Table 5.

Selected studies of physical activity and psychological symptoms

Reference	Sample	Physical activity measure	Menopausal symptom measure	Other measures	Detailed findings	Summarized findings: observed association
						Null	Positive	Negative	Mixed
Cross-sectional studies
Canário et al. 2012 [27]	Population-based sample of 370 women from Natal, Brazil aged 40–65	International Physical Activity Questionnaire with three categories of classification: sedentary, moderately active and very active (vigorous)	Blatt–Kupperman Menopausal Index with three categories of classification: mild (≤19), moderate (20–35), or severe (>35)	Socio-demographic and behavioral characteristics	Bivariate analysis revealed a statistically significant inverse association between physical activity and depression			x (depression)
Mansikkamäki et al. 2015 [30]	Random sample of 5000 women born in 1963 was obtained from the Finnish Population Register Centre, 2606 women aged 49 years old responded that responded to a postal survey in 2012	A single item pertaining to usual exercise (frequency and duration) per week during past 12-months. Women were classified as ‘active’ if they reported ≥ 150 min per week of moderate intensity or ≥75 min of vigorous intensity, with strength training and balance training	Women’s Health Questionnaire addressing nine domains of physical and emotional experiences, including anxiety/depressed mood	Sociodemographic factors, anthropometrics, self-rated health	In the unadjusted and adjusted models, inactive women had a statistically significant increased probability of anxiety/ depression [Unadjusted POR: 1.44 (95 % CI: 1.26, 1.65); Adjusted POR: 1.31 (95 % CI: 1.14, 1.51)			x (anxiety, depression)
Moilanen et al. 2010 [31]	Participants drawn from Finnish Health 2000 Study (n = 7,977), data collection included a home interview, 3 self-administered questionnaires, and a clinical exam. Analytic sample included 1427 women, ages 45–64; known menopausal status) who completed the home interview, first questionnaire	Physical activity was assessed via a single item on the questionnaire, “How much do you exercise or strain yourself physically in your leisure time” with four response options ranging from ‘sedentary’ (reading, watching television) to ‘competitive sports’. Participants were classified based on low, moderate, and high physical activity	Severity of general symptoms, including psychological symptoms (e.g., depression), were assessed via two items on the questionnaire	Socio-demographics, health behaviors, anthropometrics, menopausal status and hormone therapy use	Compared to the high active group, low active women were significantly more likely to report psychological symptoms			x (psychological symptoms)
Timur et al. 2010 [35]	Community-based randomly selected sample of 685 Turkish (Malatya) women aged 45–59 years. Data were collected from February to May, 2008	A single item to assess regular exercise, operationalized as:≥3 times per week or not (yes or no)	The Beck Depression Inventory, a 21 question survey that uses a Likert scale from 0 to 3 to assess severity of depressive symptoms	Socio-demographics, anthropometrics, health behaviors, parity, menopausal status and hormone therapy use	No significant difference in depression by regular exercise status	x
Vallance et al. 2010 [36]a	297 post-menopausal women from the Palliser Region of Alberta, Canada	Godin Leisure-Time Exercise Questionnaire which assesses the frequency and duration of mild-, moderate-, and strenuous- leisure-time physical activity	Depression was assess via the 20-item Center for Epidemiologic Studies-Depression scale. For each item, responses ranged from 0 ‘<1 day in the past week’ to 3 ‘5-7 days in the past week’	Socio-demographic factors, anthropometrics, health history, menopausal symptoms	Unadjusted and adjusted analyses found that participants meeting physical activity recommendations reported significantly fewer depression symptoms than those who did not			x (depression symptoms)
		Participants also wore a pedometer (DigiWalker SC-01) for 3 days, average steps per day were computed	Anxiety was assessed via the 10-item Spielberger’s state Anxiety Inventory (SAI). For each item, responses ranged from 1 ‘not all’ to 4 ‘very much so’
		Estimates reflecting meeting physical activity recommendations were also computed for both reported and pedometer-based (>7500 steps per day) estimates.
Chang et al. 2013 [37]	Secondary data analysis of 481 multi-racial/ethnic women who completed questions on menopausal symptoms that were part of a larger Internet survey study	Kaiser Physical Activity Survey, including four indices of physical activity: (a) household/ caregiving, (b) occupational, (c) active living, and (d) sport/exercise activity. Each index was calculated as the average score (ranged from 1 to 5)	Midlife women’s Symptoms Index, which measured psychological symptoms based on their prevalence ‘yes’ or ‘no’ and severity ‘1 = not at all and 5 = extremely’	Sociodemographic factors, self-rated health, menopausal status, hormone therapy use	After adjustment, there was a statistically significant association between the household/ caregiving index and psychological symptoms in Non-Hispanic Asians and Blacks, only. Associations were not statistically significant for any other race/ethnic group or indices of physical activity				x
Prospective cohort studies
Dugan et al. 2015 [46]	Included 2891 participants from the Study of Women’s Health Across the Nation. Women were recruited in 1995–97. Included data from follow-up, 3, 6 & 9	Kaiser Physical Activity Survey, including four indices of physical activity: (a) household/ caregiving, (b) occupational, (c) active living, and (d) sport/exercise activity. Each index was calculated as the average score (ranged from 1 to 5). Participants were then classified as: meeting physical activity guidelines, below physical activity guidelines or Inactive	Depression was assess via the 20-item Center for Epidemiologic Studies-Depression scale. For each item, responses ranged from 0 ‘<1 day in the past week’ to 3 ‘5–7 days in the past week’. High depressive symptoms were classified as ≥16	Socio-demographic factors, health behaviors, anthropometrics, menopausal status, hormone therapy use, antidepressant medication use	After adjustment for covariates, participants classified as ‘meeting physical activity guidelines’ or ‘below guidelines’ had a significantly lower odds for depressive symptoms than those classified as inactive. This association persisted over 10 years of observation			x (depressive symptoms)
de Azevedo Guimaraes et al. 2011 [45]	120 Brazilian women aged 45–59 years old volunteered for the 12-week study (recruited through work or other institutions)	Habitual PA was assessed through the short form of the International PA Questionnaire (IPAQ); Participants were classified as: maintained <30 min/day, maintained or increased to 30–60 min/day, or maintained or increased to >60 min/day	Psychological symptoms were assessed using the World Health Organization Quality of Life Brief Version Questionnaire; higher scores reflect less severe psychological symptoms	Socio-demographic factors, anthropometrics, menopausal status and symptoms, and QOL	Women classified in the highest active group (maintained or increased to 60 min per day) had increased psychological domain QOL scores after 12-weeks than the other two active groups after adjustment for baseline values		x (better psycho-social symptoms)
	104 women completed the 12-week study
Non-randomized Intervention Studies
Karacan, 2010 [50]a	112 women aged 46–55. The analytic sample included 65 participants that regularly participated in the 3- and 6-month exercise program	The 6-month exercise program included aerobic activity (75–80 % heart rate capacity) with calisthenics for 3 days a week for 55 min each session	The menopause rating scale (MRS) was composed of 11 items assessing menopausal symptoms divided into three groups: psychological, somatic-vegetative and urogenital	Physical characteristics (height, weight, and age at menopause), resting heart rate and blood pressure, lower back flexibility, hand grip strength, and body composition (skin folds)	There was a significant reduction in psychological symptoms, including depressive mood, irritability, and anxiety after 3- and 6-months of the exercise program. Reported exhaustion also significantly decreased from baseline to 3- and baseline to 6- months			x (psychosocial symptoms)
Randomized Controlled Studies
Agil et al. 2010 [51]	42 Turkish, postmenopausal women aged 45–60 years old, presented to the Department of Obstetrics and Gynecology of Bayindir Hospital between March and December 2009 and volunteered to participate in an 8-week physical activity intervention. The analytic sample included 36 participants; intent to treat analysis was not done	Participants were randomly assigned to either an aerobic (n = 18) or resistance (via elastic bands) (n = 18) physical activity intervention. Both groups were supervised, 3 days per week. No other details were provided	Menopause Rating Scale (MRS) assessed psychological symptoms, the Beck Depressive Inventory (BDI) was used to assess depressive symptoms	Socio-demographic factors, health behaviors	Psychological symptoms decreased significantly in both groups post exercise programs according to the MRS subscale. The BDI showed a decrease in depressive symptoms for both groups, but was higher in the resistance exercise group than the aerobic exercise group			x (psychosocial symptoms)
Moilanen et al. 2012 [53]a	176 Finnish white women were recruited for the study by newspaper advertisements. The analytic sample included 154 inactive participants were randomly assigned to the exercise (n = 74) or control group (n = 77) that completed the 6-month study protocol	Exercise Group: Unsupervised aerobic training intervention; 4 × per week at 64–80 % maximal heart rate for 50 min each time	The frequency of psychological symptoms (i.e., mood swings, depressive moods, irritability) were collected 2 × per day using a mobile phone- administered questionnaire	Socio-demographic factors, anthropometrics, and menopausal symptoms	The prevalence of mood-swings decreased pre- to post- intervention. No other reductions were noted				x
Sternfeld et al. 2014 [56]a	248 women aged 40–62 recruited from 3 sites in US (IN, CA, WA) and randomly assigned to a 12-week yoga (n = 107), exercise (n = 106), or usual activity (n = 142) group. Participants were and also randomly assigned to the omega-3 (n = 177) or placebo (n = 178) group. Participants were followed for 12-weeks	Exercise Group: Supervised: 3 × per week, 50–60 % HRR during month 1, 60–70 % HRR during months 2 & 3. Possible modes included, treadmill, elliptical trainer, or stationary bicycle. Trained staff recorded heart rate, workload, and perceived exertion every 5–10 min	Depressive symptoms were assessed using the Patient Health Questionnaire-8 (PHQ-8) and anxiety symptoms using the Generalized Anxiety Disorder-7 (GAD-7)	Socio-demographics, anthropometrics, daily diaries assessing vasomotor symptoms, sleep quality, and health history	Compared to the usual activity group, the exercise group had a greater decrease in depressive symptoms (p = 0.028), but did not meet the set alpha level of p < 0.0125 for multiple comparisons. Change in anxiety symptoms did not differ between the exercise and usual activity groups				x
Villaverde Gutiérrez et al. 2012 [57]a	330 postmenopausal women, aged 60–70, were recruited from a healthcare clinic in Granada, Spain. Of those, 60 (19.1 %) meet eligibility criteria and were willing to participate. Women were randomly selected to the exercise (n = 30) or control (n = 30) group and followed for 6-months. Three women from the exercise group were excluded for not completing at least 80 % of the exercise intervention	Exercise group: During the first 8 weeks of the supervised program, 2 × per week, 50 min each time, 50–70 % heart rate reserve. During weeks 8–12, 3 × per week, 60 min each time, 50–70 % heart rate reserve and muscle training exercises were added. Weeks 12–24, intensity was increased to 60–85 % heart rate reserve; all other components were similar to weeks 8–12	Depressive symptoms were assessed via the 30-item Geriatric Depression Scale (GDS). Participants were classified as: moderate depression (11–14) or severe depression (15–30). Anxiety was assessed via the 14-itemHamilton Anxiety Scale (HRSA). Responses ranged from 0 ‘absence of symptoms’ to 4 ‘total incapacitated’. Participants were classified as: minor anxiety (6–15) or major anxiety (>15)	Anthropometrics	Unadjusted results suggest that among the exercise group, women initially classified with moderate or severe depression had significantly reduced depressive symptoms after 6-months. Similarly, participants in the exercise group, classified with minor or major anxiety had significantly reduced anxiety symptoms after 6-months. In the Control group, women initially classified with moderate depression had a slight increase in depressive symptoms after 6 months. This slight increase was also shown in the control group among participants initially classified with minor anxiety			x (severe depression, depressive symptoms & anxiety)
		Control group: Received no exercise treatment

^aPhysical activity dose reflective of 2008 Physical Activity Guidelines for Americans [3]