Impact of Physical Activity on Physical and Mental Health of Postmenopausal Women: A Systematic Review

1. PhD Research Scholar, Faculty of Physiotherapy, SGT University, Gurugram and Associate Professor, School of Physiotherapy, Delhi Pharmaceutical Sciences and Research University, New Delhi, India . 2. Professor, Faculty of Physiotherapy, SGT University, Gurugram, Haryana, India. 3. Associate Professor, School of Physiotherapy, Delhi Pharmaceutical Sciences and Research University, New Delhi, India. 4. Assistant Professor, Faculty of Physiotherapy, SGT University, Gurugram, Haryana, India. 5. Assistant Professor, Faculty of Physiotherapy, SGT University, Gurugram, Haryana, India.

Abstract

Introduction: Menopause is associated with a variety of physical and mental issues. It’s critical to pay attention to postmenopausal women’s health issues and develop prevention strategies.

Aim: To evaluate association between physical activity and physical and mental health problems in postmenopausal women.

Materials and Methods: In the present systematic review, relevant studies were searched in international electronic databases such as, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed and Google Scholar from 2004 to 2021. Terms like physical activity, physical health, mental health, bone mineral density, exercise training, and postmenopausal women were searched. All papers were screened for eligibility. Inclusion criteria of the study was, studies with atleast one exercise group versus one control group, should include women who were postmenopausal at the time of the study, studies that examined effect of physical activity on physical and mental health of postmenopausal women, full text articles written in English language.

Results: Total 27 studies were included in the present review. The results revealed that resistance, aerobics, walking, pilates and aquatic exercises have shown benefits in improving physical and mental health parameters of postmenopausal women.

Conclusion: Physical activity plays a great role in maintaining overall health and Quality of Life (QOL) of Women. To avoid fractures, these women should engage in workouts with prudence. Physical and mental fitness can be achieved by incorporating exercise into daily routine of postmenopausal women.

Depression, Exercise, Menopause, Psychological health, Quality of life

Menopause is described as the end of a woman’s menstrual cycle followed by a 12-month phase of amenorrhoea. The term “postmenopause” refers to the time after the last menstrual period (1). Menopause is the most noticeable event that occurs in women during middle age as it marks the end of a woman’s reproductive life. Natural Menopause (NM) occurs between the ages of 45 and 55 years old over the world (2). Early menopause has been linked to an increased risk of cardiovascular disease and osteoporosis, whereas delayed menopause has been linked to an increased risk of breast cancer and endometrial cancer (3). It has been reported that, women who are physically inactive may experience physical and mental health problems during their menopause (4),(5).

Symptoms such as hot flashes, irritability, sleeping difficulties, exhaustion, anxiety, and loss of focus are seen in the early postmenopausal era depending on the ovarian function deficit and, as a result, lack of oestrogen. Due to the decrease of oestrogen’s preventive actions in the late period, the incidence rate of osteoporosis and obesity rises. These symptoms in the postmenopausal period have a negative impact on women’s quality of life (6). Osteoporosis is most commonly seen in women, with a considerable rise in incidence following menopause (7). Decline in bone mass consequently leads to fragility of bones and enhanced risk of fracture in postmenopausal women (8),(9).

Although, majority of women have transition to menopause without encountering psychiatric issues, an estimated 20% of women experience depression during this time (10). There are several factors that contribute to menopausal depression. Previous history of depression; personal and societal concerns; loss of motherhood, husband’s impending death, negative views regarding menopause, long-term menopause, and so on are some of these variables (10),(11). According to some experts (12) depression during menopause is caused by a drop in gonadal hormone levels, which causes exhaustion, sleep loss, and hot flashes. Biopsychological factors, relationship with husband, educational level, race, and demographic characteristics, on the other hand, have been linked to depression following menopause by certain researches (13),(14). Some believe that depression in this age group is more closely linked to psychosocial events such changes in child-parent relationships, marital status, and other life events (15).

Physical inactivity causes various physical and mental health problems in postmenopausal women and these are linked with menopause. Physical activities on the other hand are thought to be vital for physical and mental health of postmenopausal women (15). The role of exercise in the prevention of postmenopausal symptoms has been debated and recognised. According to the authors, encouraging women over the age of middle age to exercise regularly can dramatically reduce postmenopausal symptoms (15),(16). Literature has reported that sustained and long duration physical activity improves mental functioning (16),(17). Furthermore, the authors pointed out that physical therapy could improve patients health fitness and hence, quality of life (18),(19). The literature, on the other hand, has devoted little attention to the probable association between physical activity/exercise and physical or mental health.

To the best of authors’ knowledge, limited reviews have been published on this topic. Attention needs to be paid to their health issues to establish strategies to prevent these problems. The purpose of the present review was to analyse the impact of physical activity on physical and psychological health of postmenopausal women. Physical activity interventions were evaluated on adiposity markers, bone density, functional capacity measurements, and various psychological health outcomes in postmenopausal women in the current systematic review.

Material and Methods

In the present systematic review, relevant studies were searched in International electronic databases such as, Cochrane CENTRAL, PubMed and Google Scholar from 2004 to 2021.

Search terms: So as to make search more precise MESH terms and Boolean operators were used. Combinations used for search was (Postmenopausal OR Postmenopausal OR Menopausal) AND (Physical activity OR Exercise OR Exercise Training OR Physical fitness) AND (Physical health OR Body composition OR Body weight OR Bone Mineral Density OR Bone Mass or Body Fat) AND (Mental health OR Psychological health OR Depression).

PICO Framework

Participants: Women who were postmenopausal at the time of study.

Interventions: A physical activity/exercise intervention was required in all the studies. All types of interventions were included except rehabilitative protocol. Both individual and group activities were included.

Comparator: All publications included either a comparison group with different type of physical activity intervention or a control group who were either sedentary/continued with their usual routine.

Outcome measures: Physical and Mental health measures.

Inclusion criteria: Studies/study arms that had:

• At least one exercise group versus control group consisting of a sedentary/habitual active lifestyle or different type of physical activity intervention;
• Research participants who were postmenopausal at the time of study;
• Studies on the impact of physical activity on postmenopausal women’s physical and emotional well-being;
• Full text articles written in English language and published in peer-reviewed journals were included in the review.

Exclusion criteria: Publications that were:

• Published in language other than English;
• A review article; or
• A case report;
• Cross-sectional surveys were excluded.

Study Procedure

The eligibility process was divided into phases with clear inclusion and exclusion criteria. The review included only full-text academic publications published in peer-reviewed journals, excluding magazine and newspaper articles. In phase I, 3720 documents from three databases were identified using the search phrases. After removal of duplicate papers, 1861 papers were identified. The third phase introduced a new search category with papers pending under all established search strings. All full-length texts were thoroughly reviewed in phase IV, and papers that had no relevance to the study’s objectives and research issues were eliminated. Finally, 27 articles were chosen, and the results were summarised (Table/Fig 1).

Data extraction: Data for all physical and mental outcomes was gathered. A wide range of measures were used to examine outcome factors. Body composition, bone density, bone mass and physical fitness components were the physical parameters. Anxiety, depression, and QOL were the mental health outcomes.

Data analysis: Two reviewers (SK) and (SP) independently extracted the data.

Risk of Bias analysis: The risk of bias was assessed using Cochrane Risk of Bias analysis tool.

Results

The data on year of study, participants, study duration, sample size, specifications of intervention, outcome measures, and study findings were tabulated. [Tables/Fig-2] (20),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30),(31),(32),(33),(34),(35),(36),(37),(38),(39) and [Tables/Fig-3] (40),(41),(42),(43),(44),(45),(46) summarise the findings from the RCTs. Result for risk of bias has been presented in (Table/Fig 4) (20),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30),(31),(32),(33),(34),(35),(36),(37),(38),(39),(40),(41),(42),(43),(44),(45),(46).

Discussion

During the menopausal stage, women may experience a variety of symptoms as a result of ageing and changes in sex hormone levels, which can have a severe impact on their quality of life, physical and mental health (47). Despite consistent evidence of a positive relationship between physical activity, physical fitness, or exercise and cardiovascular health and quality of life during the menopausal transition, the relationship between menopause symptomatology and physical activity, physical fitness, or exercise is still controversial (48),(49). Increasing physical activity or improving physical fitness has been shown, in several studies, to be an effective means of preventing or alleviating menopause-related symptoms (50),(51). Similarly, exercise programmes have been shown to improve menopause symptomatology, particularly in the postmenopausal stage (52). Some research, on the other hand, have failed to uncover clear connections, implying that increasing physical activity levels or specialised exercise regimens for addressing menopause symptoms may not be the cure (53),(54). The current study looked at the link between physical activity and physical and mental health in postmenopausal women, as well as the effects of different types of physical activity or exercise on physical and mental parameters.

The present study finding suggest that there are various exercise training for improvement of physical health parameters like resistance training, Tai Chi, weight bearing training, aerobic exercise, aquatic resistance training etc. Four studies in the present review reported that resistance training significantly improved Bone Mineral Density (BMD), enhanced bone metabolism and reduced bone resorption (27),(31),(35),(37). One study demonstrated combination of strength and balance training had positive effects on bone health of menopausal women (28). Studies by Chubak J et al., and de Matos O et al., dematos reported adherence to exercise helped in conserving BMD but there was no significant difference with the control group (22),(26). Other exercises like aquatic exercises, Tai Chi and Pilates also helped reducing bone resorption in postmenopausal women (22),(34),(38). Six studies reported positive effects of exercises like aerobics, aquatic therapy, pilates and functional exercises on physical fitness, QOL and functional capacity of postmenopausal women (21),(24),(28),(32),(35),(36). A six weeks aerobic exercise in combination with Hormone Replacement therapy (HRT) were found to be effective in improving strength, endurance, flexibility, balance in postmenopausal women (21). Therefore, it is recommended that it should be combined with exercise training to get the best results and anthropometric measures in postmenopausal women. Resistance and aquatic training (26),(28),(29) also improved the physical parameters like BMD, body fat, Diastolic Blood Pressure (DBP) and overall health of postmenopausal women. Effects of higher levels of physical activity on anthropometric measures were recommended in a study by Swift DL et al., (29). It is clear that volume of exercise protocol play a great role to evoke physiological response in measure of physical performance.

Seven studies investigated effects of physical activity on mental health in menopausal women. Most interestingly, raised daily levels of physical activity markedly increased blood Brain Deprived Neurotrophic Factor (BDNF) levels in menopausal women, according to Takahashi M et al., (45). Memory impairment and depression have been linked to BDNF, particularly in elderly persons (55). According to prior research, regular exercise training and increased physical activity are strongly linked to a lower risk of depression and improved mental health (56). A systematic review of the effects of physical activity on cancer patients indicated that even small amounts of walking and strengthening activities improve body fat, lean body mass, BMD, strength, walking distance, mental well being, mood and QOL. Different types of exercise have been found to increase positive affect and decrease negative affect in both healthy and unwell people, while the effects of aerobic exercise like walking have the most evidence (57),(58). Elavsky S and McAuley E and Hu L et al., found that walking and yoga are beneficial in improving mental health and QOL of postmenopausal women (40),(44). Aibar-Almazan A et al., conducted a study on pilates exercise for the improvement of mental health parameters and discovered that a 12-week Pilates intervention improves sleep quality, anxiety, depression, and fatigue in postmenopausal women (46). Various cross-sectional studies have found that physical activity had a favourable influence on menopausal symptoms, with active women reporting less or milder symptoms (59),(60). Prospective and longitudinal investigations, on the other hand, are still a mystery. Longer-duration physical activity interventions would also be preferable for eliciting more significant and long-lasting intervention benefits. Any physical activity intervention’s success is also contingent on excellent programme adherence and low study attrition.

Risk of bias analysis using standard Cochrane tool showed that four trials were found to have a high risk of bias in the domain of random sequence creation, due to the lack of detailed randomisation methodologies. In the domain of allocation concealment, only three studies were found to have a low risk of bias. Blinding of participants and personnels was recorded in six research, while blinding of outcome assessors was indicated in eight studies. Almost all the studies provided complete outcome data. As a result, in future studies, allocation concealment, participant blinding, personnel blinding, and outcome assessor blinding should be prioritised in order to produce more accurate and reliable results.

Limitation(s)

It was found that many of the studies measured mental health characteristics based on self-reported methods. A limitation regarding present review was that only qualitative analysis of the included articles was done and limited outcome measures related to physical and mental health were taken. In future, it is recommended that impact of physical activity can be studied on various other measures of health and skill fitness such as cardiac fitness, balance, agility and coordination can also be analysed. Also, quantitative analysis can also be performed on different measures of physical and mental health.

Conclusion

Menopausal symptoms affected a substantial percentage of postmenopausal women. Fatigue, hot flushes, back ache/joint pain, reduced BMI, and osteoporosis were the most prevalent menopausal problems mentioned by postmenopausal women. In addition, postmenopausal women experienced melancholy, anxiety, poor sleep, and anxiety. As a result, in addition to women in reproductive age, the policy makers may focus on providing health care to women in the postreproductive age group. This can be accomplished by including components pertaining to postmenopausal women’s individual health requirements into national health programmes. For increased bone mineral density, a mixed exercise programme (resistance, aerobic/walking, Pilates) is recommended. To avoid fractures, these women should engage in workouts with prudence. As a result, it is strongly advised that these women follow an exercise programme provided by a specialist in the area, such as a physical education professional or a physiotherapist, after consulting with a physician.

DOI and Others

DOI: 10.7860/JCDR/2022/52302.15974

Date of Submission: Sep 07, 2021
Date of Peer Review: Oct 13, 2021
Date of Acceptance: Jan 14, 2022
Date of Publishing: Feb 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
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• iThenticate Software: Jan 12, 2022 (15%)

ETYMOLOGY: Author Origin