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Menopause: The Journal of The North American Menopause Society

Vol. 22, No. 12, pp. 1351-1358


DOI: 10.1097/GME.0000000000000536
ß 2015 by The North American Menopause Society

INVITED REVIEW
Menopause and exercise
Natalia M. Grindler, MD, and Nanette F. Santoro, MD

Abstract
Objective: Accumulating data suggest that regular physical exercise reduces mortality and extends the functional
life span of men and women. This review seeks to describe the current state of the medical literature on this topic.
Methods: A narrative review of the current medical literature including randomized clinical trials and clinical
guidelines that address the benefits of physical fitness and regular exercise on the health of midlife and
postmenopausal women.
Results: Reduction and avoidance of obesity and its related comorbidities (hypertension, glucose intolerance,
dyslipidemia, and heart disease) are one major benefit of exercise. However, long-term physical exercise is also
associated with reduced rates of cancer, dementia and cognitive decline, adverse mood and anxiety symptoms, and
reduction of osteoporosis, osteopenia, falls, and fractures. Beneficial physical activity includes exercise that will
promote cardiovascular fitness (aerobic), muscle strength (resistance), flexibility (stretching), and balance (many of
the preceding, and additional activities such as yoga).
Conclusions: Given that it is unambiguously beneficial, inexpensive, and minimal risk, maintaining a healthy
exercise regimen should be a goal for every participant to enhance lifelong wellness. Clinicians should use a number
of behavioral strategies to support the physical fitness goals of their participants.
Key Words: Exercise – Menopause – Physical fitness.

I
ndividuals aged 65 years or older are now the fastest- factors for maintaining normal body weight, and thereby good
growing section of the population.1 As the world popu- health into older age.6
lation increases, along with an increase in life expect- Women experience a concurrent reduction in basal meta-
ancy, many millions of women will be spending a third or bolic rate and loss of lean muscle as they transition to
more of their lives after menopause. Menopause heralds an menopause.7 Although midlife weight gain is often attributed
opportunity for prevention strategies to improve the quality of to menopause, it is primarily impacted by age, and not
life and enhance longevity. necessarily menopause itself.8,9 Midlife women gain an aver-
Obesity has emerged as a global health issue, and the age of 4.5 to 4.9 pounds over a 3-year period.8 In the Study of
prevalence of obesity, defined as body mass index (BMI) Women’s Health Across the Nation cohort of midlife women,
greater than 30 kg/m2, is higher in women than in men.2 waist circumference increased by 2.2 cm over 3 years, particu-
Obesity is associated with increases in multiple medical larly in postmenopausal women.8,10 This weight gain and
comorbidities, including diabetes mellitus, cardiovascular reduction of metabolic rate is accompanied by reduced
disease, dementia, some cancers (ie, endometrial, breast, activity, as women significantly reduce regular exercise
colon), depression, and osteoarthritis.3-5 Primary prevention during middle age by up to 40%.11,12 Menopause is also
of obesity resides in an appropriate balance between energy associated with an increase in total and central fat13 and
intake and expenditure. Emerging evidence suggests that decrease in muscular strength.14 The decrease in estrogen
regular physical activity is among the most important lifestyle at menopause is associated with increased abdominal and
visceral fat if no concomitant change in physical activity or
Received May 21, 2015; revised and accepted July 8, 2015. total body weight occurs.15 This results in a transition to an
From the Division of Reproductive Endocrinology and Infertility, android pattern of fat distribution and an increase in total body
Department of Obstetrics and Gynecology, University of Colorado fat in women.16 The accumulation of abdominal fat in post-
School of Medicine, Aurora, CO. menopausal women is important for the development of
Funding/support: None.
Financial disclosure/conflicts of interest: Both authors are lifelong,
insulin resistance, which is a major risk factor associated
enthusiastic exercisers. with the development of type 2 diabetes. Postmenopausal
Address correspondence to: Nanette F. Santoro, MD, Division of abdominal weight gain is also associated with the develop-
Reproductive Endocrinology and Infertility, Department of Obstetrics ment of an adverse lipid profile, with an increase in low-
and Gynecology, University of Colorado School of Medicine, 12631
E 17th Avenue, Aurora, CO 80045. E-mail: Nanette.santoro@ density lipoprotein cholesterol and a decrease in the total
ucdenver.edu cholesterol to high-density lipoprotein cholesterol.15 Each of

Menopause, Vol. 22, No. 12, 2015 1351

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GRINDLER AND SANTORO

these elements contributes to the atherosclerotic process and weight change.28 Individuals who are regularly physically
is a component of potentially life-threatening metabolic syn- active report better overall health, lower mobility limitations,
drome. Exercise reverses or attenuates each of the above- and lower healthcare expenditures than their sedentary
described effects of aging and menopause. counterparts.29-31 Consistent activity helps to maintain aero-
bic capacity, strength, and muscle mass over the aging
Menopause and specific exercise recommendations process.
The American Heart Association (AHA) and the American Aerobic capacity declines at about 1%/y from midlife
College of Sports Medicine provide recommendations for forward and at one-half that rate among habitually active
adults over the age of 65.17 Notably, these generalized persons.32 Loss of muscle mass and strength also accelerate
recommendations are based on laboratory training data and after midlife.33 When combined with physical inactivity, the
are not based on data collected from a free-living condition. presence of elevated central adiposity, oxidative stress,
These recommendations for exercise are categorized into four inflammatory markers, and cognitive impairment has been
broad areas of physical fitness: aerobic exercise, muscle associated with sarcopenia.34,35 Sarcopenia, in turn, interferes
strengthening, flexibility, and balance. Aerobic exercise with the activities of daily living and limits the independence
involves the use of large muscle groups and must be sustained of the elderly, particularly women.
for a minimum of 10 minutes. Examples of aerobic activities Common barriers for middle-aged women considering
include brisk walking, swimming, tennis, water aerobics, initiation of exercise are lack of time, safety concerns about
dancing, and bicycle riding. The Borg Rating of Perceived exercising outdoors, weather, and not having a family mem-
Exertion (RPE) Scale measures perceived exertion and is ber or friend to exercise with.36 Lack of time may be an
particularly useful in exercise testing. It ranges from 6 to especially significant barrier for midlife women, given their
20 where 6 means ‘‘no exertion at all’’ and 20 means multiple responsibilities and roles within their households,
‘‘maximal exertion.’’18,19 The RPE can be used to estimate extended families, and work.37 The aim of this review is to
the general heart rate of a healthy adult by multiplying by 10. evaluate the evidence supporting exercise in menopausal
For instance, a perceived exertion of 12 would be expected to women.
coincide with a heart rate of roughly 120 beats/min. The
American Heart Association and the American College of SHORT TERM BENEFITS OF EXERCISE
Sports Medicine suggest a minimum of 30 minutes of mod- Symptom relief
erate-intensity aerobic activity (RPE 12-13) on 5 days each Physical activity may be an effective way of preventing or
week or a minimum of 20 minutes of vigorous-intensity attenuating some of the common menopause-related symp-
activity (RPE 14-15) on 3 days each week, or some combi- toms.38 The North American Menopause Society and the
nation of the two.17 Muscle strength is developed with weight UK’s Royal College of Obstetricians and Gynecologists
training, resistance training, or weight-bearing calisthenics. recommend aerobic exercise and regular exercise as an
Muscle-strengthening activities should be done a minimum of intervention for treating mild to moderate menopausal symp-
2 nonconsecutive days of the week and should target 8 to 10 toms in perimenopausal women.39 The top three menopause-
major muscle groups (abdomen, bilateral arms, legs, should- related symptoms in Chinese women include fatigue, irrita-
ers, hips). Individuals should strive to perform 10 to 15 bility, and arthralgia.39 In a 12-week randomized, controlled
repetitions of each exercise at the intensity of 60% to 75% trial of brisk walking for 30 minutes at least three times a
of one-repetition maximal and increase resistance over time. week, women who exercised reported decreased paresthesia,
Flexibility in activities such as stretching and yoga is necess- insomnia, irritability, arthralgia, and fatigue. In addition,
ary to perform daily life activities such as reaching overhead weight, BMI, waist circumference, triglycerides, and total
and putting on shoes. Balance exercise improves stability and cholesterol were significantly improved in the exercise inter-
may prevent falls or reduce injuries related to falls.20-22 vention group.39 The Menopause-Specific Quality of Life
questionnaire divides menopausal symptoms into physical,
Physical activity/inactivity and health vasomotor, psychosocial, and sexual symptoms.40 In a cross-
The advantages of regular physical activity include sectional observational study of perimenopausal Korean
reduction in risk of cardiovascular events, reduction in women, Kim et al41 demonstrated that moderate levels of
obesity, diminished risk of hypertension and diabetes melli- physical activity were associated with reduced psychosocial
tus, improvement in blood lipid profile, reduction in risk of and physical menopausal symptoms, suggesting that physical
cancer, and many others.23 Physical activity improves the activity may improve some of the symptoms of menopause,
quality of life for people of all ages and may increase life- thereby increasing the quality of life in menopausal women.
span.24-27 In fact, data from the Dose-Response to Exercise in Although several studies have demonstrated that physical
Postmenopausal Women study, which examined the health activity reduces menopausal symptoms,42 others have shown
benefits of the 50%, 100%, and 150% of the NIH Consensus inconsistent results for vasomotor and sexual symptoms.43-46
Panel physical activity recommendation in postmenopausal A randomized controlled trial (RCT) that evaluated the
women, illustrated that exercise-induced improvements in effectiveness of a 6-month exercise intervention as treatment
quality of life were dose-dependent and independent of for vasomotor menopausal symptoms found it ineffective for

1352 Menopause, Vol. 22, No. 12, 2015 ß 2015 The North American Menopause Society

Copyright @ 2015 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
MENOPAUSE AND EXERCISE

both hot flushes and night sweats.47 Similarly, another RCT in impact on the cardiometabolic risk profile irrespective of
late peri- and postmenopausal sedentary women with frequent menopause status.58 A 6-month exercise program combined
vasomotor symptoms found that 12 weeks of moderate-inten- with 70 mg/d isoflavone supplementation resulted in marked
sity aerobic exercise did not alleviate vasomotor symptoms.48 improvements in body composition parameters known to
A recent Cochrane review found that evidence was insuffi- influence the development of cardiovascular disease in post-
cient to show whether exercise is an effective treatment for menopausal women.59 Suppression of obesity, and its related
vasomotor menopausal symptoms.49 The Menopause Strat- inflammation, may be a further indirect mechanism by which
egies: Finding Lasting Answers for Symptoms and Health exercise exerts beneficial effects on health.
research network similarly found that 12 weeks of moderate-
intensity aerobic exercise did not alleviate vasomotor symp- Better mobility and injury prevention
toms, but resulted in small improvements in sleep quality, Dynapenia refers to an age-related loss of muscle strength
insomnia, and depression in midlife sedentary women.50 and may be used as a marker of cardiorespiratory function, as
Taken together, evidence does not support the routine use dynapenic women have significantly poorer cardiorespiratory
of physical exercise to treat vasomotor symptoms. function than others.60 Regular exercise has also been linked
to improved mobility and reduced onset of mobility-related
Maintenance of weight and healthy body composition disability,61,62 along with reduced likelihood of falls and fall-
Regular exercise is associated with improved conditioning, related injuries,63 thereby suggesting that regular physical
strength, flexibility, and overall physical fitness in older activity assists older adults in maintaining independent func-
adults.17,51 If it is sufficiently strenuous, it can prevent weight tion and in decreasing their risk of injury.64 Postmenopausal
gain. For example, Nordic walking, a combination of walking women also gain significant psychological benefit from mod-
and cross-country skiing like movement (including pushing erate-intensity exercise with continued exercise, resulting in
oneself over the ground using poles), reduces weight gain in maintained improvements in psychological well-being and
postmenopausal women.23,52 Nordic walking results in quality of life.65 It is important to note, however, that there is
weight loss during menopause (6.4%), and decreases in blood heterogeneity of physical function responses to exercise train-
glucose (3.8%) and lipoproteins (10.4%-16.7%), all of which ing in older adults and some may not improve as much as
was substantially better than either Pilates or dietary inter- others.66 In addition, although a moderate intensity physical
vention alone at 10 weeks.23 Long-term (12 moþ) exercise activity intervention may improve physical function in older
programs in postmenopausal women have been associated adults, the positive benefits may be attenuated with obesity.67
with positive changes in basal metabolic rate, skeletal muscle Fractioning exercise regimens into multiple shorter daily
mass, percent fat, and other anthropometric and body com- regimens is feasible and effective in postmenopausal
position variables.53 These findings are supported by data women.68
from the Study of Women’s Health Across the Nation study
that has associated regular physical activity with beneficial LONG-TERM BENEFITS OF EXERCISE
changes in body composition and fat distribution in peri- and Reduced mortality
postmenopausal women,54 specifically lower BMI, less cen- There is a linear relationship between greater amounts of
tral adiposity, and lower prevalence of cardiovascular risk sedentary time and mortality risk in older women.69 Analysis
factors such as diabetes and metabolic syndrome. It is import- of NHANES data elucidates that the most sedentary age group
ant to note, however, that although mild-intensity aerobic of the population is composed of adults older than 60 years:
exercise training improves some markers of cardiovascular sedentary time is 8.5 h/d in adults aged 60 to 69 years and
disease and mortality in postemenopausal women, additional 9.4 h/d in adults 70 to 85 years.70 Postmenopausal women
markers of mortality risk (ie, aerobic fitness, glomerular studied in the Women’s Health Initiative’s Observational
filtration rate, BMI, plasma glucose dysfunction, markers cohort, who reported greater amounts of sedentary time
of endothelial dysfunction) only improve in premenopausal had an increased risk of all-cause mortality (hazard
African-American women.55 Additional studies are needed to ratio¼1.26; 95% CI 1.19, 1.34), which remained statistically
evaluate the ethnic and racial differences exercise may have significant, but was somewhat lower after controlling for
on menopausal women. physical activity, physical function, and other relevant cova-
In addition, high intrinsic aerobic fitness is protective riates (hazard ratio ¼ 1.12; 95% CI 1.05, 1.21).69 Similar
against increases in adiposity and insulin resistance in a rat results were found for cardiovascular and cancer mortality.69
model of menopause.56 Similarly, a randomized controlled Mortality risk rose in a dose-dependent manner with seden-
study showed that a low–moderate-intensity exercise pro- tary time and was consistent across all causes of death
gram resulted in decreased inflammatory cytokines (IL-1beta, examined.69
IL-6, TNF-alpha),57 all of which are characteristically elev-
ated in obesity. Other studies, however, have shown that Weight maintenance and other chronic conditions
although IL-6 expression may decrease in response to a In postmenopausal women, higher habitual physical
16-week brisk walking intervention among sedentary over- activity while participating in aerobic training is associated
weight and obese women, it did not result in a favorable with greater reductions in central adiposity, and is supportive

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GRINDLER AND SANTORO

of weight loss, compared with lower activity levels.71 In pressure in postmenopausal women with mild to moderately
addition, regular exercise has been associated with improved elevated initial levels.87 Even low physical activity levels
participant outcomes in chronic disorders, including mood improve vascular function in overweight and obese postme-
disorders, dementia, chronic pain, congestive heart failure, nopausal women.88 Habitual physical activity, specifically
stroke, constipation, and sleep disorders in older adults.17,72-74 walking 6,000 or more steps per day, was associated with
There is a dose–response relationship between exercise decreased risk of cardiovascular disease and diabetes in
duration and numerous health outcomes in postmenopausal middle-aged women, independent of menopause status.89
women, including cardiorespiratory fitness, body mass, body Future studies like the WalkMore RCT will be important
composition, waist circumference, and high-density lipopro- to our understanding of the relative benefits that walking
tein cholesterol, although no comparison has been done with a volume and/or intensity may have on blood pressure in a
premenopausal group.75 Declines in cardiorespiratory fitness population at risk for cardiovascular disease.90
in postmenopausal women are associated with an increase in
central adiposity and a decrease of the basic metabolic rate. Prevention of bone resorption
Moderate-intensity exercise programs have been found to Osteoporosis is a systemic skeletal condition of deterio-
improve cardiorespiratory fitness and to positively modify rating bone strength and predisposes women to an increased
other major risk factors for cardiovascular disease in post- risk of fractures. Up to 70% of women have osteoporosis by
menopausal women.76 Regular exercise also reduces the risk the age of 80.91,92 Osteoporotic fracture causes considerable
of the following chronic diseases: cardiovascular disease, morbidity and indirect mortality because of problems
thromboembolic stroke, hypertension, type 2 diabetes melli- related to immobility. Weight-bearing exercise is beneficial
tus, osteoporosis, obesity, colon cancer, breast cancer, to bone development and maintenance through mechanical
anxiety, depression, and cognitive decline in older adults.77 loading of bone.93 Walking as a singular exercise therapy
has no significant effects on bone mineral density at the
Prevention of heart disease lumbar spine, radius, or the whole body in perimenopausal
Perhaps the most important benefit to be gained by regular and postmenopausal women, although significant and
exercise in postmenopausal women is its protective effect on positive effects on femoral neck bone mineral density are
endothelial function and in prevention of heart disease. This is evident with interventions more than 6 months.94 Exercising
especially important to postmenopausal women because the more than two to four times per week compared with less
benefits of estrogen on the vascular endothelium seem to be than two sessions per week is also associated with more
limited to the reproductive and (perhaps) early postreproduc- favorable bone adaptive response in postmenopausal osteo-
tive years, and thereafter there are few studies that indicate a penic women.95
demonstrable protective effect of estrogen on the vasculature. Three specific types of exercise are helpful for postmeno-
Aerobic exercise specifically promotes healthy endothelial pausal women who have osteopenia or osteoporosis. The
function and is therefore a logical, nonpharmacologic, inex- overall purpose of exercises to help osteopenic or osteoporotic
pensive way for women to maintain cardiovascular health. women need not be simply to build bone or prevent bone
Cardiovascular disease is the most common cause of death in resorption. There is also value in mitigating falls and the
women, accounting for the greatest proportion of deaths over consequences of falling, which can be fractures. First, it is
the age of 50 years.78 The overall prevalence of coronary important to consider which exercises are truly ‘‘weight-
artery disease is estimated to be 5.1% in women.79 Women bearing’’ to avoid confusion. These are generally high-impact
generally face a worse prognosis than men after a primary exercises such as jogging, running, and brisk walking. Bicycle
coronary event: 18% of women develop heart failure within riding, use of an elliptical trainer, and cross-country skiing are
the first 5 years after a myocardial infarction.79 The decline in not considered weight-bearing, and exercises such as swim-
vascular function in women is accelerated during the post- ming provide no weight-bearing benefit at all. The second
menopausal period,80 and is accompanied by additional form of exercise is weight training, or resistance exercise.
unfavorable changes in cardiovascular risk factors.81-83 As Muscle strengthening through resistance exercise serves sev-
little as 12-weeks of exercise has been shown to have a eral purposes. It increases muscle mass and thereby forms a
positive impact on vascular function, as indicated by a marked physical cushion against bony surfaces, reducing their like-
improvement in the biomarker profile, in both premenopausal lihood of fracture on impact. It also transmits pressure signals
and postmenopausal women of a similar age.84 Similarly, to bone, even if it is not in weight-bearing muscle groups, that
previously sedentary, overweight, or obese postmenopausal stimulate bone formation. Furthermore, increased muscle
women experience a dose–response change in fitness across strength is likely to contribute to a better ability to avoid
levels of exercise training over a 6-month period.85 In a recent falling, through collateral muscle strengthening. Finally, the
trial, 16 weeks of aerobic exercise improved body com- third form of exercise, stretching and balancing, which
position, sex hormone binding globulin, insulin levels, improves mobility and balance, can help women with low
and metabolic syndrome factors in obese postmenopausal bone density avoid high-impact falls that can cause fractures
women.86 Regular aerobic exercise for a 12-week period by increasing their gait stability and ability to recover when
results in clinically important reductions in resting blood being thrown off balance.

1354 Menopause, Vol. 22, No. 12, 2015 ß 2015 The North American Menopause Society

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MENOPAUSE AND EXERCISE

Cognitive benefits of exercise doing so. These women are unlikely to pose problems for the
Dementia and cognitive decline are major concerns for clinician. Others do not like to experience sweatiness, especi-
women and society. Alzheimer’s disease is the most common ally a problem during the menopausal transition. Help your
cause of dementia and more than 36 million people suffer patient by directing her toward activities that are compatible
worldwide from Alzheimer’s disease or other dementia.96 with her preferences. A more meditative person may select a
Physical activity may help maintain or even improve cogni- yoga workout over an aerobic workout, and be able to stick
tive functioning and reduce apathy throughout life, especially with a regimen that may give her less overall aerobic benefit
in older age.97-99 In addition, exercise programs may improve but great improvements in flexibility, muscle strengthening,
physical and cognitive function, as well as decrease caregiver and balance. The woman who hates to sweat may enjoy taking
burden with individuals with existing dementia.100 up swimming.

RISKS OF EXERCISE Monitor progress


The benefits of physical activity far outweigh the possible It is helpful to record the current exercise regimen in the
associated risks in the majority of participants.101 Musculos- participant’s medical record and follow up with her at sub-
keletal injury is the most common risk of exercise. More sequent office visits to assure she is maintaining the habit.
serious, but much less common risks include arrhythmia, This allows for the clinician to address barriers that may arise.
sudden cardiac arrest, myocardial infarction, rhabdomyolysis, It is equally important to point out that the participant is
and bronchoconstriction. There is a general consensus that a reaping the benefits of her exercise regimen, by reporting
screening medical evaluation before exercise is not necessary back results like weight, waist circumference, blood pressure,
for asymptomatic participants at low risk for coronary artery lipid profile, and glycosylated hemoglobin results.
disease. Other risk factors to identify in a preexercise medical
evaluation include the following: age, general physical con- Encourage cross-training
dition, exercise history, medication use, history of pulmonary Participants who are lifelong exercisers in one single area
disease, anticipated type of exercise, orthopedic history and may actually risk their health over the long term. Cross-
musculoskeletal risks, and handicaps or disabilities. training can help participants touch upon all of the aspects
of physical fitness and give them an alternative exercise to do
DISCUSSION in the event of injuries, which are inevitable.
Based on the above data, exercise is a near-ideal interven-
tion for prevention of many of the morbidities to which Address recidivism
postmenopausal women are prone, and should be encouraged All habits must be learned and incorporated into the
and maintained whenever possible. It promotes longevity, and individual’s life style over time. Most women will stray from
maximizes a woman’s functional life span and quality of life. their existing regimen because of injury, boredom, or other
It should be part of every medical evaluation, and specific reasons (eg, lack of time) at one point or another. It is
barriers to exercise should be addressed. This need not take up important for the clinician to reinforce the benefits of exercise
much of the clinician’s time, as many office and participant and how it has helped the participant’s health in the past.
tools exist to estimate physical activity. Here are a few Offering alternative forms of exercise or changes in the
general recommendations. exercise environment (more social interaction vs running
along in the predawn hours, etc) can help remotivate your
Help your participant set realistic goals patient to get started again.
A general rule of thumb is to achieve at least 10,000 steps
per day. There are a number of smartphone apps, pedometers, When all else fails, bargain
and actigraphy instruments, such as the Fitbit, that can be used In the end, the clinician should take whatever can be gotten
to estimate daily activities and proximity to the fitness goal. from the patient: a commitment to start, or a commitment to
Women who have disabilities, are confined to wheelchairs, or contemplate an exercise regimen. Anything is better than
need assistive devices for walking are unlikely to be able to nothing!
achieve these targets and will need other methods to estimate
and track activity. Some women will rebel against tracking CONCLUSIONS
activity, and should be directed toward other ways of fulfilling The most common barrier middle-aged women describe as
a daily fitness goal. Parking the car farther away in the parking interfering with adhering to regular exercise is attributed to
lot to achieve more steps, avoiding the elevator whenever the demands that this stage of life places on their personal time
possible, and even having ‘‘walking meetings’’ or a standing for themselves.102 Having an established daily structure that
desk may all be helpful in maintaining activity during the day. incorporates exercise, anticipated positive feelings associated
with exercise, and accountability to others are the most cited
Work with existing preferences factors enabling adherence of middle-aged women to their
Some women are able to unfailingly keep to a daily regular exercise.102 Healthcare professionals should consider
exercise routine, and do not feel completely well without a narrative approach to assessing these barriers and focus on

Menopause, Vol. 22, No. 12, 2015 1355

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GRINDLER AND SANTORO

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