The menopausal transition is characterised by a change in sex hormone levels where progesterone levels rapidly decrease, oestrogen concentrations are initially stable before fluctuating then declining; while follicle-stimulating hormone and luteinising hormone concentrations increase.^{1 2}

These hormonal changes have significant implications for the health status of middle-aged and older women. Specifically, during the menopausal transition many women experience troublesome short- to medium-term symptoms that disrupt daily activities and reduce overall quality of life (QoL).³Furthermore, the sustained reduction in oestrogen levels postmenopause combined with the effects of ageing increases the risk of chronic disease,⁴ which impairs physical health and function ability leading to greater disability and a transition from independent to dependent living.

Menopausal hormone therapy (MHT) is the most effective treatment for the relief of symptoms and provides some protection from certain long-term chronic disease.^{5 6} However, MHT is not without risks⁷ and as such it is generally only taken short-term (one to five years). Additionally, some women may be advised not to commence MHT because of pre-existing conditions or not to continue with MHT because of poor benefit-to-risk profiles. For these women, physical activity (PA) may be an effective alternative therapy to minimise menopausal symptoms and improve health status throughout later life. This article briefly reviews the effects of PA on specific symptoms and QoL during the menopausal transition and factors influencing post-menopausal health status.

Effects on menopausal symptoms

Vasomotor symptoms

Most studies have examined hot flushes and night sweats and provide inconsistent findings for an effect of PA on the vasomotor symptoms.^{8 9} A systematic review of five randomised controlled trials (RCT), which included 733 menopausal women, reported no difference between PA versus no active treatment (standardised mean difference -0.10; 95% CI -0.33–0.13, three RCTs, 454 women) or between PA versus yoga on symptom frequency (standardised mean difference -0.03, 95% CI -0.45–0.38, two RCTs, n=279 women).¹⁰ Authors noted available evidence was low quality due to limitations in study design and imprecise methods. Therefore, evidence is currently insufficient to support the use of PA in the direct treatment of vasomotor symptoms alone. However, PA may be of indirect benefit through assisting with weight management where obesity is a known risk factor for vasomotor symptom frequency and severity.¹¹

Psychological symptoms

Most, but not all,¹² evidence is consistent that PA improves mood, anxiety, cognitive function and other psychological symptoms associated with menopause.¹³ Mansikkamaki et al¹⁴ using proportional odds ratios (PORs) from ordered logistic regression models (n=2606 menopausal women) observed that physically inactive women had an increased probability of anxiety/depressed mood (POR 1.44; 95% CI 1.26–1.65) and memory/concentration problems (POR 1.48; 95% CI 1.29–1.70) compared with women meeting recommended physical activity levels. Such findings remained significant after adjusting for confounding variables. Additionally, a four-month RCT that included previously low-active menopausal women (n=164) compared the effects of walking, yoga and a non-PA control group reported that the walking and yoga groups only improved positive affect (Cohen’s d 0.16–0.47 SD) and reduced negative affect (Cohen’s d -0.21–0.68). These effects were also observed to be associated with reductions in other menopausal symptoms and increases in aerobic fitness.¹⁵ Overall, evidence supports the use of PA in the direct treatment of psychological symptoms accompanying menopause.

Somatic symptoms

Bothersome somatic symptoms during menopause may include back pain, muscle pain and numbness, among others. Moilanen et al³ using multiple linear regression (n=1427 menopausal women; mean age 47 years) observed that after adjusting for background characteristics, reported participants that performed regular PA experienced fewer somatic symptoms compared with sedentary participants (beta coefficient 0.18, 95% CI 0.10–0.27). It was also observed that participants with chronic disease experience increased symptoms compared with asymptomatic participants. Additionally, a large cross-sectional study of women aged 46–55 years (n=2399) reported that after accounting for menopausal status women identified as being in the maintenance stage of change for PA were 21 per cent less likely to experience somatic symptoms compared with participants in the pre-contemplation, contemplation or preparation stages.¹⁶ However, these effects were also associated with body mass index (BMI) where participants with higher values experienced greater somatic symptoms. Not all studies examining the effect of PA on somatic symptoms in menopausal women report beneficial outcomes.¹⁷ As such, evidence does not support the use of PA in the direct treatment of somatic symptoms alone.

Quality of life

Higher PA levels during the menopausal transition are consistently associated with an improved QoL even after adjusting for other symptoms.¹⁸ Moilanen et al¹⁹ using ordinal regression in an eight-year follow-up study (n=1165 postmenopausal women; mean age 56 years) reported that participants with stable (Beta coefficient=1.46) or increased (Beta coefficient=1.49) PA levels relative to baseline had higher QoL scores than women whose physical activity levels declined. QoL was also influenced by stable weight (Beta coefficient=1.26) across the follow-up period. Additionally, Mansikkamaki et al¹⁴ reported after adjusting for education and BMI the POR for higher global QoL was 1.63 (9% CI 1.40–1.89) for menopausal women that achieve recommended PA levels compared with those less active. Therefore, the evidence supports the use of PA to improve QoL in menopausal women. The contrasting effects of PA on vasomotor and somatic symptoms compared with QoL suggests that PA may provide menopausal women with general symptom management rather than the therapy for specific symptoms themselves.²⁰ This may also explain why vasomotor and somatic symptom covary with BMI and aerobic fitness, which are both strongly associated with PA levels.

Cycling is one of many ways to exercise outdoors. © Monkey Business Images, Shutterstock, 12530353.

Effects on factors influencing postmenopausal health status

Skeletal muscle mass and strength

Women aged 70–80 years demonstrate declines in muscle mass and strength of 20–35 per cent compared with young and middle-aged women.^{21 22} The loss of muscle mass and strength with age impairs functional status,²³ promotes musculoskeletal disability24 and increases risk of both cardiometabolic disease²⁴ and falls.²⁵ PA may increase muscle mass and strength postmenopause by 9–13 per cent (a decade of age-related muscle loss) and 15–20 per cent (up to two decades of age-related strength loss), respectively, following as little as 10 weeks.²⁶ The effects of these changes on overall physical health, functional ability and QoL are seriously underappreciated²⁷ and should be a primary therapeutic target for maintaining or improving health status in all middle-aged and older women. Resistance training is the most effective means to stimulate muscle hypertrophy and develop strength. Many middle-aged and older women are apprehensive about participating in resistance training due to a lack of self-efficacy or fear of injury. To date, no studies have reported any adverse effects of appropriately prescribed and supervised resistance training in women of any age.

Bone health, fractures and falls

Bone mineral density (BMD) in postmenopausal women may increase through PA by a magnitude of 0–2 per cent over 1–2 years, while BMD in most control groups typically declines by around 1 per cent per annum.²⁸ Additionally, a large meta-analysis by Qu et al29 – including 14 843 fractures from 22 cohort studies – reported an overall relative risk of fracture of 0.71 (95% CI 0.63–0.80) and a 38 per cent (95% CI, 0.54–0.69) and 28 per cent (95% CI 0.49–0.96) lower risk of hip and wrist fractures, respectively, in postmenopausal women with the highest PA levels compared with the lowest.²⁹ Thus, participation in PA interventions to maintain, if not slightly improve, bone mass and reduce the risk of fractures is worthwhile. The most effective PA intervention for bone health involves resistance training combined with high-impact/weight-bearing activities.³⁰

Considerable evidence indicates that falls are inversely related to PA levels in older adults, including postmenopausal women.³¹ Furthermore, falls are not random events, but can be predicted by a number of risk factors, including lower limb muscle strength, gait and balance, all of which can be improved with appropriate PA.³² A meta-analysis of 17 RCTs (n=4305 postmenopausal women) reported that PA was associated with pooled estimates of the rate ratios of 0.63 for all injurious falls (95% CI 0.51–0.77), 0.70 for falls resulting in medical care (95% CI 0.54– 0.92), and 0.39 for falls resulting in fractures (95% CI 0.22–0.66, 6 trials).³³ PA interventions that include resistance training with balance and mobility activities that challenge stability are most effective for falls prevention in older adults.^{34 35}

Walking has shown to be a beneficial form of physical activity that improves menopausal symptoms. © FamVeld, Shutterstock, 484254748.

Effects on cardiometabolic health and mortality

PA is highly important for both the prevention and/or management of cardiometabolic disease.³⁶ where it has a clear dose-dependent effect and inverse relationship with mortality.³⁷ Postmenopausal women that are more physically active and/or have higher levels of fitness demonstrate less weight gain, reduced waist circumference, decreased abdominal obesity, higher HDL cholesterol, lower blood pressure and improved fasting glucose.^{38  39} Furthermore, physical activity is inversely associated with all-cause mortality in both older men and women. However, it appears that this relationship is stronger for women than men and that benefit can be achieved from even low-activity levels.⁴⁰ A combination of moderate intensity aerobic PA and high-intensity interval training (HIIT)⁴¹ is most effective for improving cardiometabolic risk factors mortality risk reduction.

Yoga may be beneficial in the treatment of some menopausal symptoms. © Pressmaster, Shutterstock, 207970339.

Summary and physical activity recommendations

Regular participation in PA is essential for healthy ageing, but is particularly important for middle-aged and older women to facilitate the transition through menopause and prevent and/or manage chronic disease related to oestrogen deficiency and ageing. Where PA has not been demonstrated to have a direct effect on specific menopause symptoms, it may provide benefit through assisting to modify risk factors for symptom development, such as BMI and aerobic fitness. Regardless, PA supports menopausal women by improving overall QoL.

Given the substantial health benefits associated with PA, women should be strongly encouraged and supported to commence regular PA from 40 years of age (if not earlier) to develop physiological reserves in preparation for the deleterious effects of menopause and subsequent ageing on health status and functional ability.⁴² Regular PA for all women should involve both aerobic and resistance training combined with flexibility and balance activities as described in considerable detail elsewhere.⁴³ However, the precise prescription for each type of PA should vary based on the participant’s age, menopausal stage (for example, pre-, peri- and postmenopause), and individual risk profile.

Although otherwise healthy older adults are not at greater risk of injury from participation in PA,⁴⁴ it is essential that risks for adverse PA-related events and existing comorbidities are identified and appropriately managed. Exercise scientists and exercise physiologists accredited with Exercise and Sports Science Australia (AES and AEP, respectively) hold a minimum three-year Bachelor qualification and have the knowledge, skills and competencies to design, deliver and evaluate safe and effective exercise interventions for people, including women in all stages of menopause.

Finally, although evidence that regular PA provides considerable health benefits regardless of age, gender and health status is more than compelling, long-term PA adherence in the community is typically low. As such, it is critical that any PA intervention has a strong focus on achieving behavioural change if life-long health benefits are to be achieved.⁴⁵

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