Treating the Climacteric Symptoms in Indian Women With an Integrated Approach to Yoga Therapy: A Randomized Control Study

Ritu Chattha, MSc; Nagarathna Raghuram, MD, FRCP; Padmalatha Venkatram, FRCOG, MRCPI; Nagendra R. Hongasandra, ME, PhD


Menopause. 2008;15(5):862-870. 

In This Article


In this single-blind, prospective, randomized, two-armed study of 108 perimenopausal women, climacteric symptoms, perceived stress, and personality were assessed before and after 8 weeks of intervention. On the GCS, there was a significant difference between groups in the vasomotor factor, a marginally significant difference in the psychological factor, and no change in the somatic component. There was a significantly greater decrease in stress levels in the yoga group compared with the control group on the PSS. On the EPI, there was a greater change in neuroticism in the yoga group than in the control group. There were positive correlations between age and FSH and also between GCS, PSS, and neuroticism scores.

The baseline values in this study on all variables were lower than the normative values provided in the manual,[20,24,26] except on the PSS. The most prominent difference was in the psychological and somatic symptoms on the GCS and the extroversion score on the EPI.[22,26] The differences in the scores could be explained by sociocultural differences between the two countries (United States and India). The evidence from different surveys to date indicates that cultural differences in vasomotor symptom perception and reporting reflect both the underlying biological differences and an important sociocultural factor of the attitude toward menopause.[32]

The control group in the present study who practiced physical exercises for 8 weeks demonstrated decreased perception of stress and the psychological symptoms. Physical activities of different types have been found to be beneficial in climacteric women. In a 4-month randomized, controlled exercise trial with three arms, ie, walking, yoga, and control, it was observed that both walking and yoga were equally effective in enhancing a positive affect and menopause-related quality of life and decreasing a negative affect.[16] In another study of 50 pre- and postmenopausal women, the results of a 12-week exercise program provided only partial support for the role of aerobic exercise in reducing stress responses,[33] although both groups achieved comparable improvements in aerobic fitness.

There are three published studies on yoga and perimenopausal symptoms. Of these, two were pilot studies that showed the beneficial effect and the other was the three-armed study that showed no significant difference between walking and yoga. The present study has clearly demonstrated through a randomized, controlled trial the superiority of yoga over physical activity in managing all three climacteric symptoms, stress, and neuroticism. The difference could be in the duration and frequency of administration and the type of the practices in different studies. This was also observed by Waelde et al,[34] who concluded that the duration and frequency of the practice of yoga seems to be important because the average number of minutes of weekly yoga/meditation practice had a positive association with improvement in depression in their study of a six-session yoga/meditation program designed to help caregivers of dementia patients cope with stress. To date, we have many studies that provide evidence of the role of yoga in reducing anxiety and depression in the normal adult and geriatric populations as well. In a waitlist control design, the practice of Iyengar yoga showed significant decreases in self-reported symptoms of depression and trait anxiety in 28 young adults.[35] Another three-armed study in which IAYT was introduced to 69 elderly institutionalized individuals showed a significant decrease in their scores for depression in the yoga group at both 3 and 6 months.[36]

Sympathetic arousal resulting in increased catecholamines and cortisol levels mediated through the hypothalamic-pituitary-adrenal axis has been theorized to be the mechanism of increased stress and anxiety and the vasomotor and perimenopausal syndrome. Hence, the documented evidence of a decrease in these neurohumors and electrophysiological changes of sympathetic arousal after yoga practice had been proposed as its mode of action.[37,38]

In a study that compared 20 stressed and 20 nonstressed, nonsmoking premenopausal women between the ages of 42 and 52 years, the stressed women had elevated evening salivary cortisol levels, indicating sympathetic arousal.[39]

There are randomized, controlled studies that have shown a significant decrease in stress levels after practicing yoga in participants with mild to moderate levels of stress[40] and also a trend for higher morning cortisol levels after 5 weeks of 1-hour weekly Iyengar yoga classes.[35] Robert McComb et al[41] in their study on resting levels of stress hormones, physical functioning, and submaximal exercise responses in women with heart disease undergoing an 8-week mindfulness-based stress-reduction program brought out the fact that just a once-weekly program of stress reduction is quite ineffective and fails to change stress hormone levels. An interesting study by Streeter et al[42] suggests that the practice of yoga may reduce the depressive symptoms of perimenopause by increasing GABA levels in the brain. This study examined the GABA levels by measuring the GABA-to-creatinine ratio in the brain using magnetic resonance spectroscopy in normal adult yoga and nonyoga practitioners and showed a 27% increase in GABA levels in the yoga group after a 60-minute yoga session with no change after a reading session in comparison with a nonyoga practitioner group.

Reduced sympathetic tone through yogic relaxation techniques has also been documented. In a control study on guided yogic relaxation, significant decreases in heart rate, skin conductance levels, and finger plethysmogram have been reported. In addition, the spectral analysis of heart rate variability showed a decrease in low-frequency (sympathetic tone indicator) and an increase in high-frequency (parasympathetic tone indicator) bands, indicating decreased physiological arousal.[43] Another study of seven experienced meditators studied in two types of sessions, ie, meditation (with a period of mental chanting of "OM") and control (with a period of nontargeted thinking), there was a significant decrease in heart rate and an increase in the cutaneous peripheral vascular resistance during meditation, which is a sign of increased mental alertness, even while being physiologically relaxed.[44]

A specific type of meditation called avartan dhyanam (CM) was incorporated as the main practice in the present study based on our earlier studies in which it is shown that CM brings about a deep state of physiological rest. Two days of a stress reduction program using CM in 26 executives with occupational stress showed a significant decrease in the power of the low-frequency component of the heart rate variability spectrum and low frequency-to-high frequency ratio and breath rate.[45] The oxygen consumption is considered a general index of the metabolic rate during physiological activities.[46] A significantly greater resting metabolic rate was found in a high trait anxious group than in a low trait anxious group,[47] suggesting that a higher rate of oxygen consumption may be associated with higher anxiety.[48] A reduction in oxygen consumption has been reported after meditation practices and relaxation response.[43] A rarely quoted traditional yoga scripture (Mandukya karika) points to an interesting intrinsic mental phenomenon that, in a meditative technique that involves a series of alternating activity (physical movements or mental chanting) and nonactivity (relaxation or stoppage of internal dialogue) with awareness, the degree of rest that follows will be deeper than the physiological rest achieved during only restful meditation in one posture and hence can facilitate stress release at deeper levels. During CM, the extremely slow, conscious movements of the body provide a high sense of sensitivity to grasp the subtle changes happening inside the body, which may go unnoticed in a simple meditative state.[28] The practice of CM decreased oxygen consumption to 32% compared with the preceding period as well as with a reduction of 10.1% with a period of supine rest of equal duration.[48]

Despite the emergence of a range of nonhormonal treatments for menopausal symptoms, a need still exists for safe and effective therapeutic options that directly target the underlying thermoregulatory mechanisms for women who want treatment but prefer to avoid hormone therapy or for whom hormone therapy is contraindicated.[49] Thus, this study has shown the efficacy of integrated yoga in helping perimenopausal women improve their inner mastery, which could lead to better coping capacities, gracefully accept the change in their reproductive state, overcome stressors of aging, combat anxiety and depression, and thereby improve their personality to enjoy the freedom from monthly menstruation and divert their energies toward spiritual growth.

This is the first randomized, controlled trial on yoga practice in Indian women of climacteric age. An objective measure, serum FSH level, was used as the inclusion criterion rather than only the subjective symptoms of menopausal rating scales. The types of practices for the yoga and control interventions were matched, and the practices were supervised by trained instructors for the entire period of the study.

This randomized, controlled trial included a highly selective group of women, excluding those with associated illnesses such as diabetes and hypertension, which are common diseases of this age, because this would interfere with the uniformity of the intervention and the resultant conclusions. This may raise the question of generalizability of the application of the conclusions of this study to practice. Although earlier independent studies have shown the benefits of yoga in diabetes and hypertension,[50] it will be interesting to design studies that would recruit perimenopausal women with these common problems in future studies.

It would have been interesting to see the effect of the practice of IAYT if we had assessed FSH and estradiol levels before and after the intervention.

Because the significant benefits found in the control group on the psychological factor of the GCS and PSS would lead to bias toward the null hypothesis in conclusions on the effects of yoga, inclusion of a third group who do not do any practice in the design of the study would shed light on the true treatment effects.

Inclusion of vasomotor symptom diaries as another variable could provide more detailed information about the efficacy of the intervention. Functional studies to look at the neurohormonal changes in the brain and autonomic functions during mental stress challenge before and after IAYT in perimenopausal women would shed light on the mechanism. This study has shown the benefits in Indian women. It will be useful to conduct similar studies in other countries where yoga may not be available as a traditional practice.

Because yoga is popular as a complementary and alternative therapy with more than 15 million persons (more women) practicing yoga in the United States[51] and awareness among general practitioners,[52] this study can add to the scientific evidence so that gynecologists can recommend it to their patients instead of prescribing hormone therapy. Yoga, which is a self-corrective technique when popularized as a treatment modality, not only can prevent and treat the perimenopausal syndrome but also can help in preventing many of the stress-related problems of the modern lifestyle that these women are prone to after menopause. The philosophy and practices of yoga provide a good field of study for internal experimentation during the empty nest, postretirement phase of a woman's life and help her to grow in her personality to lead a healthy and happy life.


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