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The practice of yoga has been proven to have positive effects on reducing insomnia. Studies have also shown its effects on reducing climacteric symptoms. To date, however, no studies that evaluate the effects of yoga on postmenopausal women with a diagnosis of insomnia in a randomized clinical trial have been conducted. The aim of this study was to evaluate the effect of yoga practice on the physical and mental health and climacteric symptoms of postmenopausal women with a diagnosis of insomnia. Postmenopausal women not undergoing hormone therapy, who were 50 to 65 years old, who had an apnea-hypopnea index less than 15, and who had a diagnosis of insomnia were randomly assigned to one of three groups, as follows: control, passive stretching, and yoga. Questionnaires were administered before and 4 months after the intervention to evaluate quality of life, anxiety and depression symptoms, climacteric symptoms, insomnia severity, daytime sleepiness, and stress. The volunteers also underwent polysomnography. The study lasted 4 months. There were 44 volunteers at the end of the study. When compared with the control group, the yoga group had significantly lower posttreatment scores for climacteric symptoms and insomnia severity and higher scores for quality of life and resistance phase of stress. The reduction in insomnia severity in the yoga group was significantly higher than that in the control and passive-stretching groups. This study showed that a specific sequence of yoga might be effective in reducing insomnia and menopausal symptoms as well as improving quality of life in postmenopausal women with insomnia.
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Menopause: The Journal of The North American Menopause Society
Vol. 19, No. 2, pp. 186/193
DOI: 10.1097/gme.0b013e318228225f
*2012 by The North American Menopause Society
Yoga decreases insomnia in postmenopausal women: a randomized
clinical trial
Rui Ferreira Afonso, MSc,
1
Helena Hachul, MD, PhD,
1,2
Elisa Harumi Kozasa, PhD,
1,3
Denise de Souza Oliveira, BS,
1
Viviane Goto, BS,
1
Dinah Rodrigues, BS,
4
Se´rgio Tufik, MD, PhD,
1
and Jose´ Roberto Leite, PhD
1
Abstract
Objective: The practice of yoga has been proven to have positive effects on reducing insomnia. Studies have also
shown its effects on reducing climacteric symptoms. To date, however, no studies that evaluate the effects of yoga on
postmenopausal women with a diagnosis of insomnia in a randomized clinical trial have been conducted. The aim of
this study was to evaluate the effect of yoga practice on the physical and mental health and climacteric symptoms of
postmenopausal women with a diagnosis of insomnia.
Methods: Postmenopausal women not undergoing hormone therapy, who were 50 to 65 years old, who had an
apnea-hypopnea index less than 15, and who had a diagnosis of insomnia were randomly assigned to one of three
groups, as follows: control, passive stretching, and yoga. Questionnaires were administered before and 4 months after
the intervention to evaluate quality of life, anxiety and depression symptoms, climacteric symptoms, insomnia severity,
daytime sleepiness, and stress. The volunteers also underwent polysomnography. The study lasted 4 months.
Results: There were 44 volunteers at the end of the study. When compared with the control group, the yoga group
had significantly lower posttreatment scores for climacteric symptoms and insomnia severity and higher scores for
quality of life and resistance phase of stress. The reduction in insomnia severity in the yoga group was significantly
higher than that in the control and passive-stretching groups.
Conclusions: This study showed that a specific sequence of yoga might be effective in reducing insomnia and
menopausal symptoms as well as improving quality of life in postmenopausal women with insomnia.
Key Words: Yoga YPostmenopause YInsomnia YSleep disorders.
Climacterium is the phase in a woman’s life that cor-
responds to the gradual transition from a reproduc-
tive to a nonreproductive stage. It begins around the
age of 40 years, when the first endocrine alterations are
detected. These alterations signify not only the exhaustion of
ovary follicles but also the desynchronization of the neural
signals in the hypothalamus and central nervous system.
Menopause takes place within the climacteric phase, at around
the age of 50 years, and is characterized by at least 12 months
of amenorrhea.
1,2
The most prevalent symptoms of women entering meno-
pause are vasomotor ones, which account for 70% to 80% of
symptoms.
3,4
These vasomotor symptoms are considered at
least partially responsible for sleep disorders after meno-
pause.
5,6
Many women present with sleep disorders after
menopause.
7
An epidemiological study conducted in Sa
˜o
Paulo found that 81.6% of the interviewees had sleep com-
plaints, and 52.1% of the respondents complained of insom-
nia.
8
Sleep problems tend to increase with age
9
and are more
frequent in women during the menopausal transition.
10
Astudy
that used both subjective (questionnaires) and objective (poly-
somnography) evaluations showed that 61% of postmeno-
pausal women had subjective sleep complaints. The objective
evaluation, however, revealed that 83% of women had sleep
alterations.
7
Hormone therapy (HT), that is, the exogenous replacement
of the hormones produced by the ovaries, can be used to relieve
climacteric symptoms. However, after some studies correlated
HT with a significant increase in coronary diseases, breast
cancer, stroke, and thromboembolism,
11
many women discon-
tinued HT. Since that time, hormonal treatment has become
much more individualized, with the physician and the patient
considering its risks and benefits. Therefore, an increasing
number of women have opted for other kinds of treatment,
12
such as increasing soy in the diet and using acupuncture and
Received February 16, 2011; revised and accepted June 2, 2011.
From the
1
Departamento de Psicobiologia, Universidade Federal de Sa
˜o
Paulo;
2
Departamento de Ginecologia, Universidade Federal de Sa
˜oPaulo;
3
Nu
´cleo de Estudos em Sau
´de Coletiva e da Famı
´lia, Universidade Nove de
Julho; and
4
International Yoga Teachers Association, Sao Paulo, SP, Brazil.
Funding/support: This work was supported by Associa0a
˜oFundode
Incentivo a
`Psicofarmacologia, Funda0a
˜odeAmparoa
`Pesquisa do Estado
de Sa
˜o Paulo (FAPESP), FAPESP/Centros de Pesquisa, Inova0a
˜oeDifusa
˜o
(98/143030-3 to S.T.), and Conselho Nacional de Desenvolvimento Cien-
´fico e Tecnolo
´gico.
Financial disclosure/conflicts of interest: The authors declare no conflicts
of interest, with the exception of Dinah Rodrigues, who developed the
sequence of yoga exercises evaluated in this study and teaches it to
woman in menopause.
Address correspondence to: Helena Hachul, MD, PhD, Rua Napolea
˜o
de Barros, 925 CEP 04024-002, Sao Paulo, SP, Brazil. E-mail:
helenahachul@psicobio.epm.br; helena.hachul@hotmail.com
186 Menopause, Vol. 19, No. 2, 2012
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
yoga. Research is underway to assess the benefits of these un-
conventional, nonpharmacological resources.
13
Some researchers have investigated the use of yoga for the
relief of climacteric symptoms, which include hot flashes,
insomnia, depression, and anxiety.
14<18
Other studies have also
evaluated the value of yoga for treating symptoms such as
depression, anxiety, and insomnia in women undergoing psy-
chiatric treatment and older women.
19<22
Yoga is derived from the Sanskrit root yuj, which means
Bunion.[It is the union of the individual being ( jivatman)
with the universal being ( paramatman). Yoga techniques
originated in India and have developed over thousands of
years.
23
Today, it is used to treat several illnesses, including
joint pain, hypertension, and rheumatoid arthritis,
24<26
and to
generally promote health.
21,27
The body positions in yoga are
called asanas, the respiratory exercises are called pranayama,
and the meditation is called dhyana. Despite its Indian origin,
the number of practitioners of yoga in the West is growing
quickly. In 2002, 62% of adult North Americans used some
kind of alternative or complementary practice; 5.1% of these
practiced yoga.
28
However, because there are many branches of yoga that offer
different methodologies, it is hard to standardize the studies of
yoga and generalize their results. Some kinds of yoga are
essentially meditative, whereas others focus on breathing ex-
ercises. Likewise, some studies include only respiratory tech-
niques, whereas others address the positions.
The aim of the present study was to evaluate the effects of a
standardized yoga practice as a nonpharmacological treatment
of the physical and mental health and the climacteric symp-
toms of postmenopausal women with a diagnosis of insomnia.
METHODS
Sample collection
Study participants were postmenopausal, literate women
between the ages of 50 and 65 years with insomnia diagnosed
by a specialist based on Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition criteria. They had had ame-
norrhea for 1 year or longer, had follicle-stimulating hormone
levels equal to or greater than 30 mIU/mL, and had a body
mass index lower than 30 kg/m
2
. The participants were re-
cruited via print media (local newspaper) and through the out-
patient service for climacterium provided by the Gynecological
Endocrinology Clinic in the Department of Gynecology at the
Universidade Federal de Sa
˜oPauloYEscola Paulista de Medicina.
The exclusion criteria were as follows: uncontrolled clinical
illnesses, such as systemic arterial hypertension, diabetes, and
cancer; use of HT; use of psychotropic drugs; an apnea-
hypopnea index greater than 15; and participation in psycho-
logical treatment of menopausal symptoms. The Committee of
Ethics in Research of the Universidade Federal de Sa
˜o Paulo
approved the study (CEP 0408/07).
Groups
A total of 213 women showed interest and were invited
to a lecture on sleep disorders in women. They were then se-
lected based on the inclusion/exclusion criteria and randomly
assigned to groups. All of the volunteers provided written
informed consent. The study lasted 4 months; questionnaires
were completed before the study began and at the end of the
study. All three groups ingested a daily dose of 500 mg of cal-
cium, because the ethics committee of our university recom-
mends at least one intervention for control groups. At the time
of randomization, the groups had similar scores on the follow-
ing scales: the Beck Anxiety Inventory (BAI), the Beck De-
pression Inventory (BDI), the Kupperman Menopausal Index
(KMI), the Insomnia Severity Index (ISI), the Menopause-
Specific Quality of Life Questionnaire (MENQOL), and Lipp’s
Inventory of Stress Symptoms for Adults (ISSL). They were
also similar with regard to body mass index and age.
Control group (no procedure)
The researchers contacted 15 volunteers by telephone once
a month to determine whether they were taking any drugs or
following any procedures that could exclude them from the
study. All of the volunteers were invited to participate in the
yoga class procedure after the study ended.
Passive stretching
The 14 volunteers in this group had two 1-hour sessions per
week of passive stretching. If a volunteer missed a session, she
was asked to complete it on another day and/or at another time
so that all of the participants would finish the 4 months of
intervention without a significant number of absences. The
volunteer would lie on a stretcher, first on her back and then
on her stomach, and the main articulations in her body would
be manipulated, with a soft stretching of the main muscles
of those articulations. The stretches included circumduction
of the ankle; flexion and extension of the knee; adduction,
abduction, flexion, extension, and circumduction of the thigh;
flexion and extension of the elbow; flexion, extension, and
circumduction of the shoulder; flexion and extension of the
wrist; and flexion of the neck. The passive stretching was
performed by a physical therapist. One volunteer had to be
excluded at the end of the study because she did not answer
the final questionnaires.
Yoga
The yoga group’s classes were led by a yoga teacher. The
15 volunteers were divided into groups of no more than three
women, none of whom had had any previous experience with
yoga. They completed two sessions a week that lasted 1 hour
each. If a volunteer missed a session, she was asked to make it
up on another day so that all of the participants would finish
the study without a significant number of absences. The yoga
sequence used was based on yogasana and some Tibetan tech-
niques and is known as yoga HT for menopause. The technique
uses stretching positions (asanas) along with strong and fast
breathing, called bellows breathing (bhastrika). The practice
ended with a directed relaxation.
29
Questionnaires
The following questionnaires were used in the study:
the BAI, which evaluates anxiety symptoms on four levels
Menopause, Vol. 19, No. 2, 2012 187
YOGA DECREASES INSOMNIA SYMPTOMS
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
ranging from 0 (not at all) to 3 (severely); the BDI, which
comprises 21 questions that assess depressive symptoms on
a scale from 0 to 3, in which a higher score indicates more
severe symptoms
30
; the KMI, an instrument based on the
weight/size addition of climacteric symptoms rated on a scale
of mild, moderate, or severe
31
; the ISI, a questionnaire that
evaluates the last 2 weeks of sleep, in which a higher score
indicates more severe insomnia
32
; the MENQOL,
33
a ques-
tionnaire with 32 items scored from 0 (not at all bothered) to
6 (extremely bothered); and ISSL, which evaluates the
physical and psychological symptoms related to stress levels
in the last 24 hours (alert phase), the last week (resistance
phase), or the last month (exhaustion phase).
34
A psychologist
who was not involved in the study administered the ques-
tionnaires at the beginning of treatment and 4 months after
the intervention.
Polysomnography
Overnight recording polysomnography was performed in
the sleep laboratory using the Sleep Analyzing Computer,
version 8.1 (Embla). The examination included an electro-
encephalogram, an electromyogram of the submental and tibial
regions, an electrooculogram, an electrocardiogram, measure-
ments of oronasal airflow and thoracic-abdominal movement,
and a recording of body position and oximetry. After the ex-
amination, a physician who specializes in polysomnography
evaluated the sleep stages according to the criteria described by
Rechtschaffen and Kales.
35
The respiratory events, awaken-
ings, and periodic limb movements were analyzed according
to the criteria established by the Committee of the American
Academy of Sleep Medicine.
36
The volunteers slept in the
laboratory two nights for data collection: one night before the
intervention and one night 4 months later.
FIG. 1. Flow sheet regarding the participants in all phases of the study. AHI, apnea-hypopnea index.
188 Menopause, Vol. 19, No. 2, 2012 *2012 The North American Menopause Society
AFONSO ET AL
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
Statistical analysis
The statistical program SPSS (version 17 for Windows)
was used for the data analyses. Means and SDs were used
to characterize the groups. A general linear model of repeated
measures was used to investigate the effects on the scores of
the questionnaires.
RESULTS
Of the 213 women who initially contacted our service, 83
met the inclusion criteria and were referred for polysom-
nography. Of these, 22 volunteers were excluded for having
an apnea-hypopnea index greater than 15. Before the inter-
vention, some volunteers left after they had been allocated to
the groups. One volunteer in the control group had no interest
in the study and, therefore, did not begin the procedure. Six
volunteers did not begin the group passive-stretching sessions:
one was excluded because she began treatment with fluox-
etine, one was not interested, two volunteers did not have the
time availability, one volunteer had her period, and one vol-
unteer had a health problem and began a treatment program
that prevented her from remaining in the study. Nine volun-
teers in the yoga group did not begin the treatment because of
the following reasons: three of them lived too far from the
location where the procedure was conducted, three did not
have the time availability, two had no interest, and one left
without providing any justification. No adverse effects were
reported for the procedures (Fig. 1).
Forty-four volunteers enrolled in and completed the study.
The passive-stretching group had a significantly lower score
for the exhaustion phase of stress when compared with the
control group, but not with the yoga group; however, no other
differences were detected among the groups in the pretreat-
ment stage (Table 1).
The evaluation of the treatment effect for each group when
the pretreatment and posttreatment stages were compared
showed that the yoga group experienced major improvements
in the parameters evaluated, including a significant reduction
in their BAI, BDI, KMI, ISI, and MENQOL scores and in the
three phases of stress (alert, resistance, exhaustion) evaluated
by the ISSL. The passive-stretching group had a significant
reduction only in the ISI score, whereas the control group had
a small but significant reduction in the symptoms of the alert
phase of stress (Tables 1 and 2).
In evaluating only the posttreatment phase, the yoga group
did not differ from the passive-stretching group in any of the
parameters. It did, however, present significantly lower KMI,
TABLE 1. Results of questionnaires scores
Control group Passive stretching Yoga
Pre Post Pre Post Pre Post
Mean SE Mean SE Mean SE Mean SE Mean SE Mean SE
BAI 13.7 2.5 13.5 1.9 12.2 2.5 10.2 1.9 15.3 2.5 8.8
a
1.9
BDI 16.8 2.0 14.8 1.9 12.4 2.1 10.9 1.9 15.1 2.0 11.0
a
1.9
KMI 22.3 2.6 19.9
b
2.1 18.1 2.7 14.6 2.2 17.4 2.6 12.4
a,b
2.1
ISI 15.2 1.2 13.7
b,c
1.2 16.9 1.2 11.4
a,c
1.3 14.1 1.2 9.7
a,b,c
1.2
MENQOL 134.6 11.2 127.2
b
10.8 114.6 11.6 101.6 11.1 118.5 11.2 88.1
a,b
10.8
ISSL (alert) 5.5 0.6 4.1
a
0.7 4.5 0.6 3.9 0.7 3.9 0.6 2.6
a
0.7
ISSL (resistance) 7.5 0.8 7.2
b
0.7 5.6 0.9 5.1 0.7 6.0 0.8 4.1
a,b
0.7
ISSL (exhaustion) 10.1
d
1.2 7.4 0.9 5.6
d
1.3 4.6 0.9 8.1 1.2 5.2
a
0.9
Comparison between pretreatment and posttreatment of three groups: control, passive stretching, and yoga (PG0.05). Pre, pretreatment; Post, posttreatment; BAI,
Beck Anxiety Inventory; BDI, Beck Depression Inventory; KMI, Kupperman Menopausal Index; ISI, Insomnia Severity Index; MENQOL, Menopause-Specific
Quality of Life Questionnaire; ISSL, Inventory of Stress Symptoms for Adults.
a
Comparison between the preintervention and postintervention moments of each group.
b
Comparison of the groups in the postintervention moment.
c
Comparison if the effect of treatment had difference between groups.
d
Comparison of the groups in the preintervention moment.
TABLE 2. Gand observed power (OP) of the applied questionnaires (intragroup and between-group comparison)
Intragroup comparison Between-group comparison
Before After Time Group Before After
FPGOP FPGOP FPGOP FPGOP
BAI 5.56 0.02 0.12 0.63 2.29 0.11 0.10 0.44 0.37 0.69 0.02 0.11 1.63 0.21 0.07 0.32
BDI 6.65 0.01 0.14 0.71 0.69 0.51 0.03 0.16 1.15 0.33 0.05 0.24 1.37 0.27 0.06 0.28
KMI 9.02 0.01 0.18 0.84 0.41 0.67 0.02 0.11 1.02 0.37 0.05 0.22 3.23 0.05 0.14 0.58
ISI 29.51 0.00 0.42 1.00 2.85 0.07 0.12 0.53 1.51 0.23 0.07 0.30 2.52 0.06 0.11 0.48
MENQOL 8.33 0.01 0.17 0.80 1.42 0.25 0.07 0.29 0.88 0.42 0.04 0.19 3.39 0.02 0.14 0.61
ESS 0.06 0.81 0.00 0.06 1.16 0.32 0.05 0.24 0.13 0.88 0.01 0.07 1.13 0.33 0.05 0.24
ISSL (alert) 972 0.01 0.19 0.86 0.54 0.59 0.03 0.13 1.68 0.20 0.08 0.33 1.49 0.24 0.07 0.30
ISSL (resistance) 3.79 0.06 0.09 0.48 1.25 0.30 0.06 0.26 1.30 0.29 0.06 0.27 4.97 0.01 0.20 0.78
ISSL (exhaustion) 20.18 0.01 0.33 0.99 1.49 0.24 0.07 0.30 3.32 0.05 0.14 0.60 2.66 0.08 0.12 0.50
BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; KMI, Kupperman Menopausal Index; ISI, Insomnia Severity Index; MENQOL, Menopause-
Specific Quality of Life Questionnaire; ISSL, Inventory of Stress Symptoms for Adults; ESS, Epworth sleepiness scale.
Menopause, Vol. 19, No. 2, 2012 189
YOGA DECREASES INSOMNIA SYMPTOMS
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
ISI, MENQOL, and ISSL resistance phase scores when com-
pared with the control group.
The ISI had a time group interaction; that is, the three
groups had simultaneously significant effects (Fig. 2). Figure 3
shows that both the yoga and the passive-stretching groups
improved after treatment. However, only the yoga group pre-
sented with a significant difference in the ISI scores posttreat-
ment when compared with the waiting-list control group, thus
presenting with better results than the passive-stretching group.
Figure 3 shows that there was a significant difference be-
tween the yoga and control groups in the posttreatment KMI
scores. Regarding quality of life, a significant reduction can be
observed in the MENQOL scores of the yoga group compared
with the control group (Fig. 4).
The polysomnography did not detect significant intergroup
or intragroup differences.
DISCUSSION
Sleep disorders are highly prevalent in menopause, affecting
between 28% and 63% of women.
7,37<39
Insomnia is related to
lower quality of life
40
and a higher frequency of comorbid-
ities.
41,42
The present study found that yoga yielded the best
results for reducing postmenopausal insomnia-related com-
plaints. This is the first study in the literature that demonstrates
the benefits of yoga for postmenopausal women diagnosed
with insomnia.
Many women discontinue HT because it is contraindicated
or because they choose to after experiencing vasomotor
symptoms. Many of them resort to alternative and comple-
mentary practices in their search for relief of their unpleasant
symptoms.
43
Vasomotor symptoms are the most common
complaint among climacteric women, and they are also the
factor that most threatens their well-being. These symptoms
can trigger a Bdomino effect,[leading to other symptoms,
such as insomnia and depression, and can negatively affect
the quality of life of the women who experience them.
44
The
results of the present study corroborate those of previous re-
search, in which women who practiced yoga experienced a
reduction in climacteric symptoms.
15,45
The MENQOL and
the KMI scores showed significant posttreatment differences
between the yoga group and the control group, and the yoga
group showed significant improvement in their sleep and
mental health, as assessed by analysis of pretreatment and
posttreatment scores. Comparisons with the passive-stretching
group showed no such effect. Carson et al
46
compared a yoga
group with a wait-list control of women with breast cancer, a
population whose climacteric symptoms are exacerbated and
for whom HT is contraindicated. They observed a reduction in
climacteric symptoms, which included severity and frequency
of hot flashes, joint pain, fatigue, sleep disorders, and low
vitality. Similar findings were found in a pilot study
17
in which
a yoga sequence was used to treat menopausal symptoms in
12 women between 45 and 60 years old. The women in that
FIG. 2. Results of pretreatment and posttreatment ISI scores for the three groups: control, passive stretching, and yoga.
Comparison between the
preintervention and postintervention time points for each group;
comparison of the effect of treatment between groups;
#
comparison of the groups at the
postintervention time point (PG0.05). ISI, Insomnia Severity Index.
FIG. 3. Results of the preintervention and postintervention KMI scores for the three groups: control, passive stretching, and yoga.
Comparison between
the preintervention and postintervention time points for each group;
#
postintervention comparison of the groups (PG0.05). KMI, Kupperman Meno-
pausal Index.
190 Menopause, Vol. 19, No. 2, 2012 *2012 The North American Menopause Society
AFONSO ET AL
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
study had a reduction in the symptoms of the menopausal
transition, according to the Wiklund Symptom Checklist, and
had improvements in quality of sleep (evaluated subjectively),
sleep efficiency, sleep disorders, and global sleep quality,
according to the Pittsburgh Quality of Sleep Index. Although
those studies detected sleep pattern improvements, these inter-
ventions did not work with women diagnosed with insomnia.
Cohen et al
18
reported a similar effect in a pilot study with
women who had moderate-to-severe hot flashes. Our study also
detected improvement in hot flashes and pain on the KMI and
reduced ISI scores. The program was so successful that 75% of
the volunteers continued doing yoga after the intervention. The
sleep improvement in the studies mentioned above might be
partially related to the symptoms presented by the volunteers in
those studies (mainly vasomotor symptoms) because they may
cause a worsening of sleep quality.
47
Two other studies have reported similar results related to
the quality of sleep in the older individuals. Researchers have
observed that, with regard to sleep parameters, a yoga group
responded better than did both an ayurveda group (who
ingested an Indian compound of medicinal herbs) and a wait-
list control.
21
The yoga group also had improved sleep when
compared with a group that performed physical exercise.
22
We hypothesize that the improvements our volunteers
experienced were probably due to alterations in the central,
autonomic, and neuroendocrine nervous systems.
48<50
Brown
and Gerbarg,
51
in a comprehensive literature review, postu-
lated a neurophysiological model for yoga’s treatment of
stress, anxiety, and depression. According to the authors, there
is an increase in autonomic tone and systems of response to
stress, a reduction in chemoreflex sensitivity, an increase in
the sensitivity of the baroreflex response, a predominance of
the parasympathetic system via vagus nerve stimulation, a
synchronization of the cortical areas mediated by the thalamic
nuclei, a reduction in the cortical areas involved in executive
functions, an activation of the limbic system, and an increase
in the secretion of prolactin and oxytocin. Research conducted
with a homogeneous sample of individuals from the military
who were given doses of melatonin
49
detected an increase in
the levels of that hormone, which plays an important role in
sleep and is a regulator of biological rhythms, in the group that
had practiced yoga.
52<54
There are data to suggest that the
practice of yoga leads to an increase in the brain concentrations
of F-aminobutyric acid, a potent inhibitory neurotransmitter.
50
All of these alterations lead us to believe that yoga plays an
important role in the neuroendocrine and autonomic nervous
systems, reduces sympathetic tone, and increases parasympa-
thetic tone,
55,56
factors that may improve sleep patterns and
contribute to reduced vasomotor symptoms.
With regard to anxiety and depression, the yoga group
showed a trend toward a reduction in the BDI and BAI scores.
There was an intragroup improvement, with no significant
difference when compared with the passive-stretching and
control groups. This may have been due to the small sample
size. In addition, the BDI and BAI scores were not high ini-
tially. Thus, the volunteers in the sample were not depressed
or anxious at baseline. Other studies in women with anxiety
disorders and depression have concluded that yoga has a
positive result in reducing these symptoms.
29,57<59
We observed that the passive-stretching group showed a
trend toward scores between those of the yoga group and
those of the control group. Benson
60
described a state of
calmness known as the relaxation response (as opposed to the
fight-or-flight response), during which there are reductions in
metabolism, heart rate, blood pressure, respiratory rate, and
muscle tension, among other effects. Because the women in
the passive-stretching group were lying on a stretcher and
being touched and moved, they might have accessed the re-
laxation response state, resulting in a trend toward reduced
symptoms, and, therefore, did not show significant changes
when compared with the yoga group. Considering that there
was a time group interaction and that there was a difference
between the groups, both the yoga and the passive-stretching
groups improved after treatment. However, it is important to
highlight that only the yoga group had a significant post-
treatment difference in ISI scores, as compared with the con-
trol group. In the comparison between the preintervention and
postintervention time points for each group, only the yoga
group improved on all measures: anxiety, depression, meno-
pausal symptoms, stress, and insomnia symptoms. Unlike the
yoga group, the passive-stretching group did not have any
posttreatment differences when compared with the control
group. Therefore, it is possible to conclude that the yoga
group had better results than the passive-stretching group.
FIG. 4. Preintervention and postintervention MENQOL scores for the three groups: control, passive stretching, and yoga.
Comparison between the
preintervention and postintervention time points for each group;
#
postintervention comparison of the groups (PG0.05). MENQOL, Menopause-Specific
Quality of Life.
Menopause, Vol. 19, No. 2, 2012 191
YOGA DECREASES INSOMNIA SYMPTOMS
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
Polysomnography did not detect significant differences
between groups. The clinical diagnosis of insomnia is sub-
jective. It takes the patients’ complaints
61
into consideration
because there are no insomnia-specific examinations that
can be used. Hachul et al
3
have also observed predominantly
subjective improvements in insomnia in a group treated
with HT.
With respect to stress, the results of this study are in line
with those of another study, in which women experienced a
reduction in stress and salivary cortisol levels after a 3-month
yoga program,
62
and with those of a study of workers who
practiced yoga in their workplaces.
63
CONCLUSIONS
The results of this study, the first involving postmenopausal
women with a diagnosis of insomnia, highlight the improve-
ment in sleep quality obtained in volunteers who practiced
yoga for 4 months. There are few studies in the literature that
have studied yoga in the context of menopausal symptoms or
insomnia. Overall, there are few studies of yoga that have used
rigorous, controlled, and randomized study designs. This ran-
domized, controlled study of yoga highlights the efficacy of
a specific sequence of yoga exercises in improving insomnia
symptoms, sleep quality, and menopausal symptoms in post-
menopausal women with a diagnosis of insomnia.
Acknowledgments: We thank Zila van der Meer Sanchez for the
help with statistical review.
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YOGA DECREASES INSOMNIA SYMPTOMS
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
... Two of these articles had been conducted in India 25,26 and four in United States of America. [27][28][29][30] The Menopausal Quality of Life Questionnaire (MENQOL) was used in three studies [26][27][28] to assess women's quality of life and the World Health Organization Quality of Life-BREF in the other three. 25,29,30 To assess the effect of yoga on women's quality of life, the yoga sessions were 60 to 90 min long in all six studies, while the duration of these sessions varied in other studies from 20 and 30 min to 75 min, and in most included studies, the sessions were held once or twice per week. ...
... Two of these articles had been conducted in India 25,26 and four in United States of America. [27][28][29][30] The Menopausal Quality of Life Questionnaire (MENQOL) was used in three studies [26][27][28] to assess women's quality of life and the World Health Organization Quality of Life-BREF in the other three. 25,29,30 To assess the effect of yoga on women's quality of life, the yoga sessions were 60 to 90 min long in all six studies, while the duration of these sessions varied in other studies from 20 and 30 min to 75 min, and in most included studies, the sessions were held once or twice per week. ...
... 25,29,30 To assess the effect of yoga on women's quality of life, the yoga sessions were 60 to 90 min long in all six studies, while the duration of these sessions varied in other studies from 20 and 30 min to 75 min, and in most included studies, the sessions were held once or twice per week. 25,27,29,30 Table 2 presents the details of the studies conducted on the effect of yoga on women's quality of life. ...
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Introduction The quality of life in menopausal women is considered to be an important health issue in different societies and one of the main objectives of health care in this period. This study aimed to investigate the effects of yoga on improving the quality of life in menopausal women. Method English databases of Google Scholar, Science Direct, PubMed, Scopus, and Cochrane Library were searched to access related articles using keywords of menopause, quality of life, and yoga. Furthermore, Persian equivalents of the same keywords were searched in databases of Google Scholar, SID, and Magiran, in addition to a combination of the keywords. The search interval was from the inspection to January 2020. The quality of the included studied was assessed based on CONSORT 2017 checklist. Results Out of 120 articles found in the databases, six articles entered the study based on the inclusion criteria and were investigated for intervention methods and consequences. The results indicated the positive impact of yoga on the quality of life in menopausal women. Conclusion Considering the effects of yoga on the symptoms and quality of life in menopausal women, it is suggested that this low-cost method be used to improve their quality of life and health.
... The characteristics of studies included in the review are shown in table 1. Overall, the systematic review comprised 295 individuals from three countries (Brazil, (15,33,34) United Kingdom (35) and United States of America), (36,37) who were aged 30 to 85 years (Table 1). In five studies, participant recruitment was based on a clinical diagnosis of insomnia (15,33,34,36,37) obtained via a structured interview conducted by a sleep medicine specialist, as per Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (38) and/or International Classification of Sleep Disorders (ICSD-2) criteria. ...
... Overall, the systematic review comprised 295 individuals from three countries (Brazil, (15,33,34) United Kingdom (35) and United States of America), (36,37) who were aged 30 to 85 years (Table 1). In five studies, participant recruitment was based on a clinical diagnosis of insomnia (15,33,34,36,37) obtained via a structured interview conducted by a sleep medicine specialist, as per Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (38) and/or International Classification of Sleep Disorders (ICSD-2) criteria. In the remaining study, enrollment was based on research diagnostic criteria and whether this tool was applied by a physician was not reported. ...
... Domains with higher risk of bias were blinding of participants and researchers, blinding of outcome assessment, allocation concealment and incomplete outcome data ( Figure 2). Generation of sequence of randomization: three studies failed to describe methods used for random sequence generation (15,33,36) and therefore had unclear risk of bias. The three remaining studies used stratified, block (35,37) or computer randomization and were classified as low risk of bias. ...
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Objective: To systematically review the effects (benefits and harms) of different types of physical exercise on insomnia outcomes in adult populations with no mood disorders. Objective and subjective sleep outcomes and related mismatches were analyzed. Methods: Systematic review and meta-analysis. Quality of evidence was also examined. Results: Six studies including 295 participants with insomnia diagnosis were selected. Yoga, Tai Chi, resistance exercise and aerobic exercise were used in protocols with different duration, intensity and frequency. Studies involved different populations, including inactive or sedentary individuals, older adults and postmenopausal women. Physical exercise improved subjective sleep quality (very low quality of evidence) and reduced insomnia severity (high quality of evidence). Conclusion: Findings suggest individualized physical exercise must be addressed to design optimal protocols, with standardized type, duration, intensity, and frequency. For the time being, physical exercise may be considered an alternative and/or ancillary therapeutic modality for patients diagnosed with insomnia. Physical exercise can be used to improve subjective complaints, but not objective sleep outcomes.
... Other studies on menopausal symptoms and sleep quality had yoga periods of 4 weeks (Fara et al., 2019), 8 weeks (Chattha et al., 2008), 12 weeks (Jorge et al., 2016), and 16 weeks (Afonso et al., 2012). However, most of these studies did not compare the effects of yoga on menopausal symptoms across menopause statuses or explore their relationship with sleep quality in Indonesian women. ...
... Physiologically, yoga exercises help reduce oxygen consumption in women by stabilizing their heart rate and blood pressure (Cohen et al., 2007); an unstable heart rate and blood pressure are common in menopausal women. Our results are consistent with those of studies reporting that yoga effectively reduces menopausal symptoms in perimenopausal women after 8 weeks (Chattha et al., 2008) and in postmenopausal women after 12 weeks (Jorge et al., 2016) and 16 weeks (Afonso et al., 2012). Our study revealed a significant decrease (which occurred slowly and consistently) in the menopausal symptoms of premenopausal women who practiced yoga; however, sleep quality did not change significantly (Table 3). ...
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... Yoga also motivated the young adults to be more active outside of yoga, increased their physical ability to be active, and served as a complement to an active lifestyle. Moreover, the effect on sleep found in this study is consistent with yoga research demonstrating the positive effect of yoga on insomnia in postmenopausal women (Afonso et al., 2012). Still unknown, is if there are specific types of yoga or yoga instruction that make it more likely for this type of transference to occur. ...
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OBJETIVO: avaliar a prevalência das queixas de distúrbios do sono pela polissonografia em amostra de mulheres na pós-menopausa. MÉTODOS: foram selecionadas 33 mulheres na pós-menopausa com média de idade de 56 anos, índice de massa corporal médio de 27, tempo de pós-menopausa de 7,7 anos e índice de Kupperman de 17. Adotaram-se os seguintes critérios de inclusão: idade entre 50 e 65anos, no mínimo um ano de amenorréia e FSH plasmático superior ou igual a 30 mU/mL, sem uso de terapia hormonal prévia e exames laboratoriais normais. Foram excluídas as pacientes com doenças clínicas graves e/ou descompensadas, suspeita de câncer de endométrio e/ou mama; índice de massa corporal maior ou igual a 30 e uso de hipnóticos. As pacientes responderam a questionário específico contendo perguntas sobre as características do sono e foram submetidas a polissonografia completa durante uma noite inteira. Foram calculadas separadamente as freqüências em porcentagens das queixas de sono e dos diagnósticos polissonográficos. RESULTADOS: a prevalência de insônia subjetiva foi 61%, sendo que na polissonografia foi de 83%. A queixa de apnéia foi registrada em 23% e, na polissonografia, em 27%. A prevalência subjetiva de movimentos periódicos de pernas foi de 45% e a objetiva foi de 27%. CONCLUSÃO: houve alta prevalência de distúrbios do sono na pós-menopausa, em especial de insônia, apnéia e de movimentos periódicos das pernas. Nesta fase da vida, ocorre piora da qualidade do sono.
Article
CONTEXT: Despite decades of accumulated observational evidence, the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain. OBJECTIVE: To assess the major health benefits and risks of the most commonly used combined hormone preparation in the United States. DESIGN: Estrogen plus progestin component of the Women's Health Initiative, a randomized controlled primary prevention trial (planned duration, 8.5 years) in which 16608 postmenopausal women aged 50-79 years with an intact uterus at baseline were recruited by 40 US clinical centers in 1993-1998. INTERVENTIONS: Participants received conjugated equine estrogens, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, in 1 tablet (n = 8506) or placebo (n = 8102). MAIN OUTCOMES MEASURES: The primary outcome was coronary heart disease (CHD) (nonfatal myocardial infarction and CHD death), with invasive breast cancer as the primary adverse outcome. A global index summarizing the balance of risks and benefits included the 2 primary outcomes plus stroke, pulmonary embolism (PE), endometrial cancer, colorectal cancer, hip fracture, and death due to other causes. RESULTS: On May 31, 2002, after a mean of 5.2 years of follow-up, the data and safety monitoring board recommended stopping the trial of estrogen plus progestin vs placebo because the test statistic for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits. This report includes data on the major clinical outcomes through April 30, 2002. Estimated hazard ratios (HRs) (nominal 95% confidence intervals [CIs]) were as follows: CHD, 1.29 (1.02-1.63) with 286 cases; breast cancer, 1.26 (1.00-1.59) with 290 cases; stroke, 1.41 (1.07-1.85) with 212 cases; PE, 2.13 (1.39-3.25) with 101 cases; colorectal cancer, 0.63 (0.43-0.92) with 112 cases; endometrial cancer, 0.83 (0.47-1.47) with 47 cases; hip fracture, 0.66 (0.45-0.98) with 106 cases; and death due to other causes, 0.92 (0.74-1.14) with 331 cases. Corresponding HRs (nominal 95% CIs) for composite outcomes were 1.22 (1.09-1.36) for total cardiovascular disease (arterial and venous disease), 1.03 (0.90-1.17) for total cancer, 0.76 (0.69-0.85) for combined fractures, 0.98 (0.82-1.18) for total mortality, and 1.15 (1.03-1.28) for the global index. Absolute excess risks per 10 000 person-years attributable to estrogen plus progestin were 7 more CHD events, 8 more strokes, 8 more PEs, and 8 more invasive breast cancers, while absolute risk reductions per 10 000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures. The absolute excess risk of events included in the global index was 19 per 10 000 person-years. CONCLUSIONS: Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal US women. All-cause mortality was not affected during the trial. The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases, and the results indicate that this regimen should not be initiated or continued for primary prevention of CHD.
Article
Objective: To develop a condition-specific quality of life questionnaire for the menopause with documented psychometric properties, based on women's experience. Methods: Subjects: Women 2-7 years post-menopause with a uterus and not currently on hormone replacement therapy. Questionnaire development: A list of 106 menopause symptoms was reduced using the importance score method. Replies to the item-reduction questionnaire from 88 women resulted in a 30-item questionnaire with four domains, vasomotor, physical, psychosocial and sexual, and a global quality of life question. Psychometric properties: A separate sample of 20 women was used to determine face validity, and a panel of experts was used to confirm content validity. Reliability, responsiveness and construct validity were determined within the context of a randomized controlled trial. Construct validation involved comparison with the Neugarten and Kraines'Somatic, Psychosomatic and Psychologic subscales, the reported intensity of hot flushes, the General Well-Being Schedule, Channon and Ballinger's Vaginal Symptoms Score and Libido Index, and the Life Satisfaction Index. Results: The face validity score was 4.7 out of a possible 5. Content validity was confirmed. Test-retest reliability measures, using intraclass correlation coefficients were 0.81, 0.79, 0.70 and 0.55 for the physical, psychosocial, sexual domains and the quality of life question. The intraclass correlation coefficient for the vasomotor domain was 0.37 but there is evidence of systematic change. Discriminative construct validity showed correlation coefficients of 0.69 for the physical domain, 0.66 and 0.40 for the vasomotor domain, 0.65 and -0.71 for the psychosocial domain, 0.48 and 0.38 for the sexual domain, and 0.57 for the quality of life question. Evaluative construct validity showed correlation coefficients of 0.60 for the physical domain, 0.28 for the vasomotor domain, 0.55 and -0.54 for the psychosocial domain, 0.54 and 0.32 for the sexual domain, and 0.12 for the quality of life question. Responsiveness scores ranged from 0.78 to 1.34. Conclusions: The MENQOL (Menopause-Specific Quality of Life) questionnaire is a self-administered instrument which functions well in differentiating between women according to their quality of life and in measuring changes in their quality of life.
Article
Therapy for the postmenopausal patient has three aspects: psychotherapy, sedation, and hormonal therapy. A convenient index (menopausal index) for expressing the status of a patient is calculated by assigning to each of the 11 most common symptoms a weight factor and a severity coefficient; the sum of the 11 products ranges from 0 (for complete absence of menopausal symptoms) to about 35 (for serious distress). It was used as a criterion in comparing the efficacy of 27 types of treatment, including use of conjugated equine estrogens (299 cases), ethinyl estradiol (284 cases), and chlorotrianisene (124 cases). There are objections to the prolonged use of barbiturates, and the results obtained by the use of ataractic drugs alone in this study were but slightly better than those obtained with a placebo. Superior results were obtained with conjugated equine estrogens and ethinyl estradiol alone or when the latter was used with androgens. These effects were augmented with the addition of a phenothiazine compound to the estrogen-androgen combination. The judicious use of such therapy can afford relief from unnecessary discomfort to the everincreasing number of menopausal women in the population.