Physical activity has been shown to enhance quality of life among midlife women [12, 13], and some studies suggest that physical activity is associated with a decrease of hot flushes [14, 15]. How might physical activity affect to occurrence of hot flushes? During menopause, estrogen concentrations decrease, and consequently the level of neurotransmitter β-endorphin, which is known to affect thermoregulation, decreases. It is also known that physical activity increases hypothalamic β-endorphin production and thereby may affect and stabilize thermoregulation [16] and diminish hot flushes. On the other hand, physical activity raises acutely core body temperature and thus could theoretically increase the occurrence of vasomotor symptoms [17]. The other explanations include association between physical activity, mood, and weight. Maintaining or increasing physical activity level during menopausal transition period and postmenopause has been suggested to reduce a variety of psychological symptoms, including anxiety, stress, and depression [18].

Physical activity and weight is an interesting issue when vasomotor symptoms are considered. One possible mechanism in how physical activity could affect frequency of hot flushes is controlling body weight [14, 17]. Obesity was long time thought to be a protective factor against vasomotor symptoms, because androgens are aromatized into estrogens in body fat. Women with more adipose tissue would be expected to have a lower risk of vasomotor symptoms because of higher levels of estrogen [17]. However, several studies have found that obesity may be a risk factor rather than a protective characteristic during the menopause. Evidence indicates that higher body mass index and body fat in particular are associated with greater vasomotor symptom reporting and primarily hot flushes [19]. Davis et al. [20] suggests that obesity is an independent risk factor for experiencing severe menopausal symptoms. These findings are consistent with a thermoregulatory model of vasomotor symptoms in which body fat acts as an insulator, rendering vasomotor symptoms, a putative heat dissipation event, more likely.

Weight gain during menopause is not related to menopause itself but rather to aging [20]. The hormonal changes across the menopausal transition substantially contribute to increased central abdominal fat and abdominal obesity. Reduction in weight and abdominal circumference has been associated at least partly with reduction in vasomotor symptoms among overweight and obese women [21]. Although there are multiple observational studies which have documented that women with a higher BMI report more frequent or severe hot flushes during menopause, the mechanisms underlying this association are still poorly understood. Recently proposed explanations for the observed association between BMI and hot flushes include alterations in leptin and other cytokines expressed by adipocytes that affect thermoregulatory function [22]. Finally, women who are overweight or obese may differ in psychological or social factors that affect their subjective experience of and willingness to report symptoms such as hot flushes [21].

Symptoms that are related to menopause (hot flushes, night sweats, vaginal dryness) may have a negative impact on women’s health-related quality of life [23]. If the symptoms are a result of the loss of estrogen, replacing estrogen using hormonal therapy, symptoms could disappear and improve quality of life. Hess et al. [24] found in their study that poor HRQL does not increase likelihood of initiating hormonal therapy, nor is hormonal therapy use associated with HRQL improvements. Women who initiated hormonal therapy and reported frequent menopausal symptoms reported an improvement in vitality compared with those who initiated hormonal therapy and did not report a frequent symptom. In Hess et al.’s study [24], it showed that hormonal therapy does not affect the overall feeling of “wellness” but only the symptoms which bothered their life. Similar conclusions were made in a review by Utian and Woods [25]; health-related as well as menopause-related quality of life benefits are contingent of symptoms status. Severely symptomatic women experience a significant improvement in their health-related and menopause-related quality of life, but in clinical trials women without severe symptoms at baseline do not experience an increase in quality of life [25].

Efficacy of yoga, exercise, and usual activity for the improvement of menopause-related QoL in women with vasomotor symptoms was studied in a randomized controlled trial by Reed et al. [26]. The report is part of a trial in which the main aim was to study efficacy of omega-3 treatment for vasomotor symptoms [27]. The instruction of the yoga intervention was provided during weekly 90-min classes, and daily home practice was instructed for 20 min on days when class was not attended. Women in the exercise intervention group were expected to perform resistance exercise training sessions three times per week with targeted training heart rate 50–60 % of the heart rate reserve for the first month and 60–70 % for the next 2 months. The exercise took 40–60 min per session, and the aim was to achieve the energy expenditure goal of 16 kcal/kg. The usual activity group was instructed to continue their usual physical activity and not to begin any new physical exercise. Women in all three groups received either placebo that contained olive oil or an active omega-3 capsule. The Menopausal Quality of Life Questionnaire (MENQOL) was used to evaluate menopause-related QoL in 29 items. Scoring generates a total score and four domain scores (vasomotor, physical, psychosocial, sexual functioning) (see Table 28.1).

The yoga intervention was found to have significantly greater improvement in MENQOL scores at 12 weeks when compared with the usual activity group, additionally no group differences were observed between exercise and usual activity or omega-3 and placebo [26]. According to the results, for yoga compared to usual activity, baseline to 12-week improvements were seen for MENQOL total, vasomotor symptom domain, and sexuality domain scores. However, for women who underwent exercise and omega-3 therapy compared with control subjects, improvements in baseline to 12-week total MENQOL scores were not observed. Exercise showed benefit in the MENQOL physical domain score at 12 weeks. As conclusion, yoga appears to improve menopausal quality of life among healthy sedentary women in spite of modest effect.

A Finnish trial studied quality of life effects of moderate-intensity aerobic training [28]. Women aged 43–63 years, with weekly severe hot flashes, no current use of hormone replacement therapy, and sedentary (physical exercise <2 times/week), were recruited into a randomized controlled trial. Outcomes were hot flushes and health-related quality of life (HRQL). Intervention included moderate-intensity aerobic training for 6 months, four times per week walking for 50 min at 60 % of VO₂max. Control group continued their usual activities. Hot flashes were reported by mobile phone twice a day. Health-related quality of life was estimated by the Short Form-36 Health survey and Women’s Health Questionnaire. Results of the study showed that decrease in the nighttime hot flashes was larger among the intervention group than among the control group, but not during daytime. At the end of intervention, women reported significantly fewer nighttime hot flashes (43 %) than the control women (54 %). Significant differences between the groups in SF-36 score changes were found in physical functioning, general health, vitality, and in WHQ depression.

Imayama et al. studied individual and combined effects of dietary weight loss and/or exercise interventions on HRQOL and psychosocial factors (depression, anxiety, stress, social support) in a randomized trial setting [29]. Overweight or obese postmenopausal women were randomly assigned to 12 months of dietary weight loss, moderate-to-vigorous aerobic exercise, combined diet and exercise, or control groups. According to their results, the combined diet + exercise group improved four aspects of HRQOL (physical functioning, role-physical, vitality, and mental health) and stress, whereas the diet group increased vitality score, but HRQOL did not change differently in the exercise group compared with controls. In Imayama et al.’s study, a combined diet and exercise intervention had larger positive effects on HRQOL than that from exercise or diet alone [29].

The importance of weight loss was also found in an experimental study by Guimaraes and Baptista [30]. In their study, at least moderate-intensity PA for 60 min/day had favorable influence on the prevention of menopausal symptoms and on QOL, particularly in the psychological and social domains. The influence of habitual PA was partially associated with a decrease in the symptoms of menopause and/or with weight loss.

To summarize, results from experimental studies show beneficial effects of physical activity on quality of life, independent of dose, type, or other details of physical activity.

A total of 1,165 Finnish women aged 45–64 years from a national representative population-based study were followed up for 8 years [11]. Ordinal logistic regression analysis was used to measure the effect of menopausal status on global quality of life. Other variables included in the analyses were age, education, change of physical activity as assessed with metabolic equivalents, change of weight, and hormone therapy use. According to the results, peri- or postmenopausal women increased their physical activity (28 %) during the 8-year follow-up period slightly more often than premenopausal (18 %) women. Menopausal status was not significantly correlated with change of QoL. QoL of the most highly educated women was more likely to improve than among the less educated. Women whose physical activity increased or remained stable had higher probability for improved QoL than women whose physical activity decreased. Women whose weight remained stable during follow-up also improved their QoL compared to women who gained weight. Women who had never used hormone therapy had 1.3 greater odds for improved QoL. As conclusion, the study showed that improvement of global QoL is correlated with stable or increased physical activity, stable weight, and high education, but not with change in menopausal status.

Change in global quality of life is more associated with change in physical activity than change in menopausal status [11]. However, women whose physical activity or weight remained the same, physical activity increased or women who were the most highly educated, had improved QoL over time.

Mishra et al. [9] in their longitudinal study with 2 years of follow-up found that certain domains of QoL decline with aging and physical aspects of general health and well-being measured by SF-36 scale declined during the menopausal transition. Women who were perimenopausal for at least a year reported greater decline in their physical health and psychosomatic domains than did premenopausal women [9]. In Smith-DiJulio et al.’s longitudinal study [31], it was found that negative life events predicted decreased well-being in menopausal transition, but factors associated with the menopausal transition did not. They also found that women’s sense of mastery and satisfaction with her life and ability to use available social support predicted increased well-being. These findings suggest also that for most women, the menopausal transition is not a predictor of well-being when considered in a broader life context.

Physical activity has been reported to decrease with age [32], but in Luoto et al.’s study [28], it seems that women in menopausal transition changed their behavior into another direction. Increased motivation for lifestyle modification during menopausal transition could explain this increasing physical activity.