Abstract
Metabolic and hormonal disturbances are common during the climacteric period and contribute to an increased risk of chronic diseases. Yoga has emerged as a promising complementary approach to promote women's health during midlife; however, long-term evidence remains limited. This longitudinal, community-based controlled study evaluated the effects of regular yoga practice over 24 months on anthropometric, metabolic, and hormonal parameters in climacteric women. A total of 182 Brazilian women aged 40–65 were followed; participants who chose to engage in yoga formed the intervention group, while sedentary women served as controls. Data were collected at baseline and after 6, 12, and 24 months. After 24 months, the yoga group showed significant reductions in BMI (−2.24 kg/m2; p = 0.008) and body fat percentage (−4.29%; p = 0.008), as well as decreases in systolic (−11.4 mm Hg; p = 0.012) and diastolic blood pressure (−5.5 mm Hg; p = 0.044). Improvements were also observed in fasting glucose (−9.1 mg/dL; p = 0.024), QUICKI (+0.03; p = 0.046), HDL-c (+9.6 mg/dL; p = 0.012), and non-HDL-c (−23.4 mg/dL; p = 0.018). Estradiol levels increased by 24.4 pg/mL in the yoga group and were significantly higher than in controls at 24 months (+40.9 pg/mL; p < 0.001), suggesting an endocrine-modulating effect. These findings support yoga as a promising nonpharmacological strategy to promote metabolic and hormonal health during the climacteric phase.
Keywords: menopause, yoga, climacteric, metabolic health, glucose metabolism, lipid profile
Introduction
Female reproductive aging is characterized by a progressive decline in ovarian follicle reserves and circulating estrogen levels, leading to physiological changes that typically begin around age 40 and define the menopausal transition. 1 Menopause—defined as the permanent cessation of menstruation and confirmed after 12 consecutive months of amenorrhea—marks the culmination of this transition. 2 In Western populations, menopause usually occurs around age 51, although its timing can vary due to genetic, socioeconomic, and regional factors. 3
While climacteric symptoms such as vasomotor disorders, sleep disturbances, and mood changes are well recognized, the most concerning long-term consequences of menopause involve metabolic alterations. These include changes in lipid metabolism, increased insulin resistance, central adiposity, and heightened risks of type 2 diabetes, hypertension, dyslipidemia, and cardiovascular disease. 4 Estrogen receptors are present in both subcutaneous and visceral adipocytes, and the decline in estrogen levels during the menopausal transition contributes to disrupted lipid regulation and impaired insulin sensitivity. 5 As a result, climacteric women—especially those in postmenopause—experience a higher prevalence of metabolic disturbances, including abdominal obesity, glucose intolerance, and dyslipidemia. 4 The prevalence of type 2 diabetes in this population ranges from 15% to 20%, and cardiovascular disease remains the leading cause of death. 6 Hypertension affects approximately 41% of women after menopause and rises to over 75% in those older than 60 years. 7 Similarly, the incidence of new-onset dyslipidemia during the postmenopausal period can reach up to 78.4%, highlighting the elevated risk of lipid abnormalities in this population. 8
Given that many women now spend up to one-third of their lives in the postmenopausal state, 9 identifying effective and sustainable strategies to mitigate these clinical and metabolic consequences is a significant public health priority.
Hormone therapy (HT) can relieve climacteric symptoms and improve certain metabolic parameters. 10 However, concerns about long-term safety, side effects, and contraindications have led to growing interest in non-hormonal alternatives. 11 Among these, lifestyle interventions, particularly traditional, complementary and integrative medicine practices such as yoga, are being increasingly explored. 12 Yoga has demonstrated benefits in mood regulation, metabolic function, and pain management,13,14 all of which are highly relevant to climacteric women. This evidence suggests that yoga may offer a safe, holistic strategy to support health during the menopausal transition and postmenopause.
Despite growing interest, most studies on yoga during the climacteric phase have focused on short-term symptom relief after 8–12 weeks of practice.14,15 There is a notable lack of longitudinal data evaluating its impact on metabolic outcomes. 14 Further research is needed to assess the potential of yoga as a long-term intervention to support both metabolic and clinical health during reproductive aging,
In this context, the present study aimed to evaluate the effects of regular Shivam yoga practice on anthropometric, metabolic, and clinical parameters in climacteric women.
Methods
Study Design
We conducted a longitudinal, community-based controlled study with women aged 40–65 years in Ouro Preto, Minas Gerais, Brazil. Participants were recruited through local health centers and community outreach. Those who agreed to attend yoga classes were allocated to the intervention group, while sedentary women who declined yoga but agreed to follow-up formed the control group. Participants were instructed to maintain their usual daily routines throughout the study.
Women were considered sedentary if they reported not engaging in regular physical activity or if they performed light exercise for up to 30 min once or twice per week. Exclusion criteria included prior yoga experience, new engagement in physical activity, use of complementary or alternative therapies after baseline, or failure to complete the minimum follow-up assessments. Written informed consent was obtained, and data were collected at baseline and at 6, 12, and 24 months. Ethical approval was granted by the appropriate Research Ethics Committee.
Interviews
Trained research personnel conducted confidential, face-to-face interviews to collect data on medical history, medication use, reproductive background, sociodemographic characteristics (age, education, income, marital status), and lifestyle factors such as smoking and alcohol intake. Menopausal stage was classified as late reproductive, menopausal transition, or postmenopausal according to the STRAW+10 criteria. 2 The late reproductive stage is characterized by a declining ovarian reserve and rising FSH levels with regular or slightly shorter cycles. The menopausal transition involves variable cycle lengths, elevated FSH, and episodes of amenorrhea lasting ≥60 days. The postmenopausal stage begins after 12 consecutive months of amenorrhea and is marked by low estradiol concentrations and persistently high FSH levels (> 25 IU/L). 2
Anthropometric and Blood Pressure Measurements
At each visit, participants underwent standardized anthropometric and cardiovascular assessments. Weight and body fat percentage were measured using a calibrated Tanita® digital bioimpedance scale (precise to 100 g), with individuals standing barefoot in light clothing. Height was recorded using a stadiometer with 0.1 cm precision, and these values were used to calculate body mass index (BMI) and waist-to-height ratio. Waist circumference was measured with a flexible tape at the midpoint between the last rib and the iliac crest, or at the umbilicus when anatomical landmarks were unclear. In addition, blood pressure was assessed on the left wrist, positioned at heart level, while the participant was seated and at rest, using a Bioland®-3005 wrist sphygmomanometer.
Laboratory Analyses and Cardiometabolic Risk Assessment
To evaluate biochemical parameters, fasting blood samples (12-14 h) were collected by trained personnel, following strict hygiene protocols. Participants were instructed to avoid alcohol for 72 h and refrain from intense physical activity for 24 h prior to sampling. After collection, serum was separated by centrifugation (2500 rpm for 15 min) and processed at the LAPAC/UFOP laboratory. Biochemical analyses included measurements of glucose, total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), and apolipoproteins A1 and B, using enzymatic/colorimetric and immunoturbidimetric methods. Hormonal markers—insulin, estradiol, follicle-stimulating hormone (FSH), and total testosterone—were determined by chemiluminescence using the ACCESS 2 Immunoassay System® (Beckman Coulter). We also calculated Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), Quantitative Insulin Sensitivity Check Index (QUICKI), and non-HDL cholesterol.
Yoga Classes
After eligibility screening via medical evaluation, participants in the yoga arm were assigned to one of five classes and received written guidance. Classes occurred twice weekly, lasting 60 min, and were led by Shivam Yoga instructors with at least one year of certification. A preparatory meeting ensured standardization of the session structure, which included mental concentration (Dharana, 5 min), energy practices (Pujas, 4 min), breathing techniques (Pranayamas, 15 min), posture sequences (Asanas, 20 min), relaxation (Yognidra, 8 min), and meditation (Dhyana, 8 min). Instructors were also provided with a manual highlighting the postures (Asanas) to be prioritized, specifically those intended to stimulate endocrine glands associated with midlife hormonal regulation. Key postures included Bhadrasana, Parshwa Janusirshasana, Raja Janusirshasana, Prasarita Padasana, Viparita Karani, Sarvangasana, Halasana, Matsyasana, Setu Bandhasana, and Ekapada Setu Bandhasana. Participants who attended at least 60% of the sessions were re-assessed for anthropometric, blood pressure, biochemical, and hormonal parameters at 6, 12, and 24 months, with control group comparisons performed at the same intervals.
Statistical Analysis
All information obtained during the interviews was systematically coded and entered twice into EpiData version 3.2 to minimize input errors. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA).
Baseline comparability and attrition were evaluated via Pearson's Chi-Square test for categorical variable comparisons between groups, while within-group changes were examined with McNemar's test. Continuous variables were assessed for normality using the Kolmogorov-Smirnov test. Normally distributed data were summarized as mean ± SD and tested with paired t-tests (within-group) or independent t-tests (between-group). Non-normally distributed data were described using median and interquartile range and analyzed using Wilcoxon signed-rank (within-group) or Mann-Whitney U tests (between-group). A p-value less than 0.05 was considered statistically significant in all analyses.
Effect sizes for between-group differences were calculated using Cohen's d. 16 Effect magnitude was interpreted as small when values were around 0.1, moderate around 0.4, and large around 0.8. 17
Results
A total of 373 women aged 40 to 65 years participated in the study, with 187 allocated to the Yoga group and 186 to the Control group. After applying the exclusion criteria, 90 women in the Yoga group completed 6 months of practice, 51 completed 12 months, and 31 completed 24 months. In the Control group, 92, 77, and 59 women completed follow-up at the corresponding time points.
Most dropouts were due to personal or logistical reasons, such as schedule incompatibility, relocation, or family responsibilities. A differential loss analysis indicated that group comparability was preserved throughout the study period (data not shown), confirming that baseline characteristics were similar between participants who completed the study and those who withdrew.
Baseline sociodemographic and behavioral characteristics of participants who completed 6, 12, or 24 months of follow-up are summarized in Table 1. In both groups, most women were aged 50–59 years. A significantly higher proportion of participants in the Yoga group had more than 8 years of schooling, whereas the majority in the Control group had 8 years or less (p < 0.05 at both 6 and 12 months). No other sociodemographic differences were observed. Smoking and alcohol consumption were infrequent (3.4% to 13.6%), and approximately 60% of participants reported regular medication use. Most women were postmenopausal, with prevalence ranging from 56.9% to 63.3% in the Yoga group and 49.2% to 53.3% in the Control group. The median age at menarche was 13 years, and menopause typically occurred between ages 47 and 50. Time since menopause ranged from 4.5 to 6.5 years across groups.
Table 1.
Baseline Analysis of the Sociodemographic and Behavioral Characteristics of Participants in the Yoga and Control Groups who Completed six, Twelve, and Twenty-Four Months of Follow-up.
| Variável | 6-Month (n = 182) | 12-Month (n = 128) | 24-Month (n = 90) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Yoga (n = 90) |
Control (n = 92) | p | Yoga (n = 51) |
Control (n = 77) |
p | Yoga (n = 31) |
Control (n = 59) |
p | |
| n (%) | n (%) | n (%) | |||||||
| Age range | |||||||||
| 40 to 44 years | 12 (13.3) | 16 (17.4) | 0.194 | 5 (9.8) | 14 (18.2) | 0.624 | 3 (9.7) | 11 (18.6) | 0.528 |
| 45 to 49 years | 15 (16.7) | 24 (26.1) | 12 (23.5) | 19 (24.7) | 7 (22.6) | 15 (25.4) | |||
| 50 to 54 years | 26 (28.9) | 26 (28.3) | 17 (33.3) | 23 (29.9) | 12 (38.7) | 17 (28.8) | |||
| 55 to 59 years | 30 (33.3) | 24 (26.1) | 15 (29.4) | 20 (26.0) | 7 (22.6) | 15 (25.4) | |||
| 60 to 65 years | 7 (7.8) | 2 (2.2) | 2 (3.9) | 1 (1.3) | 2 (6.5) | 1 (1.7) | |||
| Education level | |||||||||
| 0 to 8 years | 15 (16.7) | 40 (43.5) | 0.000 | 9 (17.6) | 32 (41.6) | 0.004 | 8 (25.8) | 23 (39.0) | 0.155 |
| More than 8 years | 75 (83.3) | 52 (56.5) | 42 (82.4) | 45 (58.4) | 23 (74.2) | 36 (61.0) | |||
| Smoking* | 10 (11.1) | 5 (5.4) | 0.131 | 6 (13.7) | 3 (3.9) | 0.090 | 3 (9.7) | 2 (3.4) | 0.221 |
| Alcohol consumption ** | 5 (5.6) | 11 (12.0) | 0.103 | 4 (7.8) | 10 (13.0) | 0.270 | 2 (6.5) | 8 (13.6) | 0.259 |
| Medication use | 57 (63.3) | 62 (67.4) | 0.337 | 33 (64.7) | 50 (64.9) | 0.563 | 20 (64.5) | 38 (64.4) | 0.590 |
| SRA | |||||||||
| LR | 22 (24.4) | 23 (25.0) | 0.200 | 15 (29.4) | 21 (27.3) | 0.595 | 8 (25.8) | 17 (28.8) | 0.694 |
| MT | 11 (12.2) | 20 (21.7) | 7 (13.7) | 16 (20.8) | 5 (16.1) | 13 (22.0) | |||
| PM | 57 (63.3) | 49 (53.3) | 29 (56.9) | 40 (51.9) | 18 (58.1) | 29 (49.2) | |||
| Age at menarche | 13 (12 - 15) |
13 (12-14) |
0.441 | 13 (12-15) |
13 (12-14.25) |
0.442 | 13 (12-15) |
13 (12-14) |
0.784 |
| Age at menopause | 47.5 (42.5-50) |
48 (44.75-51) |
0.374 | 47 (43-50) |
49 (44.5-51) |
0.346 | 50 (43.5-51.5) |
48.5 (44-52) |
0.756 |
| Postmenopausal duration | 6.5 (4-10) |
4.5 (2-9) |
0.054 | 6 (3-11) |
5 (2-9) |
0.131 | 6 (3-10.5) |
5 (1.75-9) |
0.511 |
Note: These data refer to the characteristics of the women prior to the start of the study (Baseline Information), that is, they represent the initial profile of the women who completed 6, 12, and 24 months of follow-up.
SRA = stages of reproductive aging; LR = late reproductive stage; MT = menopausal transition; PM = postmenopause;
* Women who reported current cigarette use; ** Women who reported alcohol consumption with a frequency of four (4) or more times per week.
Anthropometry and Blood Pressure
Anthropometric outcomes are summarized in Table 2. After 6 months of Yoga practice, all variables—weight, waist circumference (WC), body mass index (BMI), body fat percentage (BF), and waist-to-height ratio (WHtR)—either decreased or remained stable, with a significant reduction in BF (–0.87%; p = 0.036). In contrast, the Control group exhibited significant increases in all parameters.
Table 2.
Anthropometric Variables and Blood Pressure of Participants in the Yoga and Control Groups who Completed six, Twelve, and Twenty-Four Months of Follow-up.
| Variables | Timepoint | Yoga | Control | Yoga Versus Control | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Baseline | Follow-up | Variation Baseline – Follow-up |
Baseline | Follow-up | Variation Baseline – Follow-up |
Baseline | Follow-up | ||||
| Mean (SD) | Mean (SD) | Variation | Cohens’ D | Variation | Cohens’ D | ||||||
| Anthropometric variables | |||||||||||
| Weight (kg) | 6-month | 66.43 (11.15) | 66.33 (11.11) | −0.09 | 66.82 (9.94) | 67.80 (10.25) | 0.98a | −0.39 | −0037 | −1.47 | −0138 |
| 12-month | 65.39 (10.70) | 65.28 (10.72) | −0.11 | 66.78 (9.71) | 67.22 (9.98) | 0.44 | −1.39 | −0137 | −1.94 | −0189 | |
| 24-month | 63.41 (8.48) | 63.01 (8.99) | −0.40 | 67.32 (9.16) | 67.76 (9.78) | 0.44 | −3.91 | −0438 | −4.75b | −0499 | |
| WC (cm) | 6-month | 89.70 (10.69) | 89.21 (11.51) | −0.49 | 90.91 (8.33) | 92.40 (8.83) | 1.49a | −1.21 | −0126 | −3.19b | −0311 |
| 12-month | 89.00 (9.77) | 90.63 (9.40) | 1.63a | 90.81 (8.71) | 94.05 (9.34) | 3.24a | −1.81 | −0198 | −3.42b | −0365 | |
| 24-month | 91.13 (8.54) | 88.45 (6.79) | −2.68 | 89.39 (9.42) | 94.95 (8.60) | 5.56a | 1.74 | 0191 | −6.50b | −0810 | |
| BMI (kg/m2) | 6-month | 26.12 (3.59) | 25.96 (3.56) | −0.16 | 26.74 (3.62) | 27.16 (3.71) | 0.42a | −0.62 | −0172 | −1.20b | −0330 |
| 12-month | 25.77 (3.02) | 25.52 (3.10) | −0.25 | 26.76 (3.78) | 26.88 (3.75) | 0.12 | −0.99 | −0283 | −1.36b | −0388 | |
| 24-month | 27.28 (3.52) | 25.04 (2.74) | −2.24a | 25.82 (3.58) | 27.03 (3.54) | 1.21 | 1.46 | 0410 | −1.99b | −0605 | |
| BF (%) | 6-month | 34.37 (6.73) | 33.50 (7.79) | −0.87a | 35.16 (6.67) | 36.02 (6.00) | 0.86a | −0.79 | −0118 | −2.52b | −0363 |
| 12-month | 33.49 (7.11) | 33.10 (6.89) | −0.39 | 35.19 (6.94) | 35.13 (6.80) | −0.06 | −1.70 | −0243 | −2.03 | −0297 | |
| 24-month | 36.48 (7.19) | 32.19 (5.40) | −4.29a | 33.85 (6.91) | 35.54 (6.15) | 1.69 | 2.63 | 0375 | −3.35b | −0567 | |
| WHtR | 6-month | 0.56 (0.06) | 0.56 (0.07) | 0.00 | 0.58 (0.06) | 0.59 (0.06) | 0.01a | −0.02 | −0333 | −0.03b | −0461 |
| 12-month | 0.56 (0.06) | 0.57 (0.05) | 0.01 | 0.58 (0.06) | 0.60 (0.08) | 0.02a | −0.02 | −0333 | −0.03b | −0431 | |
| 24-month | 0.58 (0.06) | 0.56 (0.04) | −0.02 | 0.56 (0.06) | 0.60 (0.06) | 0.04a | 0.02 | 0333 | −0.04b | −0740 | |
| Blood pressure | |||||||||||
| SBP (mm Hg) | 6-month | 128.64 (14.04) | 127.40 (15.59) | −1.24 | 133.20 (16.94) | 134.21 (15.04) | 1.01 | −4.56 | −0293 | −6.81b | −0445 |
| 12-month | 129.86 (15.57) | 127.12 (13.84) | −2.74 | 132.79 (16.40) | 129.52 (15.24) | −3.27 | −2.93 | −0182 | −2.40 | −0163 | |
| 24-month | 136.48 (18.49) | 125.10 (13.90) | −11.38a | 130.81 (15.37) | 133.20 (16.02) | 2.39 | 5.67 | 0344 | −8.10b | −0528 | |
| DBP (mm Hg) | 6-month | 81.83 (9.64) | 82.60 (9.11) | 0.77 | 84.97 (10.51) | 86.71 (10.75) | 1.74 | −3.14 | −0311 | −4.11b | −0412 |
| 12-month | 81.73 (9.95) | 83.45 (13.20) | 1.72 | 84.62 (10.27) | 83.70 (10.51) | −0.92 | −2.89 | −0285 | −0.25 | −0021 | |
| 24-month | 85.61 (10.24) | 80.16 (9.64) | −5.45a | 83.08 (10.14) | 85.27 (12.77) | 2.19 | 2.53 | 0249 | −5.11 | −0433 | |
Note: WC = waist circumference; BMI = body mass index; BF = body fat; WHtR = waist-to-height ratio;
a = p < 0.05 compared to BI (within-group); b = p < 0.05 between Yoga and Control groups (between-group). No significant differences were observed between the Yoga and Control groups at baseline. Sample size for the Yoga and Control groups, respectively: 90 and 92 (6 months); 51 and 77 (12 months); and 31 and 59 (24 months).
After 6 months, between-group comparisons showed significantly lower values in the Yoga group for waist circumference (–3.19 cm), body mass index (–1.20 kg/m2), body fat percentage (–2.52%), and waist-to-height ratio (–0.03), all with p < 0.05.
At 12 months, WC increased in both groups but remained significantly lower in the Yoga group (90.63 cm vs 94.05 cm; p = 0.016). WHtR also increased significantly in the Control group (+0.02; p < 0.001), while the Yoga group maintained significantly lower WHtR and BMI values.
After 24 months, the Yoga group experienced significant reductions in BMI (–2.24 kg/m2; p = 0.008) and body fat percentage (–4.29%; p = 0.008) compared to baseline, while the Control group showed increases in waist circumference (+5.56 cm; p = 0.002) and waist-to-height ratio (+0.04; p = 0.001). Between-group comparisons revealed that, after 24 months, the Yoga group had significantly better outcomes than the Control group for all anthropometric parameters evaluated. Consistent with these findings, the between-group effect sizes (Cohen's d) were moderate to large for anthropometric outcomes (|d| = 0.499-0.810) (Table 2).
Blood pressure improvements were observed in the Yoga group over time, with significant intragroup reductions at 24 months in both systolic (–11.38 mm Hg; p = 0.012) and diastolic (–5.45 mm Hg; p = 0.044) pressures. In intergroup comparisons, systolic and diastolic pressures were significantly lower in the Yoga group at 6 months, and systolic pressure remained significantly lower at 24 months (125.10 ± 13.90 mm Hg vs 133.20 ± 16.02 mm Hg; p = 0.019) compared to the Control group (Table 2).
Glucose-Insulin
Biochemical and hormonal outcomes are presented in Table 3. Fasting glucose levels decreased in the Yoga group and increased in the Control group over time. At 24 months, the changes were statistically significant (–9.06 mg/dL in the Yoga group, p = 0.024; +13.42 mg/dL in the Control group, p = 0.003), with lower glucose levels in the Yoga group at all time points (p < 0.05) and a moderate effect size at 24 months (Cohen's d = -0.512). While insulin levels did not change significantly, HOMA-IR decreased slightly in the Yoga group, and QUICKI increased significantly at 24 months compared to baseline (+0.03; p = 0.046).
Table 3.
Laboratory Parameters of Participants in the Yoga and Control Groups who Completed six, Twelve, and Twenty-Four Months of Follow-up.
| Variables | Timepoint | Yoga | Control | Yoga Versus Control | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Baseline | Follow-up | Variation Baseline – Follow-up |
Baseline | AF | Variation Baseline – Follow-up |
Baseline | Follow-up | ||||
| Mean (SD) | Mean (SD) | Variation | Cohen's D | Variation | Cohen's D | ||||||
| Glucose (mg/dL) | 6-month | 93.23 (10.57) | 93.02 (8.96) | −0.21 | 95.60 (18.36) | 98.36 (19.59) | 2.76 | −2.37 | −0158 | −5.34b | −0349 |
| 12-month | 93.76 (10.20) | 92.02 (9.61) | −1.74 | 95.90 (19.09) | 97.44 (18.89) | 1.54 | −2.14 | −0132 | −5.42b | −0342 | |
| 24-month | 101.03 (18.91) | 91.97 (11.01) | −9.06a | 91.56 (13.10) | 104.98 (30.28) | 13.42a | 9.47b | 0618 | −13.01b | −0512 | |
| Insulin (mUI/mL) | 6-month | 5.47 (3.89-8.57) |
5.61 (3.94-8.16) |
0.14 | 5.85 (4.58-8.24) |
6.23 (4.16-8.23) |
0.38 | −0.38 | −0055 | −0.62 | −0060 |
| 12-month | 5.34 (3.71-8.52) |
4.98 (3.41-7.11) |
−0.36 | 5.79 (4.44-7.98) |
5.75 (3.95-8.53) |
−0.04 | −0.45 | −0147 | −0.77 | −0359 | |
| 24-month | 6.02 (4.59-10.67) |
4.59 (3.51-7.29) |
−1.43 | 5.73 (4.43-8.00) |
5.20 (3.30-6.90) |
−0.53 | 0.29 | 0420 | −0.61 | −0189 | |
| HOMA-IR | 6-month | 1.30 (0.89-2.05) |
1.26 (0.88-1.91) |
−0.04 | 1.37 (0.98-2.04) |
1.46 (0.93-2.09) |
0.09 | −0.07 | −0111 | −0.20 | −0141 |
| 12-month | 1.19 (0.79-2.02) |
1.15 (0.77-1.62) |
−0.04 | 1.33 (0.97-2.02) |
1.35 (0.89-2.09) |
0.02 | −0.14 | −0184 | −0.20 | −0355 | |
| 24-month | 1.49 (1.01-2.78) |
0.96 (0.76-1.50) |
−0.53 | 1.31 (0.95-1.72) |
1.30 (0.73-2.10) |
−0.01 | 0.18 | 0524 | −0.34 | −0304 | |
| QUICKI | 6-month | 0.37 (0.34-0.39) |
0.37 (0.35-0.39) |
0.00 | 0.36 (0.34-0.38) |
0.36 (0.34-0.39) |
0.00 | 0.01 | 0000 | 0.01 | 0333 |
| 12-month | 0.37 (0.34-0.40) |
0.37 (0.35-0.40) |
0.00 | 0.37 (0.34-0.39) |
0.37 (0.34-0.39) |
0.00 | 0.00 | 0000 | 0.00 | 0250 | |
| 24-month | 0.36 (0.33-0.38) |
0.39 (0.36-0.40) |
0.03a | 0.37 (0.35-0.39) |
0.37 (0.34-0.40) |
0.00 | −0.01 | −0250 | 0.02 | 0271 | |
| Triglycerides (mg/dL)* | 6-month | 107.00 (79.50-145.50) |
106.50 (79.75-134.25) |
−0.50 | 106.00 (76.00-130.50) |
100.00 (73.50-123.50) |
−6.00 | 1.00 | 0191 | 6.50 | 0056 |
| 12-month | 101.50 (75.00-160.50) |
104.00 (79.75-147.25) |
2.50 | 106.50 (82.25-133.25) |
103.50 (76.50-138.25) |
−3.00 | 5.00 | 0016 | 0.50 | −0026 | |
| 24-month | 113.00 (78.00-149.50) |
96.00 (70.50-133.50) |
−17.00 | 109.00 (76.00-142.00) |
105.00 (74.00-159.00) |
−4.00 | 4.00 | 0169 | −9.00 | −0364 | |
| Total cholesterol (mg/dL)* | 6-month | 210.01 (39.24) | 212.16 (37.57) | 2.15 | 213.56 (42.70) | 211.61 (44.35) | −1.95 | −3.55 | −0086 | 0.55 | 0013 |
| 12-month | 208.00 (39.05) | 215.45 (38.56) | 7.45 | 217.98 (44.88) | 215.68 (44.61) | −2.30 | −9.98 | −0233 | −0.23 | −0005 | |
| 24-month | 228.60 (41.95) | 214.88 (29.08) | −13.72 | 216.96 (44.61) | 217.80 (44.97) | 0.84 | 11.64 | 0266 | −2.92 | −0072 | |
| HDLc (mg/dL)* | 6-month | 58.14 (12.85) | 58.81 (16.54) | 0.67 | 55.97 (12.15) | 58.18 (13.42) | 2.21a | 2.17 | 0174 | 0.63 | 0042 |
| 12-month | 57.90 (13.22) | 60.30 (16.36) | 2.40 | 56.00 (12.43) | 57.68 (12.68) | 1.68 | 1.90 | 0149 | 2.62 | 0185 | |
| 24-month | 55.76 (11.45) | 65.40 (13.56) | 9.64a | 59.69 (13.42) | 54.86 (11.88) | −4.83 | −3.93 | −0307 | 10.54b | 0847 | |
| Não-HDLc (mg/dL)* | 6-month | 151.88 (40.78) | 153.36 (39.16) | 1.48 | 157.58 (41.14) | 153.43 (43.45) | −4.15 | −5.70 | −0139 | −0.07 | −0002 |
| 12-month | 150.10 (43.23) | 155.15 (42.71) | 5.05 | 161.98 (44.64) | 158.00 (46.55) | −3.98 | −11.88 | −0269 | −2.85 | −0063 | |
| 24-month | 172.84 (43.52) | 149.48 (31.52) | −23.36a | 157.27 (46.32) | 162.94 (46.12) | 5.67 | 15.57 | 0343 | −13.46 | −0321 | |
| LDLc (mg/dL)* | 6-month | 125.96 (36.94) | 130.55 (34.02) | 4.59 | 127.12 (39.71) | 131.05 (38.84) | 3.93 | −1.16 | −0030 | −0.50 | −0014 |
| 12-month | 123.75 (39.14) | 128.64 (35.50) | 4.89 | 130.58 (41.95) | 134.15 (40.22) | 3.57 | −6.83 | −0167 | −5.51 | −0143 | |
| 24-month | 136.24 (35.69) | 123.49 (27.47) | −12.75 | 130.12 (43.59) | 144.94 (40.84) | 14.82 | 6.12 | 0149 | −21.45b | −0579 | |
| Apo A1 (mg/dL)* | 6-month | 157.62 (28.47) | 156.05 (32.70) | −1.57 | 165.49 (29.00) | 183.52 (36.08) | 18.03a | −7.87 | −0274 | −27.47b | −0797 |
| 12-month | 159.05 (28.63) | 160.88 (31.80) | 1.83 | 166.18 (30.22) | 166.71 (25.55) | 0.53 | −7.13 | −0241 | −5.83 | −0208 | |
| 24-month | 161.88 (31.08) | 170.72 (27.13) | 8.84 | 168.98 (29.06) | 151.68 (20.99) | −17.30a | −7.10 | −0239 | 19.04b | 0822 | |
| ApoB (mg/dL)* | 6-month | 104.04 (28.68) | 99.54 (26.63) | −4.50 | 109.57 (30.50) | 116.10 (32.94) | 6.53a | −5.53 | −0187 | −16.56b | −0552 |
| 12-month | 104.58 (31.65) | 106.38 (30.78) | 1.80 | 113.14 (32.71) | 115.55 (33.82) | 2.41 | −8.56 | −0265 | −9.17 | −0280 | |
| 24-month | 117.68 (29.92) | 105.24 (25.22) | −12.44 | 110.39 (36.14) | 109.42 (31.84) | −0.97 | 7.29 | 0213 | −4.18 | −0140 | |
| Estradiol (pg/mL)† |
6-month | 34.00 (16.50-71.50) |
28.00 (18.00-54.00) |
−6.00 | 10.30 (8.35-14.70) |
12.25 (7.45-16.49) |
1.95 | 23.70b | 0107 | 15.75b | 0624 |
| 12-month | 38.50 (17.75-65.75) |
40.50 (21.75-71.75) |
2.00 | 10.71 (8.82-16.07) |
15.00 (7.81-19.06) |
4.29 | 27.79b | 0087 | 25.50b | 1360 | |
| 24-month | 23.06 (8.71-125.95) |
47.50 (16.17-82.50) |
24.44 | 17.16 (11.51-85.00) |
6.60 (3.30-8.95) |
−10.56a | 5.90 | 0207 | 40.90b | 1724 | |
| Testosterone (ng/dL)† | 6-month | 27.90 (21.54) | 28.24 (19.30) | 0.34 | 25.49 (14.32) | 25.57 (14.61) | 0.08 | 2.41 | 0130 | 2.67 | 0154 |
| 12-month | 27.60 (17.20) | 28.64 (18.30) | 1.04 | 27.21 (13.46) | 28.51 (15.72) | 1.30 | 0.39 | 0026 | 0.13 | 0008 | |
| 24-month | 34.50 (14.73) | 29.31 (14.43) | −5.19 | 35.28 (15.78) | 24.66 (13.42) | −10.62 | −0.78 | −0051 | 4.65b | 0337 | |
Note: HOMA-IR = Homeostasis Model Assessment – Insulin Resistance; QUICKI = Quantitative Insulin Sensitivity Check Index;
a = p < 0.05 compared to baseline (within-group); b = p < .05 between the Yoga and Control groups (between-group);
Sample sizes for the Yoga and Control groups were 90 and 92 at 6 months, 51 and 77 at 12 months, and 31 and 59 at 24 months.
*For the analysis of the lipid profile, which excluded women using hypolipidemic agents, the corresponding sample sizes were 74 and 77, 40 and 66, and 25 and 51.
†For the analysis of sex hormones, which included only postmenopausal women, the corresponding sample sizes were 57 and 49, 29 and 40, and 18 and 29, respectively.
Lipid Profile and Apolipoproteins
Lipid profile analysis excluded participants using lipid-lowering medications. In this analysis, the Yoga group included 74 women at 6 months, 40 at 12 months, and 25 at 24 months; the Control group included 77, 66, and 51 women, respectively.
After 6 months, the Yoga group showed no significant changes in lipid markers. The Control group, however, exhibited increases in HDLc (+2.21 mg/dL; p = 0.011), apoA1 (+18.03 mg/dL; p < 0.001), and apoB (+6.53 mg/dL; p = 0.019).
Between-group comparisons revealed lower levels of apoA1 (–27.47 mg/dL) and apoB (–16.56 mg/dL) in the Yoga group (both p < 0.01). No significant differences were observed at 12 months.
At 24 months, the Yoga group showed improvements in several lipid markers: triglycerides (–17.00 mg/dL), total cholesterol (–13.72 mg/dL), non-HDLc (–23.36 mg/dL), LDLc (–12.75 mg/dL), apoB (–12.44 mg/dL), HDLc (+9.64 mg/dL), and apoA1 (+8.84 mg/dL), with significant differences for HDLc (p = 0.012) and non-HDLc (p = 0.018). The Control group showed a decline in apoA1 (–17.30 mg/dL; p = 0.002). Between-group comparisons at 24 months showed significantly higher levels of HDLc (+10.54 mg/dL; p = 0.001; Cohen's d = 0.847) and apoA1 (+19.04 mg/dL; p = 0.001; Cohen's d = 0.822), as well as lower LDLc (–21.45 mg/dL; p = 0.020; Cohen's d = -0.579), in the Yoga group (Table 3).
Hormones
Sex hormone analysis included only postmenopausal women. At 24 months, estradiol levels increased in the Yoga group (+24.44 pg/mL) and decreased in the Control group (–10.56 pg/mL; p < 0.001) compared to baseline. At this time point, the median estradiol level was significantly higher in the Yoga group than in the Control group (+40.90 pg/mL; p < 0.001), with a very large effect size (Cohen's d = 1.724). Significant differences were also observed at 6 and 12 months, but these were already present at baseline, limiting interpretation.
Total testosterone levels were significantly higher in the Yoga group compared to the Control group after 24 months (+4.65 ng/dL; p = 0.018; Cohen's d = 0.337). Notably, estradiol levels in the Yoga group exceeded 40 pg/mL after both 12 and 24 months, approaching levels typically observed in premenopausal women. No relevant trends or significant differences were observed for LH and FSH; therefore, these data are not presented.
Discussion
To our knowledge, this is among the first longitudinal studies to evaluate the effects of yoga over a 24-month period on anthropometric, biochemical, and hormonal parameters in climacteric women. Most published studies assess the impact of yoga on menopausal symptoms after short interventions lasting 8 to 12 weeks, often without a control group or including only postmenopausal women or participants with pre-existing metabolic conditions.14,15
Anthropometry and Blood Pressure
In this study, women in the Yoga group showed favorable changes in anthropometric measures. Reductions in BMI (after 24 months) and body fat percentage (after 6 and 24 months) were observed, while WC, BMI, and WHtR remained significantly lower compared to the Control group across all time points. In contrast, the Control group exhibited increases in body weight, BMI, WC, WHtR, and fat percentage over time. These changes likely reflect the combined effects of a sedentary lifestyle and the hormonal and metabolic alterations typical of the menopausal transition, which favor central fat accumulation and reduced energy expenditure.4,18 In addition, effect sizes at 24 months were moderate to large, suggesting clinically meaningful improvements in adiposity-related measures in the Yoga group compared with the Control group.
Yoga involves physical movement, breath control, and meditation, all of which are associated with greater body awareness and behavioral changes. 19 Although dietary habits were not assessed, previous studies suggest that yoga can influence eating behavior and promote healthier lifestyle patterns.20,21 A randomized trial showed that long-term yoga can support weight loss in adult women. 22 Similarly, a meta-analysis indicated that yoga may help reduce BMI in individuals with overweight or obesity. 23
Glucose-Insulin
Regarding glycemic parameters, yoga practice was associated with improvements in fasting glucose, insulin, and HOMA-IR over time, particularly at 24 months. QUICKI also increased significantly, suggesting enhanced insulin sensitivity. In contrast, the Control group showed increased fasting glucose after 24 months. Between-group comparisons indicated significantly lower glucose levels in the Yoga group at all follow-up points, with a moderate effect size at 24 months. Similar patterns were observed among women with impaired fasting glucose (≥100 mg/dL), reinforcing the potential benefit of yoga in this subgroup. These findings are supported by studies showing that yoga may modulate insulin signaling, pancreatic β-cell responsiveness, and inflammatory activity, contributing to glycemic control.24,25
Lipid Profile and Apolipoproteins
Improvements in lipid profile were observed primarily after 24 months of yoga practice. Women in the Yoga group had higher HDLc and lower non-HDLc levels compared to baseline. Between-group analysis showed more favorable values for HDLc, LDLc, and apoA1 in the Yoga group, supported by moderate to large effect sizes. These findings are consistent with previous studies suggesting that yoga may influence lipid metabolism, potentially by enhancing the activity of enzymes such as hepatic lipase and lipoprotein lipase, which play key roles in the catabolism of triglyceride-rich lipoproteins. 26
Changes in apolipoproteins followed a similar pattern. At 24 months, apoA1 increased and apoB decreased in the Yoga group, with significant between-group differences in apoA1. Given the established roles of apoA1 (as the main protein component of HDLc) and apoB (as the primary apolipoprotein in LDLc), these changes support a more favorable cardiometabolic profile among yoga practitioners. A temporary increase in apoA1 observed in the Control group at 6 months may have occurred by chance, as no consistent evidence supports such a response in sedentary individuals. To our knowledge, there are no studies reporting significant increases in apoA1 among inactive populations without lifestyle interventions, suggesting that this result is unlikely to reflect a true physiological effect.
Hormones
The climacteric period is marked by a progressive decline in ovarian function, resulting in reduced estradiol production and altered secretion of other hormones such as FSH and progesterone.2,4 These hormonal changes are strongly associated with the onset or worsening of clinical, metabolic, and anthropometric alterations, including central adiposity, insulin resistance, dyslipidemia, and elevated cardiovascular risk. 4 Estradiol plays a critical role in maintaining glucose and lipid homeostasis, regulating body fat distribution, and supporting energy balance through its effects on insulin sensitivity, hepatic lipid metabolism, and hypothalamic appetite control. 27
In this context, our finding of a 24.44 pg/mL increase in estradiol levels in the Yoga group after 24 months is noteworthy. At this time point, median estradiol concentrations were significantly higher in the Yoga group than in the Control group, with a very large effect size, suggesting a potential endocrine-modulating effect of long-term yoga practice. Although significant differences were also observed at 6 and 12 months, they may reflect baseline variability rather than a physiological response.
Previous studies have shown that yoga may help regulate endocrine function by reducing physiological stress and restoring balance in neuroendocrine pathways.28,29 Chronic stress and sympathetic overactivity can disturb the hypothalamic–pituitary–adrenal (HPA) and hypothalamic–pituitary–ovarian (HPO) axes, 30 leading to hormonal fluctuations and impaired ovarian function. Regular yoga practice has been associated with lower cortisol levels, decreased sympathetic tone, and enhanced parasympathetic activity, thereby supporting hormonal equilibrium.28,29 Through these mechanisms, yoga may contribute to improved regulation of the HPO axis and broader neuroendocrine and autonomic adjustments that promote hormonal homeostasis.
Findings from previous studies with Brazilian women support this interpretation, with non-significant increases in estradiol reported after 12 weeks of yoga and a substantial increase described in a case report after four months of practice.28,31 Our study adds to this evidence by demonstrating a longer-term effect and contributing to the limited data on endocrine outcomes associated with yoga in climacteric women.
The elevated estradiol levels observed at 24 months may also help explain several of the favorable outcomes in this study. Most improvements, including reductions in BMI and body fat percentage, enhanced insulin sensitivity, and a more favorable lipid profile, became statistically significant only after 24 months of practice. These findings are consistent with estradiol's metabolic functions and support the hypothesis that yoga may promote health through both behavioral and hormonal mechanisms, particularly relevant for women in the menopausal transition.
Earlier studies from our group also showed beneficial effects of yoga in climacteric women, including reduced symptom severity, better anthropometric measures, and lower glucose and insulin concentrations.14,32,33 These effects appeared more pronounced in our cross-sectional analyses than in the current longitudinal cohort, possibly because participants in those studies had initiated yoga practice before entering the menopausal transition. This observation may suggest a time-dependent effect, particularly when yoga is adopted as part of a sustained lifestyle approach.
Limitations and Future Directions
This study has some limitations. Dietary intake was not monitored, which may have influenced the metabolic outcomes. Attrition over the 24-month follow-up, especially in the yoga group, reduced the sample size in the later analyses and may have limited the statistical power to detect some effects. However, baseline characteristics were comparable between completers and dropouts, suggesting minimal attrition bias. In addition, the absence of randomization and the self-selection of participants into groups may have introduced selection bias, as reflected by the higher schooling level observed in the yoga group. Because of the limited number of eligible participants and the relatively low adherence to yoga practice, random allocation was not feasible, and a pragmatic group assignment was adopted. This approach mirrors real-world conditions but represents a methodological limitation that should be considered when interpreting the findings. Despite these limitations, the consistent trends observed across anthropometric, biochemical, and hormonal parameters support the potential benefits of long-term yoga practice. Future studies with larger samples, objective monitoring of lifestyle behaviors, and mechanistic analyses are warranted to better understand the pathways through which yoga may impact women's health during the climacteric phase.
Conclusion
The findings of this study suggest that yoga practice is associated with significant improvements in anthropometric parameters, increased HDLc levels, and reductions in blood pressure, fasting glucose, and non-HDL cholesterol concentrations in climacteric women. The most pronounced effects on anthropometric, biochemical, and blood pressure measures were observed after 24 months of regular practice. These results indicate that long-term yoga practice may be a promising strategy to promote metabolic and cardiovascular health during the climacteric period.
Footnotes
ORCID iD: Laura Alves Cota e Souza https://orcid.org/0000-0001-8625-6995
Ethical Statement: All procedures were performed in compliance with relevant laws and institutional guidelines. Selected participants provided written informed consent. The Research Ethics Committee of the Federal University of Ouro Preto (CEP/UFOP) approved this study under protocol number 95824318.2.0000.5150 on October 15th, 2018.
Author Contributions: Laura Alves Cota e Souza participated in the conception and design of the study, data acquisition, data analysis and interpretation, and manuscript writing.
Ilka Afonso Reis contributed to the statistical analysis, critically revised the manuscript, and approved the final version.
Angélica Alves Lima participated in the conception and design of the study, critically revised the manuscript for important intellectual content, and approved the final version.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001 and Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG).
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Statement: Data are available from the authors upon reasonable request.
Declaration of AI Use: During the preparation of this work, the authors used ChatGPT by OpenAI to improve language and readability. After using this tool, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication.
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