 outlines the recent evidence including three prospective cohort studies [47–49] and one non-randomized intervention study , supporting an inverse association between physical activity and weight gain Cross-sectional studies were not included in this review because the outcome was weight change or weight loss over time,. In a study by Choi and colleagues , 346 participants from the Biobehavioral Health in Diverse Midlife Women Study, the 2-year change in physical activity was categorized as increase, decrease, or maintained. Participants who increased physical activity levels had significantly less weight gain and less of an increase in waist circumference when compared to those who decreased physical activity levels, after controlling for age, initial physical activity and relevant outcome value (both p < 0.05). Similarly, in an analysis of Nurses’ Health Study II participants , a 30-min increase in leisure-time physical activity levels between 1989 and 2005 was significantly associated with less weight gain [−1.31 kg (95 % CI: −1.44, −1.18)], and these same findings were found for the associations with weight change and walking and bicycling, specifically [−1.81 kg (95 % CI: −2.05, −1.56) and −1.59 kg (95 % CI: −2.09, −1.08), respectively]. In an analysis of 58,610 Women’s Health Initiative participants , the associations between physical activity groups (sedentary, low-, moderate-, and high- active) and weight change were examined by age group (50–59 years, 60–69 years, and 70–79 years). Interestingly, Sims et al., reported that among the youngest age group, women in the moderate activity group experienced a significant weight loss [−0.30 (95 % CI: −0.53, −0.07) compared to the sedentary group. Yet, in women aged 70–79 years, higher physical activity was associated with the attenuation of the expected age-related weight loss due to loss of lean mass observed in this age group [0.34 (95 % CI: 0.04, 0.63). Authors posit that this attenuation in weight loss was due to the retention of lean muscle mass rather than a loss in adipose tissue . Finally, Karacan  reported a significant decrease in body weight, body mass index (BMI), and body fat percentage (via skinfolds) after a 6-month supervised, aerobic-based physical activity program. However, these associations were not adjusted for potential confounders or other covariates. These findings generally support the conclusions of the 2008 Physical Activity Guidelines for Americans  Advisory Committee that rated the evidence supporting the benefit of physical activity for the prevention of weight gain and promotion of weight loss as strong, particularly when combined with reduced dietary intake. There is also currently moderate to strong evidence to support the inverse association between physical activity and abdominal adiposity.
The recent evidence, accumulated over the past 5 years, regarding the association between physical activity and hormone-related (i.e., primary) menopausal symptoms in midlife women generally mirrors previous research in this area in that the evidence remains either null or inconclusive. However, with more general health outcomes that result from biological aging, including poor sleep quality, increased depressive symptoms, and weight gain, the evidence supporting the beneficial effect of physical activity is quite conclusive. For primary menopausal symptoms, the inconsistencies across studies may be due to differences in targeted study populations. (i.e., study eligibility based on general age range, reflecting midlife versus menopausal status) as well as measurement strategies used to assess physical activity and menopausal symptom outcomes. Further, many studies did not examine and/or report the observed physical activity-menopausal symptom associations by menopausal status. This is particularly important given that the prevalence and severity of reported symptomology varies by menopausal status, as reported by Woods et al. . Finally, for studies including a physical activity intervention component, there have also been distinct differences in the specific targets in terms of prescribed activity mode (i.e., aerobic versus resistance), frequency, intensity, and duration.
While it is intuitive that physical activity measurement strategies may vary across studies due to differences in the target population (e.g., race and cultural differences, menopausal status), a preponderance of studies included in this review utilized physical activity questionnaires with unreported and/or unknown measurement properties. This is despite recently published evaluation studies demonstrating the test-retest reliability and validity of physical activity questionnaires designed specifically for midlife women . It is well-established that physical activity behaviors in women are quite different than in men and can vary by activity domain and/or preferred activity type . For example, midlife women may accumulate the majority of their daily physical activity in domestic pursuits (e.g., caretaking) and walking or yoga during leisure-time. Therefore, it is critically important that, whenever possible, physical activity questionnaires used in this population are structured to elicit the most accurate information (i.e., reliable and valid) on the types of physical activities that are most pertinent to midlife women. This practice was implemented in a few studies included in this review that utilized more established questionnaires including, the International Physical Activity Questionnaire (IPAQ), Kaiser Physical Activity Survey (KPAS), or Modifiable Activity Questionnaire (MAQ) was used. A few additional studies included in this review used accelerometers, with known measurement properties, to quantify the physical activity exposure [41, 42].
Another weakness is that several observational studies included in this review, classified participants into physical activity groups in analyses, and did not provide details on the threshold limits used to distinguish groups. While these categories, distinguishing non-exerciser from exerciser or low and moderate active from high active, may have acceptable internal study validity, the categorization is a substantial limitation to interpreting overall study findings within the context of the entire body of literature relevant to physical activity and menopausal symptoms during midlife. Further, the practice of utilizing cut-point thresholds that are not meaningful from a clinical or public health standpoint may increase the likelihood for potential misclassification bias of the physical activity exposure and also lead to spurious findings.
Since there is currently a lack of evidence regarding the specific dose of physical activity that confers menopausal symptom risk reduction, threshold values used for analysis should be based on meaningful categories that reflect current physical activity recommendations for general health benefit . This same practice should also be applied when designing physical activity interventions. The specific physical activity targets or components of interventions should allow participants to accumulate at least 150 min of moderate intensity physical activity per week to reflect current physical activity guidelines . However, it is important to note that midlife women may also have pre-existing disease or disability that may preclude their ability to fully meet recommended physical activity levels. For these women, even low to moderate increases in daily physical activity may be beneficial to health, which is also noted in the 2008 Physical Activity Guidelines for Americans . Further, the intervention should include activity modes or types that are common and acceptable among midlife women, including brisk walking or bicycling. These intervention specific details should be included in the methods section of all peer-reviewed publications to facilitate the interpretation of the study findings. The MsFLASH [54–56] and DREW studies  provide excellent examples of how best to implement these recommendations when designing and/or reporting findings from physical activity intervention studies.
In summary, the recent evidence has not provided much clarity regarding the role of physical activity with menopausal symptoms in mid-life women beyond what was already known . Yet, the evidence supporting the beneficial role of physical activity for more general health outcomes, including sleep quality, psychological distress, and weight gain, is quite conclusive. Given the considerable prevalence of sleep disturbances , depressive symptoms [72, 73], and overweight/obesity  in midlife women, health care and physical fitness professionals should encourage their patients or clients to engage in regular physical activity levels to reduce risk of these important health outcomes. For some midlife women, this may be sufficient “reward” to overcome the “risk” of allocating sufficient time, in an already busy schedule, to be physically active. In addition, midlife is a particularly vulnerable period when individuals are at immediate risk for disability, and there is moderate to strong evidence to support the beneficial role of physical activity for optimizing functional health and reducing risk of falls among older adults . However, midlife women initiating a new exercise program should strive to make small, incremental increases in physical activity levels over time to reduce risk of acute musculoskeletal injuries, including sprains and strains . Finally, while the evidence is still accumulating regarding the role of physical activity for specific menopausal symptoms, health care professionals should periodically remind midlife women that they will experience a reduced lifetime risk of chronic disease and disability development if they remain physically active as they age.
Hogan H, Perez D, Bell WR. Who (Really) are the first baby boomers? In: Statistical meetings proceedings, social statistics section; Alexandria, VA. 2008.
U.S. Department of Health and Human Services. Physical activity guidelines advisory committee report. 2008. Available from: http://www.health.gov/paguidelines/report/pdf/CommitteeReport.pdf. Accessed: June 18, 2015.
U.S. Department of Health and Human Services. 2008 Physical activity guidelines for Americans. 2008. Available from: http://www.health.gov/paguidelines/pdf/paguide.pdf. Accessed: June 18, 2015.
U.S. Department of Health and Human Services. Behavioral Risk Factor Surveillance System [database on the Internet]. Centers for Disease Control and Prevention. 2013. Available from: http://www.cdc.gov/brfss/annual_data/annual_2013.html. Accessed: January 24, 2015.
U.S. Department of Health and Human Services. National Health and Nutrition Examination Survey, Accelerometer Data 2003–04 & 2005–06 [database on the Internet]. Available from: http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. Accessed: January 25, 2015.
Freedson PS, Melanson E, Sirard J. Calibration of the Computer Science and Applications, Inc. accelerometer. Med Sci Sports Exerc. 1998;30(5):777–81.
Sowers M, Pope S, Welch G, Sternfeld B, Albrecht G. The association of menopause and physical functioning in women at midlife. J Am Geriatr Soc. 2001;49(11):1485–92.
Tseng LA, El Khoudary SR, Young EA, Farhat GN, Sowers M, Sutton-Tyrrell K, et al. The association of menopause status with physical function: the Study of Women’s Health Across the Nation. Menopause. 2012;19(11):1186–92.
Wilcox S, Castro C, King AC, Housemann R, Brownson RC. Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. J Epidemiol Community Health. 2000;54(9):667–72.
King AC, Castro C, Wilcox S, Eyler AA, Sallis JF, Brownson RC. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychol. 2000;19(4):354–64.
Heesch KC, Masse LC. Lack of time for physical activity: perception or reality for African American and Hispanic women? Women Health. 2004;39(3):45–62.
Pierret CR. The ‘sandwich generation’: women caring for parents and children. Mon Labor Rev. 2006;129(9):3.
Leonard T, Shuval K, de Oliveira A, Skinner CS, Eckel C, Murdoch JC. Health behavior and behavioral economics: economic preferences and physical activity stages of change in a low-income African-American community. Am J Health Promot. 2013;27(4):211–21.
U.S. Department of Health and Human Services. Centers for Disease Control and Prevention: Leading Causes of Death in Females by Age Group. 2011. http://www.cdc.gov/women/lcod/. Accessed June 9 2015.
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–322.
American Cancer Society. Cancer facts & figures 2015. 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. Accessed June 9 2015.
Woods NF, Mitchell ES. Symptoms during the perimenopause: prevalence, severity, trajectory, and significance in women’s lives. Am J Med. 2005;118(Suppl 12B):14–24.
Sampselle CM, Harlow SD, Skurnick J, Brubaker L, Bondarenko I. Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstet Gynecol. 2002;100(6):1230–8.
Sternfeld B, Wang H, Quesenberry Jr CP, Abrams B, Everson-Rose SA, Greendale GA, et al. Physical activity and changes in weight and waist circumference in midlife women: findings from the Study of Women’s Health Across the Nation. Am J Epidemiol. 2004;160(9):912–22.
Sowers M, Zheng H, Tomey K, Karvonen-Gutierrez C, Jannausch M, Li X, et al. Changes in body composition in women over six years at midlife: ovarian and chronological aging. J Clin Endocrinol Metab. 2007;92(3):895–901.
Guthrie JR, Dennerstein L, Dudley EC. Weight gain and the menopause: a 5-year prospective study. Climacteric. 1999;2(3):205–11.
Lovejoy JC, Champagne CM, de Jonge L, Xie H, Smith SR. Increased visceral fat and decreased energy expenditure during the menopausal transition. Int J Obes (Lond). 2008;32(6):949–58.
Freeman EW, Sammel MD, Lin H, Gracia CR, Pien GW, Nelson DB, et al. Symptoms associated with menopausal transition and reproductive hormones in midlife women. Obstet Gynecol. 2007;110(2 Pt 1):230–40.
Dennerstein L, Dudley EC, Hopper JL, Guthrie JR, Burger HG. A prospective population-based study of menopausal symptoms. Obstet Gynecol. 2000;96(3):351–8.
Avis NE, Crawford SL, Greendale G, Bromberger JT, Everson-Rose SA, Gold EB, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531–9.
Sowers M, Harlow S, Karvonen C, Bromberger J, Cauley JA, Gold EB et al. Menopause: Its Epidemiology. Women and Health. Academic Press; 2013.
Canario AC, Cabral PU, Spyrides MH, Giraldo PC, Eleuterio Jr J, Goncalves AK. The impact of physical activity on menopausal symptoms in middle-aged women. Int J Gynaecol Obstet. 2012;118(1):34–6.
Haimov-Kochman R, Constantini N, Brzezinski A, Hochner-Celnikier D. Regular exercise is the most significant lifestyle parameter associated with the severity of climacteric symptoms: a cross sectional study. Eur J Obstet Gynecol Reprod Biol. 2013;170(1):229–34.
Kandish J, Amend V. An exploratory study on perceived relationship of alcohol, caffeine, and physical activity on hot flashes in menopausal women. Health. 2010;2(9):989–96.
Mansikkamaki K, Raitanen J, Malila N, Sarkeala T, Mannisto S, Fredman J, et al. Physical activity and menopause-related quality of life - a population-based cross-sectional study. Maturitas. 2015;80(1):69–74.
Moilanen J, Aalto AM, Hemminki E, Aro AR, Raitanen J, Luoto R. Prevalence of menopause symptoms and their association with lifestyle among Finnish middle-aged women. Maturitas. 2010;67(4):368–74.
Pimenta F, Leal I, Maroco J, Ramos C. Perceived control, lifestyle, health, socio-demographic factors and menopause: impact on hot flashes and night sweats. Maturitas. 2011;69(4):338–42.
Tan MN, Kartal M, Guldal D. The effect of physical activity and body mass index on menopausal symptoms in Turkish women: a cross-sectional study in primary care. BMC Womens Health. 2014;14(1):38.
Aydin Y, Hassa H, Oge T, Yalcin OT, Mutlu FS. Frequency and determinants of urogenital symptoms in postmenopausal Islamic women. Menopause. 2014;21(2):182–7.
Timur S, Sahin NH. The prevalence of depression symptoms and influencing factors among perimenopausal and postmenopausal women. Menopause. 2010;17(3):545–51.
Vallance JK, Murray TC, Johnson ST, Elavsky S. Quality of life and psychosocial health in postmenopausal women achieving public health guidelines for physical activity. Menopause. 2010;17(1):64–71.
Chang SJ, Chee W, Im EO. Menopausal symptoms and physical activity in multiethnic groups of midlife women: a secondary analysis. J Adv Nurs. 2013;69(9):1953–65.
Casas RS, Pettee Gabriel KK, Kriska AM, Kuller LH, Conroy MB. Association of leisure physical activity and sleep with cardiovascular risk factors in postmenopausal women. Menopause. 2012;19(4):413–9.
Lambiase MJ, Thurston RC. Physical activity and sleep among midlife women with vasomotor symptoms. Menopause. 2013;20(9):946–52.
Kline CE, Irish LA, Krafty RT, Sternfeld B, Kravitz HM, Buysse DJ, et al. Consistently high sports/exercise activity is associated with better sleep quality, continuity and depth in midlife women: the SWAN sleep study. Sleep. 2013;36(9):1279–88.
Elavsky S, Gonzales JU, Proctor DN, Williams N, Henderson VW. Effects of physical activity on vasomotor symptoms: examination using objective and subjective measures. Menopause. 2012;19(10):1095–103.
Elavsky S, Molenaar PC, Gold CH, Williams NI, Aronson KR. Daily physical activity and menopausal hot flashes: applying a novel within-person approach to demonstrate individual differences. Maturitas. 2012;71(3):287–93.
Gibson C, Matthews K, Thurston R. Daily physical activity and hot flashes in the Study of Women’s Health Across the Nation (SWAN) Flashes Study. Fertil Steril. 2014;101(4):1110–6.
Gjelsvik B, Rosvold EO, Straand J, Dalen I, Hunskaar S. Symptom prevalence during menopause and factors associated with symptoms and menopausal age. Results from the Norwegian Hordaland Women’s Cohort study. Maturitas. 2011;70(4):383–90.
de Azevedo Guimaraes AC, Baptista F. Influence of habitual physical activity on the symptoms of climacterium/menopause and the quality of life of middle-aged women. Int J Womens Health. 2011;3:319–28.
Dugan SA, Bromberger JT, Segawa E, Avery E, Sternfeld B. Association between physical activity and depressive symptoms: midlife women in SWAN. Med Sci Sports Exerc. 2015;47(2):335–42.
Choi J, Guiterrez Y, Gilliss C, Lee KA. Physical activity, weight, and waist circumference in midlife women. Health Care Women Int. 2012;33(12):1086–95.
Lusk AC, Mekary RA, Feskanich D, Willett WC. Bicycle riding, walking, and weight gain in premenopausal women. Arch Intern Med. 2010;170(12):1050–6.
Sims ST, Larson JC, Lamonte MJ, Michael YL, Martin LW, Johnson KC, et al. Physical activity and body mass: changes in younger versus older postmenopausal women. Med Sci Sports Exerc. 2012;44(1):89–97.
Karacan S. Effects of a long-term aerobic exercise on physical fitness and postmenopausal symptoms with menopausal rating scale. Sci Sports. 2010;25(1):39–46.
Agil A, Abike F, Daskapan A, Alaca R, Tuzun H. Short-term exercise approaches on menopausal symptoms, psychological health, and quality of life in postmenopausal women. Obstet Gynecol Int. 2010;2010.
Luoto R, Moilanen J, Heinonen R, Mikkola T, Raitanen J, Tomas E, et al. Effect of aerobic training on hot flushes and quality of life--a randomized controlled trial. Ann Med. 2012;44(6):616–26.
Moilanen JM, Mikkola TS, Raitanen JA, Heinonen RH, Tomas EI, Nygard CH, et al. Effect of aerobic training on menopausal symptoms--a randomized controlled trial. Menopause. 2012;19(6):691–6.
Newton KM, Reed SD, Guthrie KA, Sherman KJ, Booth-LaForce C, Caan B, et al. Efficacy of yoga for vasomotor symptoms: a randomized controlled trial. Menopause. 2014;21(4):339–46.
Reed SD, Guthrie KA, Newton KM, Anderson GL, Booth-LaForce C, Caan B, et al. Menopausal quality of life: RCT of yoga, exercise, and omega-3 supplements. Am J Obstet Gynecol. 2014;210(3):244 e1-11.
Sternfeld B, Guthrie KA, Ensrud KE, LaCroix AZ, Larson JC, Dunn AL, et al. Efficacy of exercise for menopausal symptoms: a randomized controlled trial. Menopause. 2014;21(4):330–8.
Villaverde Gutierrez C, Torres Luque G, Abalos Medina GM, Argente del Castillo MJ, Guisado IM, Guisado Barrilao R, et al. Influence of exercise on mood in postmenopausal women. J Clin Nurs. 2012;21(7–8):923–8.
Kline CE, Sui X, Hall MH, Youngstedt SD, Blair SN, Earnest CP, et al. Dose–response effects of exercise training on the subjective sleep quality of postmenopausal women: exploratory analyses of a randomised controlled trial. BMJ Open. 2012;2(4):e001044.
Mansikkamaki K, Raitanen J, Nygard CH, Heinonen R, Mikkola T, Tomas E, et al. Sleep quality and aerobic training among menopausal women--a randomized controlled trial. Maturitas. 2012;72(4):339–45.
Sternfeld B, Dugan S. Physical activity and health during the menopausal transition. Obstet Gynecol Clin North Am. 2011;38(3):537–66.
Ivarsson T, Spetz AC, Hammar M. Physical exercise and vasomotor symptoms in postmenopausal women. Maturitas. 1998;29(2):139–46.
Portman DJ, Gass ML. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Maturitas. 2014;79(3):349–54.
Lorenz TA, Meston CM. Acute exercise improves physical sexual arousal in women taking antidepressants. Ann Behav Med. 2012;43(3):352–61.
Legendre G, Ringa V, Panjo H, Zins M, Fritel X. Incidence and remission of urinary incontinence at midlife, a cohort study. BJOG. 2015;122(6):816–24.
Youngstedt SD. Effects of exercise on sleep. Clin Sports Med. 2005;24(2):355–65. 2.
Ravussin E, Bogardus C. A brief overview of human energy metabolism and its relationship to essential obesity. Am J Clin Nutr. 1992;55(1 Suppl):242S–5.
Daley A, Stokes-Lampard H, Thomas A, MacArthur C. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev. 2014;11:CD006108.
Physical activity and cardiovascular health. NIH consensus development panel on physical activity and cardiovascular health. JAMA. 1996;276(3):241–6.
Pettee Gabriel K, McClain JJ, Lee CD, Swan PD, Alvar BA, Mitros MR, et al. Evaluation of physical activity measures used in middle-aged women. Med Sci Sports Exerc. 2009;41(7):1403–12.
Ainsworth BE. Issues in the assessment of physical activity in women. Res Q Exerc Sport. 2000;71(2 Suppl):S37–42.
National Institutes of Health State-of-the-Science Conference statement: management of menopause-related symptoms. Ann Intern Med. 2005;142(12 Pt 1):1003–13.
Bromberger JT, Harlow S, Avis N, Kravitz HM, Cordal A. Racial/ethnic differences in the prevalence of depressive symptoms among middle-aged women: The Study of Women’s Health Across the Nation (SWAN). Am J Public Health. 2004;94(8):1378–85.
Bromberger JT, Matthews KA, Schott LL, Brockwell S, Avis NE, Kravitz HM, et al. Depressive symptoms during the menopausal transition: the Study of Women’s Health Across the Nation (SWAN). J Affect Disord. 2007;103(1–3):267–72.
Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA. 2012;307(5):491–7.
This work was supported by the Michael & Susan Dell Foundation through resources provided at the Michael & Susan Dell Center for Healthy Living, part of The University of Texas School of Public Health Austin Regional Campus (KPG). The authors would also like to thank Ms. Eun Me Cha for computing the BRFSS and NHANES prevalence estimates presented in the introduction.
The authors declare that they have no competing interests.
KPG and BS participated in the design of the literature review, KPG and JMM conducted the literature review and summarized the literature, KPG drafted the manuscript, and JMM and BS provided a critical review of the manuscript. All authors read and approved the final manuscript.
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Pettee Gabriel, K., Mason, J.M. & Sternfeld, B. Recent evidence exploring the associations between physical activity and menopausal symptoms in midlife women: perceived risks and possible health benefits. womens midlife health 1, 1 (2015). https://doi.org/10.1186/s40695-015-0004-9
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