Menopause, which occurs at an average age of 52 years, is defined as a woman's final menstrual period. This event results from lack of endometrial stimulation by estrogen as the ovarian follicles become depleted. For 5 to 10 years preceding menopause and for 5 to 10 years following it, a woman is hormonally different from the way she was before and the way she will be after this climacteric interval.

Premenopausal women (prior to the climacteric or perimenopausal years) usually experience cyclic production of estrogen and progesterone, with high concentrations of estrogen prior to each ovulation and high concentrations of estrogen and progesterone during the luteal phase, after ovulation. Postmenopausal women (following the climacteric or perimenopausal years) usually have low levels of estrogen and progesterone, with little fluctuation and no cyclicity. Perimenopausal women commonly have fluctuating levels of estrogen that lack cyclicity and predictability.

Symptoms are common among perimenopausal and postmenopausal women. Some symptoms and problems are due to hormonal changes of the menopausal transition, while others result from the aging process and adverse lifestyle factors (eg, sedentary behavior, cigarette smoking, poor diet). It is often impossible to isolate these etiologic factors in evaluating and counseling individual women.

Benefits of Exercise

There's no better time than the years surrounding menopause for a woman to start or renew an exercise program. Exercise may reduce the immediate symptoms of menopause, and it decreases the long-term risk of cardiovascular disease, osteoporosis, and obesity. The exercise prescription includes aerobic exercise, resistance training, and stretching components, and should be individualized according to the woman's exercise history.

Vasomotor Symptoms.

The cause of vasomotor symptoms (hot flushes) is not yet known. However, these symptoms can be very uncomfortable and can lead to chronic sleep deprivation, as well as mood and behavior changes. Vasomotor symptoms are less common among physically active postmenopausal women than among sedentary controls (1), but exercise has not been shown to relieve such menopause symptoms. Estrogen remains the most effective treatment for vasomotor symptoms and menopause.

Bone Loss.

Bone loss results from deficiencies of estrogen, exercise, and dietary calcium. The rate of bone loss in women accelerates at menopause because of the marked reduction in serum estrogen concentrations.

It is preferable to prevent bone loss before it occurs, rather than to treat osteopenia or osteoporosis. Strategies for prevention of bone loss include hormone replacement therapy, calcium supplementation (unless dietary sources are adequate), and exercise. Both weight training and aerobic exercise enhance and maintain bone density. Postmenopausal women require 1,500 mg of calcium daily if they are not taking exogenous estrogen therapy and 1,000 mg of calcium daily if they are. Estrogen therapy prevents bone loss better than calcium supplementation or resistance exercise does; however, the combination of hormone replacement therapy and resistance exercise leads to a greater increase in bone density than does hormone replacement therapy alone (2), and it is likely that the combination of estrogen, calcium, and exercise is even more beneficial.

Cardiovascular Disease.

Cardiovascular disease risks rise with age among both sexes as a result of aging, other risk factors, and the cumulative effects of an adverse lifestyle. In women, cardiovascular disease risks rise sharply after menopause because estrogen deficiency induces lipid and vascular changes. Many of the adverse effects of aging and menopause on lipids (3) are reversed by aerobic exercise. Aerobic exercise promotes cardiovascular fitness and reduces risks of cardiovascular disease and cardiovascular mortality. Estrogen replacement therapy leads to a reduction in mortality from coronary heart disease and other causes (4).

Urogenital Atrophy.

Urogenital atrophy results from estrogen deficiency and is best treated with estrogen therapy, administered by any route. Exercise does not affect urogenital atrophy.

Some mood and sleep disturbances are related to estrogen deficiency; vasomotor symptoms can impair sleep and induce chronic sleep deprivation, which can cause mood disorders. Estrogen therapy improves sleep quality and enhances mood for many women with these symptoms. Regular aerobic exercise improves cognitive function, enhances mood, and promotes daytime alertness and nocturnal sleepiness. If mood and sleep disturbances are not relieved by estrogen therapy and/or exercise, antidepressant or other psychotropic medication should be prescribed, depending on the specific diagnosis.

Weight gain.

Weight gain and accumulation of fat from aging and inactivity are common among perimenopausal and postmenopausal women. Aerobic and resistance exercise, which increase energy expenditure and lean-body mass, are the most effective ways to treat this problem.

Muscle weakness.

Another common accompaniment of the aging process is loss of muscle tissue and strength. Many older women lack sufficient strength to remain functional and independent. Resistance exercise is the most effective way to increase and maintain muscle strength.

Hormone Replacement Therapy

Hormone replacement therapy includes both estrogen and progestogen. Nearly all of the benefits result from estrogen alone. Progestational therapy should be added for endometrial protection in any woman who has a uterus but should not be prescribed for any woman who has had a hysterectomy.

Benefits

As described, estrogen therapy relieves vasomotor symptoms, prevents bone loss, reduces cardiovascular disease risk, relieves urogenital atrophy, and improves mood and sleep quality.

In general, estrogen should not be prescribed for women who have breast or endometrial cancer, a history of thromboembolic disease, active hepatic dysfunction, or undiagnosed vaginal bleeding. Rare exceptions to these contraindications should be considered and managed on an individual basis. Relative contraindications include hormonally induced headaches and myomata uteri.

Hormone replacement therapy has not been associated with weight gain (5), despite nonscientific beliefs to the contrary. The major risk of hormone replacement therapy is the inconvenience of vaginal bleeding, which can often be minimized, eliminated, or regulated. If progestational therapy is adequate, the risk of endometrial cancer is less than in untreated women.

A Commitment to Exercise

All women should be encouraged to exercise regularly, and older women often need instruction in specific, individualized programs. A plan that includes both aerobic and resistance training can help to prevent or relieve problems that are common among menopausal women, such as cardiovascular disease, obesity, muscle weakness, osteoporosis, depression, and sleep disturbances. It is the responsibility of physicians caring for these women to educate them appropriately and monitor their compliance.

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