Yoga decreases insomnia in postmenopausal women: A randomized clinical trial

Article (PDF Available)inMenopause (New York, N.Y.) 19(2):186-93 · October 2011with184 Reads
DOI: 10.1097/gme.0b013e318228225f · Source: PubMed
Abstract
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.
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.
REFERENCES
1. Gracia CR, Sammel MD, Freeman EW, et al. Defining menopause status:
creation of a new definition to identify the early changes of the meno-
pausal transition. Menopause 2005;12:128-135.
2. Hall JE. Neuroendocrine physiology of the early and late menopause.
Endocrinol Metab Clin North Am 2004;33:637-659.
3. Hachul H, Bittencourt LRA, Andersen ML, Haidar MA, Tufik S,
Baracat EC. Effects of hormone therapy with estrogen and/or progester-
one on sleep pattern in postmenopausal women. Int J Gynaecol Obstet
2008;103:207-212.
4. Moilanen J, Aalto AM, Hemminki E, Aro AR, Raitanen J, Luoto R.
Prevalence of menopause symptoms and their association with lifestyle
among Finnish middle-aged women. Maturitas 2010;67:366-374.
5. Zervas IM, Lambrinoudaki I, Spyropoulou AC, et al. Additive effect of
depressed mood and vasomotor symptoms on postmenopausal insomnia.
Menopause 2009;16:837-842.
6. Terauchi M, Obayashi S, Akiyoshi M, Kato K, Matsushima E, Kubota T.
Insomnia in Japanese peri- and postmenopausal women. Climacteric
2010;13:479-486.
7. Campos HH, Bittencourt LRA, Haidar MA, Tufik S, Baracat EC.
Prevale
ˆncia de distu
´rbios do sono na po
´s-menopausa. Rev Bras Ginecol
Obstet 2005;27:731-736.
8. Tufik S, Nery LE, Bittencourt LR, et al. Distu
´rbios do sono. Rev Bras
Med 1997;54:12-30.
9. Mellinger GD, Balter MB, Uhlenhuth EH. Insomnia and its treatment.
Prevalence and correlates. Arch Gen Psychiatry 1985;42:225-232.
10. Shin C, Lee S, Lee T, et al. Prevalence of insomnia and its relationship to
menopausal status in middle-aged Korean women. Psychiatry Clin
Neurosci 2005;59:395-402.
11. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of
estrogen plus progestin in healthy postmenopausal womenVprincipal
results from the Women’s Health Initiative randomized controlled trial.
JAMA 2002;288:321-333.
12. Bardel A, Wallander MA, Sva¨rdsudd K. Hormone replacement therapy
and symptom reporting in menopausal women. Maturitas 2002;41:7-15.
13. Kronemberg F, Berman AF. Complementary and alternative medicine
for menopausal symptoms: a review of randomized, controlled trials.
Ann Intern Med 2002;137:805-813.
14. Khalsa SB. Treatment of chronic insomnia with yoga: a preliminary
study with sleep-wake diaries. Appl Psychophysiol Biofeedback 2004;29:
269-278.
15. Lee MS, Kim JI, Ha JY, Boddy K, Ernst E. Yoga for menopausal
symptoms: a systematic review. Menopause 2009;16:602-608.
16. Chattha R, Raghuram N, Venkatram P, Hongasandra NR. Treating the
climacteric symptoms in Indian women with an integrated approach to
yoga therapy: a randomized control study. Menopause 2008;15:862-870.
17. Booth-LaForce C, Thurston RC, Taylor MR. A pilot study of a Hatha
yoga treatment for menopausal symptoms. Maturitas 2007;57:286-295.
18. Cohen BE, Kanaya AM, Macer JL, Shen H, Chang AA, Grady D. Fea-
sibility and acceptability of restorative yoga for treatment of hot flushes:
a pilot trial. Maturitas 2007;56:198-204.
19. Javnbakht M, Hejazi Kenari R, Ghasemi M. Effects of yoga on depression
and anxiety of women. Complement Ther Clin Pract 2009;15:102-104.
20. Sephton SE, Salmon P, Weissbecker I, et al. Mindfulness meditation
alleviates depressive symptoms in women with fibromyalgia: results of a
randomized clinical trial. Arthritis Rheum 2007;57:77-85.
21. Manjunath NK, Telles S. Influence of yoga and ayurveda on self-rated
sleep in a geriatric population. Indian J Med Res 2005;121:683-690.
22. Chen KM, Chen MH, Chao HC, Hung HM, Lin HS, Li CH. Sleep
quality, depression state, and health status of older adults after silver
yoga exercises: cluster randomized trial. Int J Nurs Stud 2009;46:154-163.
23. Feuerstein G. The Yoga Tradition, 3rd ed. Prescott, AZ: Hohm Press, 2002.
24. Williams KA, Petronis J, Smith D, et al. Effect of Iyengar yoga therapy
for chronic low back pain. Pain 2005;115:107-117.
25. McCaffrey R,Ruknui P, Hatthakit U, Kasetsomboon P. The effects of yoga
on hypertensive persons in Thailand. Holist Nurs Pract 2005;19:173-180.
26. Badsha H, Chhabra V, Leibman C, Mofti A, Kong KO. The benefits of
yoga for rheumatoid arthritis: results of a preliminary, structured 8-week
program. Rheumatol Int 2009;29:1417-1421.
27. Ross A, Thomas S. The health benefits of yoga and exercise: a review of
comparison studies. J Altern Complement Med 2010;16:3-12.
28. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and
alternative medicine use among adults: United States, 2002. Adv Data
2004;343:1-19.
29. Rodrigues D. Hormone Yoga Therapy.Sa
˜o Paulo: JCR Produ0o
˜es
Cientı
´ficas e Artı
´sticas, 2009.
30. Beck AT. Depression Inventory. Philadelphia: Center for Cognitive Ther-
apy, 1978.
31. Kupperman HS, Wetchler BB, Blatt MHG. Contemporary therapy of the
menopausal syndrome. JAMA 1959;171:1627-1637.
32. Bastien CH, Vallie
`res A, Morin CM. Validation os the Insomnia Sever-
ity Index as an outcome measure for insomnia research. Sleep Med
2001;2:297-307.
33. Hilditch JR, Lewis J, Peter A, et al. A Menopause-Specific Quality of
Life Questionnaire: development and psychometric properties. Maturitas
1996;24:161-175.
34. Lipp ML. Manual do Inventa´rio de Sintomas de Estresse para Adultos de
Lipp.Sa
˜o Paulo: Casa do Psico
´logo, 2000.
35. Rechtschaffen A, Kales A. A Manual of Standardized Terminology:
Techniques and Scoring System for Sleep Stages of Human Subjects.
Los Angeles: Brain Information Service/Brain Research Institute, 1968.
36. Iber C, Ancoli-Israel S, Chesson A Jr, Quan S. The AASM Manual for the
Scoring of Sleep and Associated Events: Rules, Terminology and Tech-
nical Specifications, 1st ed. Westchester, NY: American Academy of
Sleep Medicine, 2007.
37. Hachul de Campos H, Brandao LC, D’Almeida V, et al. Sleep
disturbances, oxidative stress and cardiovascular risk parameters in
postmenopausal women complaining of insomnia. Climacteric 2006;9:
312-319.
38. Kuh DL, Hardy R, Wadsworth M. Women’s health in midlife: the
influence of the menopause, social factors and health in earlier life.
Br J Obstet Gynaecol 1997;104:1419.
39. von Mu
¨hlen DG, Kritz-Silverstein D, Barrett-Connor E. A community-
based study of menopause symptoms and estrogen replacement in older
women. Maturitas 1995;22:71-78.
192 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.
40. Hajak G; SINE Study Group. Study of insomnia in Europe. Epidemiol-
ogy of severe insomnia and its consequences in Germany. Eur Arch
Psychiatry Clin Neurosci 2001;251:49-56.
41. Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mor-
tality associated with sleep duration and insomnia. Arch Gen Psychiatry
2002;59:131-136.
42. Ancoli-Israel S. Sleep and its disorders in aging populations. Sleep Med
2009;10:S7-S11.
43. Kupferer EM, Dormire SL, Becker H. Complementary and alterna-
tive medicine use for vasomotor symptoms among women who have
discontinued hormone therapy. J Obstet Gynecol Neonatal Nurs
2009;38:50-59.
44. Sousa RL, Filizola RG, Moraes JLR. O efeito domino
´dos fogachos:
sintomatologia depressiva e inso
ˆnia no climate
´rio. Rev Bras Med 2003;60:
191-194.
45. Innes KE, Selfe TK, Vishnu A. Mind-body therapies for menopausal
symptoms: a systematic review. Maturitas 2010;66:135-149.
46. Carson JW, Carson KM, Porter LS, Keefe FJ, Seewaldt VL. Yoga of
Awareness program for menopausal symptoms in breast cancer survivors:
results from a randomized trial. Supp ort Care Cancer 20 09;17:1301-1309.
47. Ohayon MM. Severe hot flashes are associated with chronic insomnia.
Arch Intern Med 2006;166:1262-1268.
48. Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in the treat-
ment of stress, anxiety, and depression. Part IIVclinical applications and
guidelines. J Altern Complement Med 2005;11:711-717.
49. Harinath K, Malhotra AS, Pal K, et al. Effects of Hatha yoga and Omkar
meditation on cardiorespiratory performance, psychologic profile, and
melatonin secretion. Altern Complement Med 2004;10:261-268.
50. Streeter CC, Jensen JE, Perlmutter RM, et al. Yoga Asana sessions
increase brain GABA levels: a pilot study. J Altern Complement Med
2007;13:419-426.
51. Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in the treat-
ment of stress, anxiety, and depression: part IVneurophysiologic model.
J Altern Complement Med 2005;11:189-201.
52. Tufik S. Medicina e Biologia do sono.Sa
˜o Paulo: Manole, 2008.
53. Arendt J. Melatonin and the pineal gland: influence on mammalian sea-
sonal and circadian physiology. Rev Reprod 1998;3:13-22.
54. Nowak JZ, Zawilska JB. Melatonin and its physiological and therapeutic
properties. Pharm World Sci 1998;20:18-27.
55. Satyapriya M, Nagendra HR, Nagarathna R, Padmalatha V. Effect of
integrated yoga on stress and heart rate variability in pregnant women.
Int J Gynaecol Obstet 2009;104:218-222.
56. Khattab K, Khattab AA, Ortak J, Richardt G, Bonnemeier H. Iyengar yoga
increases cardiac parasympathetic nervous modulation among healthy yoga
practitioners. Evid Based Complement Alternat Med 2007;4:5 11-517.
57. Uebelacker LA, Tremont G, Epstein-Lubow G, et al. Open trial of
Vinyasa yoga for persistently depressed individuals: evidence of feasi-
bility and acceptability. Behav Modif 2010;34:247-264.
58. Evans S, Ferrando S, Findler M, Stowell C, Smart C, Haglin D.
Mindfulness-based cognitive therapy for generalized anxiety disorder.
J Anxiety Disord 2008;22:716-721.
59. Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga for depres-
sion: the research evidence. J Affect Disord 2005;89:13-24.
60. Benson H. The relaxation response. Psychiatry 1974;37:37-46.
61. American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV). Washington, DC: American Psychiatric
Press, 1994.
62. Michalsen A, Grossman P, Acil A, et al. Rapid stress reduction and
anxiolysis among distressed women as a consequence of a three-month
intensive yoga program. Med Sci Monit 2005;11:555-561.
63. Gura ST. Yoga for stress reduction and injury prevention at work. Work
2002;19:3-7.
Menopause, Vol. 19, No. 2, 2012 193
YOGA DECREASES INSOMNIA SYMPTOMS
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
    • "Several yoga-cLBP studies found associated psychological benefits in mood and self- efficacy [34, 36, 42, 43, 47] . Yoga research on psychological health is growing, showing promising evidence for benefit in depression [48][49][50][51][52][53][54][55][56], anxiety [56][57][58][59], and insomnia [60, 61]. Yoga classes can also increase social connectedness and spirituality [62]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations. Methods/design: This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18years old with low back pain present on at least half the days in the past sixmonths and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0-10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, theVeterans Health Administration, and society using electronic medical records, self-reported cost data, and study records. Discussion: This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities.
    Full-text · Article · Dec 2016
    • "Although the authors only mentioned Cognitive Behavioral Therapy for insomnia and Mindfulness Based Interventions, there are many other approaches that offer an improvement in sleep quality, such as exercise, therapeutic massage, acupuncture, physiotherapy , yoga, hypnotism, biofeedback and prayer [2,3]. We have conducted controlled trials using some of these methods in our clinical center within a population with sleep disorders and promising results have been obtained [4][5][6], especially when considered the effects of mindfulness in postmenopausal women [7]. Since these non-pharmacological interventions may alter the sleep quality, caution should be exercised when researchers select their patients, excluding possible bias in the sample selection and consequently, in the results. "
    Article · Sep 2014
    • "These methods include stress management,[12] physical exercises, relaxation and psychological counseling, education of social skills,[13] Yoga,[14] and laughter therapy.[15] Various methods of complementary medicine enable the nurses to help their patients control their anxiety.[16] "
    [Show abstract] [Hide abstract] ABSTRACT: Promotion and provision of individuals' health is one of the bases for development in societies. Students' mental health is very important in each society. Students of medical sciences universities, especially nursing students, are under various stresses in clinical environment, in addition to the stress they experience in theoretical education environment. With regard to the importance of nursing students' general health and considering the various existing strategies to promote general health components, use of complementary treatments is more considered because of their better public acceptance, low costs, and fewer complications. One of the new strategies in this regard is laughter Yoga. The present study was conducted with an aim to define the effect of laughter Yoga on general health among nursing students. This is a quasi-experimental two-group three-step study conducted on 38 male nursing students in the nursing and midwifery school of Isfahan University of Medical Sciences in 2012. In the study group, eight 1 h sessions of laughter Yoga were held (two sessions a week), and in the control group, no intervention was conducted. The data of the present study were collected by Goldberg and Hiller's General Health Questionnaire and analyzed by SPSS version 12. The findings showed a significant difference in the mean scores of general health before and after laughter Yoga intervention in the two groups of study and control. The findings showed that laughter Yoga had a positive effect on students' general health and improved the signs of physical and sleep disorders, lowered anxiety and depression, and promoted their social function. Therefore, laughter Yoga can be used as one of the effective strategies on students' general health.
    Article · Mar 2014
Show more

Comment

September 12, 2016
The Wright Institute
THANK YOU OSO MUCH - I AM SO HEARTENED TO SEE YOUR STUDY ON THE BENEFITS OF YOGA TO IMPROVE SLEEP ESP IN A SLEEP DEPRIVED POPULATION LIKE MENOPAUSAL WOMEN