Menopause Live (18 March, 2013) From IMS

Recently, Holger and colleagues [1] reviewed randomized, controlled trials on the effects of yoga (posture, breathing, and meditation) on psychological, somatic, vasomotor and urogenital symptoms related to menopause. While they began with 207 studies, only five studies were included in the qualitative analysis – mainly ones in Europe and India – and three of these had a high risk of bias [2-4]. One of the two studies with a low risk of bias [5,6] was not included in the meta-analysis. The types of yoga practices, frequency of sessions and length of follow-up varied between the studies. The outcomes measured were mostly in the short term, i.e. 8 weeks, with only one randomized, controlled trial measuring the outcomes at 20 weeks. They found no statistically significant effects of yoga on menopausal symptoms except for psychological symptoms, where a moderate short-term benefit was found; however, even that disappeared when subgroup analyses (yoga vs. control and yoga vs. exercise) were conducted. The authors acknowledged that their conclusions differed from the conclusions of previous systematic reviews where yoga was shown to have moderate benefits for psychological and vasomotor symptoms. They attributed the difference to the inclusion of only randomized, controlled trials and new studies.

Comment

In this review, generalizability was towards more Western populations. Yoga is an Asian eastern tradition which originated in India more than 4000 years ago and has increasingly become an accepted practice [7], so valuable data from other countries may have been omitted. The discussion in the paper regarding bias in the studies – recruitment through advertising, selection bias, reporting bias by participants, inadequate blinding of outcome assessors, detection bias – prompts the reader to question the efficacy evaluation. Yoga seems to have benefits without serious adverse events; this is very important for women and their health-care providers to understand since it may limit drop-outs. 

In addition, the studies included lacked long-term follow-up. Just as treatment for psychological symptoms with medications and behavioral techniques can take from several months to a year to have effect, it seems likely that a mind–body intervention such as yoga might also take longer to show benefits. Further limitations include the restriction to only four eligible publication languages, and the use of compound scores for psychological symptoms in most of the included studies. Therefore, the specific variables that showed improvement with yoga interventions, for example, depression, anxiety, or sleep, were not evaluated. 

Great limitations inherent in mind–body studies are the heterogeneity of the intervention and the inability to double-blind, both of which compromise the external and internal validities of these studies. Furthermore, the psychological benefits can be a result of the placebo effect. In order to measure the true benefits, chemical markers, e.g. serotonin levels and homocysteine levels, would require the use of functional magnetic resonance imaging, which is an expensive procedure. Researchers from the Boston University Medical School have found that regular yoga practice may increase levels of certain brain substances, low levels of which are linked to depression and anxiety [8]. Currently, pharmaceutical treatment for mood disorders elevates the level of the neurotransmitter gamma amino butyric acid (GABA). The new findings, appearing in the Journal of Alternative and Complementary Medicine, suggest that yoga science be explored as a possible treatment for depression and anxiety disorders associated with a low GABA level. It has been demonstrated that meditation increases plasma melatonin levels and it seems that melatonin effectively improves sleep quality. Studies have demonstrated the effectiveness of yoga in improving sleeping patterns, suggesting its effectiveness in combating symptoms of insomnia and other sleep disorders in postmenopausal women [9,10].

I understand that yoga studies are difficult to fund, so it is difficult to measure the efficacy in larger groups in the long term, especially in developing countries like India. However, to my pleasant surprise, the University of Texas M.D. Anderson Cancer Center has recently been awarded more than $4.5 million to study the efficacy of incorporating yoga into the treatment program for women with breast cancer. This grant, the largest ever awarded by the National Cancer Institute for the study of yoga in cancer, will allow researchers to conduct a phase-III clinical trial in women with breast cancer to determine the improvement in physical function and quality of life during and after radiation treatment. It will also investigate whether such stress reduction programs result in economic and/or work productivity benefit.

There is increasing evidence suggesting that even the short-term practice of yoga can decrease both psychological and physiological risk factors for cardiovascular disease and may reduce signs and complications and improve the prognosis of those with clinical or underlying disease [11].

Yoga has been theorized to exert its positive effects by working on stress hormone pathways and by reducing the arousal of the sympathetic nervous system. Since stress and anxiety are important contributors to menopausal hot flushes, yoga can be beneficial in reducing them. A pilot study on integrated yoga practice measured changes in hot flush severity subjectively and also objectively by using skin conductance monitors. Although there were improvements in women’s perceptions of hot flushes and sleep quality before and after the study, there were no significant changes noted by the skin monitors. But the important thing was that the women felt better as a result of the yoga practice [12]. Yoga can also improve cognitive functions such as remote memory, mental balance, attention and concentration, delayed and immediate verbal retention and recognition test [13]. Even 8 weeks of an integrated approach to yoga therapy resulted in a better outcome in reducing climacteric symptoms, perceived stress and neuroticism in perimenopausal women, as compared to physical activity [14].

There is no doubt that menopausal women find it difficult to overcome the symptom of reduced self-esteem and self-image. Yoga can be used as a form of exercise to overcome this issue [15]. Yoga practices may provide a source of distraction from daily life, responsibilities and demands, reduce anxiety and depression, and thereby enhance self-esteem [16]. Multiple studies have investigated many aspects of yoga to evaluate the effects on menopausal symptoms, with results ranging from moderate relief [17] to no effect [18]. The validated tools for measuring quality of life at menopause with yoga have also shown effectiveness in measuring psychological components. But to reap maximum health benefits from yoga, it is important not only to have a good yoga teacher but also to practice the correct technique. 

In conclusion, this study is a good review of the short-term effectiveness of yoga for psychological symptom relief in menopausal women. Since many menopausal women request complementary therapies instead of, or in addition to, hormone replacement therapy, yoga can be provisionally recommended as an adjunct intervention for menopausal women with psychological complaints. However, more rigorous research is warranted to unveil the positive effects using interventions with an integrated approach to yoga that combines physical yoga poses (yoga asana), meditation techniques, yoga breathing and education on yogic principles and philosophy. In my opinion, yoga practice can be incorporated in menopause management as a lifestyle intervention for women, especially those who do not want medicalization of menopause.

Sunila Khandelwal
Senior Consultant Gynecologist, Fortis Escort Hospital, Jaipur, India

References

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http://www.ncbi.nlm.nih.gov/pubmed/23304220
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http://www.ncbi.nlm.nih.gov/pubmed/18463543
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http://www.ncbi.nlm.nih.gov/pubmed/18019884
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