Abstract & Commentary
The Effect of Yoga, Exercise, and Omega-3s on Menopausal Symptoms
By Melissa Quick, DO, and David Kiefer, MD
Dr. Quick is a third-year resident in New York at the Beth Israel Residency in Family Medicine.
Dr. Quick reports no financial relationships relevant to this field of study.
Synopsis:This 12-week, randomized, controlled trial assessed the effect of yoga, exercise, and omega-3 supplements on menopausal symptoms in 355 women. Yoga slightly improved quality of life, whereas exercise and omega-3s did not.
Source:Reed SD, et al. Menopausal quality of life: RCT of yoga, exercise and omega-3 supplements. Am J Obstet Gynecol 2013; doi: 10.1016/j.ajog.2013.11.016 [Epub ahead of print].
This study examined the effect of three common non-hormonal supplements — yoga, exercise, and omega-3 fatty acids (omega-3s) — on the vasomotor symptoms (VMS) associated with menopause. The study enrolled 355 eligible women (aged 40-62 who were perimenopausal or postmenopausal) in a multisite, 3 × 2 factorial randomized, controlled trial. The women were randomized to 12 weeks of yoga, exercise, or usual activity. Concurrently, the group of 355 women was also randomized to take 1.8 g/day of omega-3 or placebo capsules.
The yoga component consisted of both studio and home practice techniques including breathing exercises, 13 poses, and guided meditation. Instruction included 12 weekly, 90-minute classes, and daily home practice was expected to be completed for 20 minutes on days without classes. The exercise arm included 12 weeks of three individual cardiovascular conditioning training sessions per week at local fitness facilities, supervised by trained and certified exercise trainers. The usual activity group was asked to maintain current exercise practices and to not begin a new yoga or new exercise regimen during the study.
The omega-3 supplement contained 425 mg ethyl eicosapentaeonic acid (EPA), 100 mg docosahexaenoic acid (DHA), and 90 mg of other omega-3s. The placebo capsule contained olive oil.
The main outcome of the study was to assess quality of life (QOL). A 29-item evaluation known as MENQOL (Menopause Quality of Life) assessed women's outcomes at baseline and at week 12. The MENQOL focused on four main domains: vasomotor, physical, psychosocial, and sexual functioning. Each scored item received a "1" for non-endorsement or a "2" for endorsement of symptoms, and also a "bother score" ranging from 0 to 6 (0 indicating the symptom was not bothersome and 6 indicating the woman was extremely bothered) for a maximum score of 8.
With regard to VMS, the frequency and severity of the symptoms were recorded retrospectively on daily diaries in the morning for night sweats and in the evening for daytime hot flashes. Additional validated menopause QOL measures included the Hot Flash-Related Daily Interference Scale (HFRDIS); Perceived Stress Scale (PSS); Pain Intensity, Interference with Enjoyment of Life, and Interference with General Activity scale (PEG); and Female Sexual Function Index (FSFI), collected at baseline and 12-weeks.
Other outcomes of the study — insomnia, subjective sleep quality, depressive symptoms, and anxiety — were gauged using several other questionnaires.
Of the 355 randomized women, 338 (95%) completed 12-week assessments. The mean baseline VMS frequency was 7.6/day and the mean baseline MENQOL score was 3.8 (ranging from 1, indicating "better," to 8, indicating "worse"). There was a modest yet significant improvement in the total MENQOL for the yoga cohort: -0.3 (95% confidence interval [CI], -0.6 to 0.0; P = 0.02). An additional statistically significant difference in MENQOL domain scores favoring the yoga intervention was observed in the sexual domain (-0.5; 95% CI, -1.0 to 0.0; P = 0.03).
For the exercise and omega-3 cohorts, there was only one statistically significant treatment difference: The MENQOL score for physical symptoms improved with exercise intervention (-0.2; 95% CI, -0.5 to 0.0; P = 0.02). There was no domain score difference between the omega-3 and placebo groups.
Approximately 80% of all women experience perimenopausal symptoms, ranging from mild to severe.1 Common perimenopausal symptoms include mood changes, bloating, headaches, hot flashes, night sweats, tiredness, insomnia, weight gain, depression, irritability, vaginal atrophy, and dyspareunia.
More than 88% of U.S. women experience VMS (primarily daytime hot flashes and night sweats) as they transition into menopause.2 In general, the overall duration of hot flashes tends to range from 6 months to 2 years.3 VMS are among the most common reasons for clinical visits for mid-life women and, subsequently, increases health care expenditures.4 As such, physicians must be poised to counsel women on a variety of treatment modalities, ranging from hormonal therapy (HT) to effective nonhormonal modalities.
In the past, HT was commonly prescribed to treat menopausal symptoms. Indeed, current evidence demonstrates estrogen therapy is the most effective treatment of menopause-related VMS.5 However, despite estrogen's efficacy on reducing VMS, concerns regarding the side effects of HT have reduced the prescription duration for hormones and, perhaps more importantly, have raised women's awareness to seek alternative treatments for their symptoms. An additional option during menopause counseling that may ease women's concerns is to emphasize that menopause is a natural transition, not a disease state. This may help reframe the idea for women and perhaps ease the transformation.
The evaluation of the QOL of women experiencing menopause may be one of the best ways to determine just how bothersome symptoms are. Correspondingly, if QOL is evaluated both before and after a given intervention, such as in the study reviewed above, this might provide the best evidence of efficacy for a treatment. Remarkably, there are no hormone therapy products with government approval specifically for the improvement of QOL in menopausal women.6 Additionally, a literature review reveals there are limited studies evaluating menopause-related QOL in menopausal women.
Physical activity has been advocated for the management of mild-to-moderate menopausal symptoms in the past.3 Interestingly, a high body mass index is associated with an increased prevalence of VMS.5 As such, it is reasonable to ascertain that an alternative modality that encourages physical activity and that can lead to weight loss — exercise or yoga — may have beneficial effects on decreasing VMS and other menopausal symptoms.
In this study, exercise did improve scores in the "physical function domain" of the MENQOL (-0.2; 95% CI, -0.5 to 0.0; P = 0.02) when compared to usual activity, but did not affect overall menopause-related QOL. The yoga cohort, conversely, did demonstrate an improvement, albeit small, in VMS. As mentioned above, statistically significant differences in MENQOL domain scores favoring the yoga intervention were observed for the "vasomotor domain" (-0.3; 95% CI, -0.8 to 0.2; P = 0.02) and "sexual domains" (-0.5; 95% CI, -1.0 to 0.0; P = 0.03).
Yoga is gaining popularity in the CAM world for multiple ailments and has been shown to reduce fatigue, blood pressure, and anxiety.7 Previous literature reviews indicate that yoga may have a more pronounced effect on the psychological aspects of menopause, rather than somatic vasomotor symptoms.7 While the exact beneficial mechanism of yoga is unknown, it is postulated that yoga may normalize the psychological state by controlling counter regulatory hormones. Additionally, yoga may create a hypothermic state and could alter the sympathetic/parasympathetic nervous system1 — one explanation for possible improvement of VMS with this technique.
In this study, omega-3 supplementation did not improve QOL or decrease VMS in menopausal women. While some data exist for the benefit of omega-3s for cardiovascular disease, rheumatoid arthritis, and depression, current data are incomplete and inconsistent for any benefit on VMS.8 If the women who were randomized to take omega-3 supplements took the capsules three times a day, as instructed, they would have received a total daily dose of 1.845 g (1.575 g of EPA plus DHA) of fish oil daily. This is within the scope of commonly prescribed doses of fish oil: Clinically studied doses range from 1-4 g of EPA plus DHA daily for cardiovascular disease, hypertriglyceridemia, and hypertension.9
In conclusion, providers should be familiar with common menopausal symptoms and be prepared to offer mid-life women a variety of options in which to alleviate their discomfort. This study represents another step in our exploration of safe, alternative modalities to treat menopausal symptoms. While we continue to research the efficacy of yoga and other alternative modalities, we should emphasize to women that although menopause can be uncomfortable, it can also be a time for personal growth and new perspective. Based on the results of this study, it is reasonable to recommend yoga as a low-cost, non-invasive technique to alleviate discomfort associated with this life transition. Moreover, given the potential benefits of yoga discussed above, providers should present yoga as a healthy option to menopausal patients not just for perimenopausal symptoms, but for their general health as well.
- Joshi S, et al. Effect of yoga on menopausal symptoms. Menopause Int 2011;17:78-81.
- Williams RE, et al. Frequency and severity of vasomotor symptoms among peri and postmenopausal women in the United States. Climacteric 2008;11:32-43.
- Treatment of Menopause-Associated Vasomotor Symptoms: Position Statement of The North American Menopause Society. Menopause. 2004;11:11-33.
- Freeman EW, et al. Duration of menopausal hot flushes and associated risk factors. Obstet Gynecol 2011;117:1095-1104.
- National Institutes of Health State-of-the-Science Panel. National Institutes of Health State-of-the-Science Conference Statement: Management of Menopause-Related Symptoms. Ann Intern Med 2005;142:1003-1013.
- Schmidt P. The 2012 Hormone Therapy Position Statement of The North American Menopause Society. Menopause 2012;19:257-271.
- Cramer H, et al. Effectiveness of yoga for menopausal symptoms: A systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Altern Med 2012:863905. Epub 2012 Nov 7.
- Cohen LS, et al. Efficacy of omega-3 for vasomotor symptoms treatment: A randomized controlled trial. Menopause 2013; Aug 26 [Epub ahead of print].
- Natural Medicines Comprehensive Database. Fish Oil. Available at: http://naturaldatabase.therapeuticresearch.com/nd/Search.aspx?cs=AZ&s=ND&pt=100&id=993&ds=dosage&name=FISH+OIL&searchid=44645253. Accessed Jan. 11, 2014.