The day I left my Doctor’s clinic with my first ever prescription for anti-depressants, was the day I pulled out all the research I could find relating to menopause-related depression, including the role of exercise.
I was confused as to why, when I have never had depression in my life, it had arrived during my early 50s. The relationship to menopause and the type of exercise I was doing at the time and my weight gain, never crossed my mind. Nor, I imagine, did it cross the mind of my medical practitioner either.
That day was pivotal to me. I still remember it.
But in a way, I’m pleased that it happened, because it moved me into a new phase of my ‘exercise life’ and the consideration of the purpose of exercise as I went into my 50s.
It moved me away from exhausting higher intensity exercise, to getting back to doing good old-fashioned aerobic exercise.
With the continued emphasis on high-intensity performance-based activity and heavy weight training, aerobic exercise has been relatively forgotten in the fitness industry but my aim for those of you who are working in the area of exercise prescription is to change that perspective for you.
Most women have experienced transient feelings of sadness or depressed mood over their life-time. Importantly, for some females, depression can present or worsen during periods of dynamic hormonal flux such as the premenstrual phase of their monthly cycle, during or after pregnancy, and during the perimenopause and menopause phases of their life. (Bromberger & Epperson, 2018).
For women in mid-life suffering from menopause-related depression, it’s important that Exercise Practitioners understand the causes of this and of course, the scientific evidence as to the type and amount of exercise and physical activity, that is known to help women reduce the incidence of depression.
Australian Psychiatrist and academic, Professor Felice Jacka, is very clear on how and why exercise helps with depression and when I heard her speak at a Lifestyle Medicine conference, it reminded me, as a Sport and Exercise Educator and Health Practitioner, that we need to be very clear on the role of exercise for menopause-related depression.
Why do Women in Menopause Feel Depressed?
Depression is a generic term used by the media, the general public and health care professionals to refer to negative mood symptoms that range in severity from unhappy and sad psychological states to major depressive disorder (MDD).
There is a gold-standard clinical interview that is undertaken by trained Physicians to diagnose depressive disorders, so please be aware that ‘typical’ menopause symptoms are included in this clinical diagnosis,
- fatigue,
- feelings of worthlessness,
- insomnia,
- body-weight changes,
- difficulty concentrating and heightened anxiety.
So you may need to refer your clients for further investigation by their medical specialist if they talk to you about any or all of these symptoms.
In relatively new research, Blomberg and Epperson (2018), suggest that for many decades, there has been ongoing debate about whether the menopause transition and/or post-menopause is associated with an increased risk for depressive symptoms or disorder.
Exploring outcomes from a variety of longitudinal studies on menopause and depression, including the Study of Women’s Health Across the Nation (SWAN), the Australian Longitudinal Study of Women’s Health (ASWH) and the Seattle Midlife Women’s Health Study, the authors concluded that endocrine changes driving the menopause transition and affecting numerous tissues and biological systems including those in the brain are primarily responsible for unmasking the risk for depression symptoms or disorder in susceptible women.
But there are other factors too. These include, psycho-social factors (e.g. stress, personality trait, lifetime exposure, social support); health factors (e.g. physical condition, menopause symptoms, health behaviours e.g. smoking and alcohol intake); and biological factors (e.g. genetics, environment).
Menopause seems to be a time when all of these factors converge, leaving 1 in 5 women vulnerable to changing moods, motivation and of course, melancholy.
Many women also go on Anti-depressants during Menopause:
The history of menopause-related anti-depressant use is fascinating.
A medication called Iproniazid, developed in the early 1950’s for treatment of tuberculosis, was never intended to become one of the first pharmaceutical anti-depressants.
But when Physician’s noticed that tuberculosis patients became more cheerful, optimistic and more physically active, further research revealed that the change from melancholy to motivation in these patients was due to the slowing down of the enzymes that broke down the two main mood-enhancing hormones, serotonin and dopamine. [Leibermann, 2003]
So began the genesis of anti-depressant pharmacology and alongside the growing interest in psychiatry as a medical discipline in the 1960’s and 1970’s, the use of anti-depressants to help women in menopause cope better with their melancholy, emerged as a treatment of choice.
Throughout the 1970’s, the development of Fluoxetine flourished and this was the first Selective Serotonin Reuptake Inhibitor (SSRI) medication which helped millions of women cope better with everyday life. In the United Kingdom, two-thirds of anti-depressants are now prescribed to women in mid-life.
Anti-depressants interact with receptors located on nerve endings. As such, this interaction changes neural (nerve) functioning and the uptake of our mood hormone serotonin. They are known to help millions of women, including many women who come onto the MyMT™ programmes.
However, as a researcher in exercise and sports science, I was also aware of the powerful role that exercise plays in the mental health of women during the menopause transition.
In fact, every one of the women I interviewed during my doctoral study, told me that the main reason that they took up exercise over their lifetime, was simply because not only did it make them ‘feel good‘, but as they moved into mid-life, it helped them to cope. (Sweet, 2018).
The problem for them however, was that they were undertaking the type of exercise that they had been doing for years, and for many, this was higher-intensity exercise (anaerobic exercise) and heavy weight training.
At the time, I was doing this type of exercise too. But this is not the type of exercise that is best suited to women with changing hormones during menopause and who are exhausted from not sleeping and therefore, at higher risk for menopause-related depression.
How Much Is Enough?
Over the past 30 years, numerous studies have been undertaken examining the benefits of exercise on depression as well as the amount and type of exercise that is most beneficial.
Like most lifestyle factors, it seems that the word ‘moderation‘ also applies to exercise. Researchers know that being sedentary increases the risk for depression but conversely, high levels of intense exercise which induce over-training, may not be any more protective against depression either.
Proposed explanations for the psychological benefits of exercise include a number of neuro-scientific studies.
Many of these indicate that certain neuro-chemicals (dopamine, and other β-endorphins) are produced by the brain, pituitary gland and other tissues and these act as natural opiates that produce compounds which bind to opiate receptor sites involved in pain perception and they have now been implicated in reward mechanisms and positive emotions. [Bouchard, Blair & Haskell, 2008]
As such, the exercise prescription that is needed to stimulate these chemical reward systems are recommended to be (Xie, Wu et al., 2021):
Frequency: 3-5 sessions per week lasting for a minimum of 4 weeks up to 16 weeks.
Intensity: 65 – 75% of maximal effort
Type: Aerobic exercise and mind-body exercise e.g. yoga, tai chi, pilates, other types of exercise which emphasise breath-work
Time: 30 minutes to 75 minutes
This is why, I mainly promote aerobic exercise for women who aren’t sleeping and who are experiencing symptoms of depression and cognitive change.
For women transitioning into peri-menopause and moving into post-menopause, the importance of aerobic exercise, [i.e. steady-state exercise, up to an hour], needs to return as ‘exercise of choice’. It’s been forgotten for too long and this is partly because research has not kept up with the exercise needs of mid-life women. Much of the fitness-industry research is driven by sports and athletic conditioning.
That’s why for the women who join me on the MyMT™ symptom reduction programmes, whether they are on menopause-related anti-depressants or not, I get them back doing aerobic exercise.
Not only does aerobic exercise help with blood pressure management but it also helps with improving arterial blood flow and reducing vascular stiffness.
The add-on effect with improved blood flow is that aerobic exercise also improves our mental health, through boosting serotonin and dopamine levels – the two hormones of mood management. As we move through menopause, the production of these hormones declines, so aerobic exercise mitigates this.
Ann (in the banner above) is a Personal Trainer. For years she was a power-lifter and specialises in this with clients at her gym. But her own menopause transition left her feeling exhausted. As she mentioned,
“As a woman going through menopause in all its various stages, there were times when I felt so inadequate and unsure of myself. When I spoke to my GP at the time, he offered me anti-depressants!
In one of our first modules in the Practitioner Course, Wendy shared a quote from Dr Dorothy Barbo, which said, “Menopause is an event in life, not a disease”, how true this is.
We don’t have a disease and personally, I didn’t need anti-depressants, what I needed what was the information and science behind what was happening to my body and mind. Now that I have that, I am excited to be able to help other women on their journey and encourage each of us to shout Menopause loudly from the rooftops and normalise it.
Thanks Wendy and Georgia of course for showing me the way and giving me the knowledge to help others. You have really helped me shape and change the direction of my personal training business to focus more on menopause and working with women to encourage them to stop doing their endless HIIT classes and get out there and walk/swim/cycle and do some strength training.
Thank you for helping me and giving me the ability to help others.”
References:
*Australian Institute of Health and Welfare (2018). Physical activity across the life stages. Cat. no. PHE 225. Canberra: AIHW.
Bouchard, C., Blair, S. & Haskell, W. (2008). Physical Activity and Health. Human Kinetics: Champaign, IL.
Doyne, E. et al. (1983). Aerobic exercise as treatment for depression in women. Behavior Therapy, 14(3), 434 – 440.
Firth, J., Solmi, M., Wootton, R.E., Vancampfort, D., Schuch, F.B., Hoare, E., Gilbody, S., Torous, J., Teasdale, S.B., Jackson, S.E., Smith, L., Eaton, M., Jacka, F.N., Veronese, N., Marx, W., Ashdown-Franks, G., Siskind, D., Sarris, J., Rosenbaum, S., Carvalho, A.F. and Stubbs, B. (2020). A meta-review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry, 19: 360-380. https://doi.org/10.1002/wps.20773
Freeman EW. Depression in the menopause transition: risks in the changing hormone milieu as observed in the general population. Womens Midlife Health. 2015 Aug 11;1:2. doi: 10.1186/s40695-015-0002-y.
Jacka FN, Berk M. Depression, diet and exercise. Med J Aust. 2013 Sep 16;199(S6):S21-3. doi: 10.5694/mja12.10508.
Leibermann, J. (2003). History of the use of anti-depressants in Primary Care. J. Clinical Psychiatry, 5(7), 1-5.
Schreiber DR, Dautovich ND. Depressive symptoms and weight in midlife women: the role of stress eating and menopause status. Menopause. 2017 Oct;24(10):1190-1199. doi: 10.1097/GME.0000000000000897.
Xie Y, Wu Z, Sun L, Zhou L, Wang G, Xiao L, Wang H. The Effects and Mechanisms of Exercise on the Treatment of Depression. Front Psychiatry. 2021 Nov 5;12:705559. doi: 10.3389/fpsyt.2021.705559.
