The financial, health, and social costs of vasomotor disturbances and other menopausal symptoms are substantial and are projected to continue increasing in coming years with the progressive aging of populations in the U.S. and other western industrialized countries [13
]. In response to publication of findings regarding serious adverse health effects of HRT, once widely prescribed for menopausal complaints, use of HRT has fallen dramatically [16
]. In addition, use of HRT is generally contraindicated in certain populations, including breast cancer patients, for whom cancer treatment often leads to particularly severe vasomotor and other menopausal symptoms [65
]. Thus, identification of alternative, safe and cost-effective therapies for alleviating menopausal symptoms is needed. As indicated above, recent research suggests that certain mind-body therapies may have potential utility in this regard. Collectively, studies to date offer modest evidence that yoga-based programs may be helpful in reducing common symptoms of menopause, including vasomotor, sleep, and mood disturbances, and that certain breath-based practices may be useful in reducing hot flashes. Additional research suggests that muscle and other relaxation therapies may also have some benefit for attenuating vasomotor and other common menopausal complaints, although interpretation of findings is complicated by the lack of a placebo/attention control. In addition, follow-up data available from 8 of the 18 existing studies indicate that the improvement in vasomotor and certain other symptoms observed with yoga [34
] and other mind-body therapies [44
] may be sustained post-intervention. No adverse events were reported in the trials reviewed.
Also important to consider is that mind-body therapies may carry several advantages from the standpoint of safety, satisfaction, implementation, and possible ancillary social, psychological, and health benefits. Side effects and risks of mind-body practice are generally minimal, implementation costs are low, and most mind-body therapies can be performed by a broad range of populations, including overweight, sedentary, chronically ill, and elderly women [25
]. The use of mind-body therapies to alleviate menopause symptoms is increasingly common [20
], and satisfaction with the perceived therapeutic benefits of these practices is generally high [20
]. In addition, a growing body of research suggests that mind-body practices may have multi-faceted effects on health, enhancing psychological, physiological, and physical function and well-being in both healthy and chronically ill individuals [25
]. This is a particularly important consideration, in light of the sharp increase in risk for both CVD and osteoporosis that occurs with menopause [73
]. This dramatic rise in chronic disease risk likely in part reflects the abrupt hormonal alterations, especially the decline in estrogen levels that occur during this period, along with the associated constellation of atherogenic, neuroendocrine, and metabolic changes linked to the insulin resistance syndrome. Menopause is associated with activation of the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system [25
], factors that have been linked not only to the development and exacerbation of menopausal symptoms [7
], but also to the etiology and progression of CVD [25
] and osteoporosis [77
]. In fact, recent research suggest that vasomotor and other climacteric are strongly related to health functioning [79
] and to adverse CVD profiles [75
], and may themselves be important markers for chronic disease risk, reflecting changes in underlying health status [75
Clearly, there is a need for safe, cost-effective, comprehensive therapies that alleviate climacteric symptoms without serious short or long term health sequellae, that encourage sustained compliance, and that reduce risk for the major chronic conditions associated with the menopausal transition- notably CVD and osteoporosis, inter-related disorders of major and growing public health significance [80
]. As indicated above, mind-body therapies may have promise not only for mitigating the acute symptoms of menopause, but also for reducing longer term health effects of adverse neuroendocrine, metabolic, and cardiovascular changes associated with menopause [25
]. These factors have, in turn, been strongly linked to CVD etiology and progression [25
] and more recently (e.g., lipid profiles, oxidative stress, inflammation, psychosocial stress, and depression) to osteoporosis [82
]. In addition, findings from a number of recent controlled studies in post-menopausal women suggest that tai chi may be instrumental in retarding bone loss [63
], and increasing bone formation [87
]; likewise, a recent RCT of qigong [92
], and a small UCT of yoga [93
], suggest that these practices may also prove beneficial in reducing bone loss.
While underlying mechanisms remain speculative, there are several ways in which mind-body practices could alleviate vasomotor and other symptoms of menopause. Yoga, tai chi, meditation, and other relaxation therapies have been reported to reduce sympathetic activity, decrease sympathoadrenal reactivity, and enhance parasympathetic output [7
], which may, in turn, reduce the prevalence and severity of vasomotor disturbances, sleep impairment, and other common menopausal symptoms [7
]. Mind-body practices may also attenuate climacteric symptoms by improving other indices of psychological and physical health. For example, several mind-body practices, including yoga, meditation, and tai chi have been reported to reduce body weight, body fat and weight gain, improve lipid profiles, decrease blood pressure, and alleviate stress and depressive symptoms [24
] which have, in turn, been associated with severity of hot flashes [75
] and other menopausal symptoms [75
]. Group and individual practice may also lead to beneficial changes in dietary intake, smoking, and other lifestyle factors that have been related to climacteric symptom severity [22
]. Finally, pronounced placebo effects have been observed in trials evaluating complementary and alternative, and particularly nutraceutical, therapies for vasomotor and other symptoms of menopause [103
]. However, as detailed above, several studies of mind-body therapies reported improvement in hot flashes and other climacteric symptoms relative to other plausible interventions, including exercise, reading, and alternative relaxation practices; a number of studies also indicated sustained benefits post-intervention, when the placebo effects would be expected to wane. Nonetheless, participant expectancies were reported in only one of the studies reviewed [39
], and not all trials included comparison conditions that controlled for non-specific effects of treatment; thus, that placebo or other non-specific effects may in part account for the improvements observed cannot be ruled out, underscoring the need for further rigorous controlled trials.
Limitations in the Literature and Directions for Future Research
While collectively, studies to date suggest that certain mind-body therapies, including yoga-based programs, breathing practices, and other relaxation therapies may hold promise for reducing vasomotor and other symptoms of menopause, most suffer methodological and other limitations that preclude definitive conclusions regarding efficacy and render specific clinical recommendations premature. Several trials included in this review were uncontrolled, non-randomized, and/or lacked a comparison condition that controlled for potential non-specific effects of treatment. Sample sizes in most studies were small, with only 4 of the 18 trials including over 20 participants in the experimental treatment. Interpretation of most existing studies is also hampered by other limitations, including exposure to multiple interventions, high attrition rates or failure to report drop-outs, low or non-reporting of compliance, poorly defined or non-validated outcome measures, inadequacies in statistical analysis and presentation, or other methodological problems. Trials to date have also varied considerably in study design, study population, attrition and compliance, comparison group(s), outcome measures employed, and content, delivery, duration, and intensity of the intervention, rendering comparison across studies difficult. In addition, few studies have examined the long-term effects of mind-body therapies on vasomotor and other symptoms of menopause. While 8 of the 18 trials included in this review assessed at least some outcomes post-intervention, follow-up periods were relatively short, with none exceeding 6 months in duration, and only two studies [36
] reported information on participant adherence post-intervention. In addition, the effects of several popular and potentially beneficial practices on specific menopausal symptoms remain little studied. For example, the effects of tai chi, qigong, and meditation-based programs on climacteric symptoms remain little explored, and rigorous, controlled studies are lacking, despite a growing body of literature suggesting that these practices may have a range of beneficial effects on both physical and mental health [25
In light of the need for safe, cost-effective treatments for vasomotor and other troublesome menopausal symptoms, the current widespread and increasing use of mind-body therapies, and apparent therapeutic potential of these practices for both managing climacteric symptoms and mitigating the risk for CVD and osteoporosis that rises sharply with the menopausal transition, further research is clearly warranted regarding the possible benefits of promising mind-body therapies. In particular, there is a need for large, rigorous, methodologically sound controlled trials to examine the influence of standardized, well-defined mind-body therapy programs on well-validated measures of vasomotor and other common climacteric symptoms, to assess potential long-term benefits of and adherence to these therapies, and to investigate possible meditating factors and underlying mechanisms. While placebo effects are unlikely to explain the substantial gains observed in previous controlled trials, the influence of expectancy, attention, and other non-specific effects can be substantial and is particularly important to consider in designing future studies. In the case of programs demonstrating clear, reproducible, improvement of symptoms in climacteric women, the development and evaluation of strategies to promote long-term maintenance of practice and associated benefits, perhaps the biggest challenge in lifestyle intervention programs, is needed. The development of specific recommendations regarding standardized outcome measures, based on expert consensus, would help guide investigators in designing trials, facilitate future comparisons across studies and thus aid in the systematic evaluation of evidence and establishment of informed clinical guidelines.
Limitations of this review
Limitations of this review include restriction of studies to those published in English language. We did not perform meta-analyses due to the extreme heterogeneity of existing studies. While meta-analyses can be informative when the combined studies are relatively homogeneous with respect to design, attrition, outcome measures, and interventions, they are of limited utility when included studies differ widely in these factors [106
]. Publication bias may also have led to differential reporting of benefits, although persistent skepticism in the medical and research community regarding the therapeutic merit of mind-body practices [108
] renders selective publication of positive findings less likely.
In short, findings from studies to date suggest that yoga-based programs, breathing practices, and certain other mind-body therapies may be beneficial for reducing vasomotor and other menopausal symptoms. However, most existing studies suffer methodological limitations that hinder interpretation of findings and preclude firm conclusions. Additional rigorous, high-quality controlled trials are needed to determine both the short and long term effects of specific mind-body therapies on menopausal symptoms, to investigate potential mediating factors and underlying mechanisms of action, and to compare these treatments with other existing therapies.