Effects of different physiotherapy modalities on insomnia and depression in perimenopausal, menopausal, and post-menopausal women: a systematic review

Menopause is the time that marks passing 12 months after the last menstruation cycle. It happens in elderly women between 40 and 50 s with a mean age of 51 [1]. Menopause has three phases: perimenopause, menopause, and postmenopause. Perimenopause phase represents the last few years before menopause when women start to have irregular menstrual cycles and hot flashes. Menopause is about experiencing a full year without a monthly menstrual cycle. In this phase, many menopausal symptoms start to show up. Post-menopause phase demonstrates the rest of women’s life after menopause [2].

The transition to menopause can be a challenging time for women, as it is associated with a range of physical and psychological symptoms that affect most of menopausal women. Depression and insomnia are two common symptoms that women experience during the menopausal transition. These symptoms can negatively affect their health, well-being, and daily activities, leading to a decline in their overall quality of life [3].

Depression is a mood disorder that is characterized by feeling of sadness, loss of interest or pleasure, and a range of other emotional and physical symptoms [4]. Depression in menopausal women happens due to fluctuating and declining of estrogen levels in the body. Studies showed that women without a pre-existing depression history are at a high-risk of getting depression during menopause with a 16% prevalence of new-onset depression and/or anxiety [6].

Furthermore, menopause has a negative impact on sleep quality, causing insomnia. Insomnia is a sleep disorder that is characterized by difficulty falling asleep or staying asleep [4]. A survey of over 12,000 women in a study of women’s health across nations (SWAN) reported that nearly 40% of women have a difficulty with sleeping during menopausal transition [6].

Treatment for menopause symptoms includes Hormonal therapy (HT), non-hormonal medications, or non-pharmacologic therapies. While HT can be effective in alleviating menopausal symptoms, its use is associated with several risks, including an increased risk of breast cancer, stroke, and blood clots [5]. HT is only safe and effective for women without any underlying coronary heart disease or history of breast cancer and for those less than 60 years old [7]. That means the risks of HT in some cases may outweigh the benefits, and alternative treatments should be considered.

In contrast, physiotherapy is a non-hormonal and non-pharmacological intervention that has been suggested to be effective in improving both insomnia and depression in menopausal women. Previous studies assured that physiotherapy has an effective role in dealing with menopausal symptoms with no adverse effects on their health. It increases hormones levels such as serotonin and the serum concentration of the brain-derived neurotrophic factor, thus, reducing depression and improving sleep without any change in oxidative stress [8, 9].

The aim of this study is to provide an updated comprehensive review of the existing literature to identify the most recent and effective physiotherapy modalities for the treatment of insomnia and depression in perimenopausal, menopausal, and post-menopausal women. We aim to fill any gaps in the literature and highlight areas for future research. The findings of this study will be useful for clinicians and researchers in developing effective physiotherapy interventions and providing evidence-based recommendations for women experiencing insomnia and depression during the menopausal transition.

A total of 4007 studies were retrieved from the 5 databases: PubMed (n = 1065), Cochrane (n = 2693), ScienceOpen (n = 199), Ovid Embase and MIDRIS (n = 49). We used EndNote [42] to identify and delete duplicates (n = 818), and 3189 studies remained.

According to our inclusion/exclusion criteria, we excluded 3068 papers. After deletion of non-full text studies (n = 71), the full-text papers assessed for eligibility were 50. During the full-text screening, more irrelevant studies of invasive and non-physiotherapy-based modalities or different population or outcomes were excluded. Only 21 studies from the databases and 10 studies from manual search were included, illustrated in PRISMA flowchart [43] (Fig. 1). The included physiotherapy modalities are exercise (n = 9), reflexology (n = 4), walking (n = 4), massage (n = 5), yoga (n = 7), footbath (n = 1), and acupressure (n = 1) with a total number of 2,705 menopausal women in both intervention and control group.

Due to the heterogeneity of the data, all studies were analyzed using qualitative analysis.

The aim of this systematic review was to investigate the effects of various physiotherapy modalities, including exercise, yoga, walking, footbath, reflexology, and massage, on insomnia and depressive symptoms in menopausal women.

In terms of insomnia or sleep quality, our findings revealed a limited number of studies for Pilates system, walking, footbath, aromatherapy, and acupressure [16], [22], [33], [42], [38], [23]. However, reflexology and yoga were found to have a positive impact on insomnia, improving sleep quality and reducing sleep disorders, as supported by 8 studies [11], [14], [24], [25], [27], [29], [31], [37]. Among these modalities, yoga emerged as the most common intervention for menopausal women experiencing insomnia in the included studies.

Regarding mental health, specifically depression and mood swings, we found a varying number of studies for each modality. We identified studies for stretching, strengthening, warming up, and cooling down exercises, walking, and aromatherapy [15], [17], [18], [19], [20], [21], [33], [34], [40] and only two studies each for aerobic exercise and reflexology [11], [15], [26], [39]. Similar to the findings related to insomnia, yoga was the most frequently tested intervention for menopausal women with depressive symptoms in the 5 included studies [27], [28], [29], [30], [31]. However, insufficient evidence was available for the effect of TRX, Pilates, and craniofacial massage [10], [16], [35] on depression or insomnia.

Our review indicated that aerobic exercise and TRX had a significant impact on improving menopausal symptoms, including decreasing mood swings in the intervention group. Furthermore, when combined with nutrition education, aerobic exercise demonstrated a positive effect on enhancing the overall quality of life during menopause. The Pilates system showed promise in reducing depression and anxiety in menopausal women, as suggested by one study. Physical activity programs involving warming-up exercises, stretching, strengthening exercises with an elastic band, and cooling-down exercises were associated with a positive impact on overall quality of life. Additionally, reflexology studies indicated a decrease in hot flashes among women, which in turn contributed to reduced fatigue and decreased depression symptoms. Massage, encompassing therapeutic, placebo, aromatherapy, and craniofacial techniques, demonstrated improvements in menopausal quality of life by reducing anxiety and depression in postmenopausal women. Aromatherapy and placebo massage were found to be particularly effective in reducing irritability, mental exhaustion, anxiety, and depression symptoms in menopausal women. Notably, walking intervention studies indicated that adhering to a daily one-hour walking regimen significantly improved depression symptoms and menopausal symptoms in menopausal and post-menopausal women.

A systematic review conducted by Kalra et al. in 2022 [46], which included 27 studies, assessed the effects of various types of physical activities and exercises (such as resistance training, aerobics, walking, Pilates, and aquatic exercises) on physiological and psychological parameters. Their findings align with ours, as they reported a strong association between these activities and a reduced risk of depression, improved mental health, increased BDNF levels, reduced memory impairment, enhanced quality of life (QOL), improved fitness, and other physiological parameters. Similarly, the results of a study by Nguyen et al. in 2020 [47] demonstrated that yoga significantly improves psychological and physical quality of life scores. Their analysis of other types of exercises also indicated positive effects on overall, social, sexual, vasomotor, and menopause-specific QOL scores in women experiencing menopausal symptoms.

Regarding physiotherapy modalities, our focus is primarily centered on exercise, yoga, walking and general physical activity due to their appropriateness and popularity within Egypt, as compared to other physiotherapy modalities. The results clearly indicate a positive impact of exercise and physical activity on improving mental health, mood swings, depression, and sleep quality, consequently enhancing the overall quality of life. However, it is important to note that while physical activity is a crucial aspect that positively influenced both physical and mental well-being in the participants, there are multiple factors that may have been contributed to improved mental health such as social and private life and thus sleep quality.

The underlying causes of physical and mental health complaints in perimenopausal women are multifactorial, involving a complex interplay between physiological and psychosocial factors. Physiological factors commonly observed include autonomic nervous system dysregulation, including alterations in sympathetic tone and/or parasympathetic inhibition, as well as decreased estrogen levels [17].

A previous review conducted by Sternfeld [11] suggests that exercise has a positive effect on mental health by influencing various biological mechanisms. These mechanisms include increased release of neurotransmitters, heightened parasympathetic activation, and distraction from stressful stimuli. As a result, exercise contributes to better quality of life and can alleviate vasomotor symptoms (VMS) experienced during menopause.

In a study by Takahashi et al. [18], several plausible mechanisms were proposed to explain the impact of exercise on mental health and depression biomarkers. The research found that increased daily physical activity significantly raised the concentrations of brain-derived neurotrophic factor (BDNF) in postmenopausal women. BDNF plays a crucial role in reducing depression symptoms among older adults and is also associated with memory impairment. Therefore, increasing physical activity becomes important not only as a form of exercise but also for elevating BDNF levels and positively affecting mental well-being.

Furthermore, physical activity can help combat depression by boosting serotonin concentration. Aging has been linked to impaired brain serotonin transmission, which can contribute to the development of depressive symptoms. Long-term engagement in physical activity can enhance serotonin levels in the brain, thus improving mental health and reducing the risk of depressive disorders.

Studies have shown that regular exercise training not only improves mental health and depression but also positively impacts oxidative stress status. Physical activity increases antioxidant capacity, which in turn reduces oxidative stress and thus depression [44] as elevated oxidative stress has been associated with the development of depression [45].

Encouraging individuals to track their step count can lead to increased physical activity, particularly moderate to vigorous physical activity (MVPA). This tracking method has proven to be a key factor in promoting and maintaining mental health, reducing depression, and improving health-related quality of life.

Considering the complex nature of menopausal symptoms, it is essential to incorporate regular exercise and physical activity into interventions. The frequency of exercise sessions, with at least three sessions per week, has been shown to positively influence mood changes and psychological symptoms. Another form of exercise, stretching, is particularly beneficial for middle-aged women as it improves muscle flexibility and alleviates somatic symptoms such as joint pain and shoulder stiffness.

In a review conducted by Nguyen et al. [41], several mechanisms were proposed to explain the positive effect of exercise on vasomotor symptoms. These mechanisms include increased vagal tone, the influence of stress hormones and parasympathetic activation, and thermoregulatory center activity. These findings suggest that exercise may effectively improve vasomotor symptoms in menopausal women.

In light of the findings mentioned above, our recommendation is to encourage menopausal women to increase their physical activity levels to improve their overall quality of life. Women whose physical activity levels remained stable or decreased during menopause experienced worse quality of life. Increased endorphin levels resulting from exercise positively influence mental health, and engaging in exercise groups can have a positive impact on social functioning.

Quality of life is closely linked to sleep quality, and menopausal women often suffer from insomnia, which significantly affects their daily lives. The relationship between sleep and depressive symptoms has been well-documented, with difficulty falling asleep being strongly associated with subsequent depression.

Stretching exercises performed before bedtime have been shown to decrease sleep latency and contribute to better sleep quality, thereby positively affecting menopausal and depressive symptoms. Acute stretching also suppresses sympathetic nervous activity and increases parasympathetic activity, promoting better sleep. Daily stretching routines over a 28-day period can yield chronic effects on the autonomic nervous system.

In conclusion, our paper aims to provide practical and cost-effective solutions to improve the quality of life for menopausal women. By incorporating exercise and physical activity into daily routines, women can experience positive effects on mental health.

Regarding the time period and number of sessions per week for exercise interventions, several studies [10], [14], [15], [18] included in this review examined the effect of physical activity on the quality of life (QoL) in women with mood changes or depression. These studies observed that engaging in daily physical activity for at least 12 weeks or three sessions per week for 6 months can have a positive impact on mood changes, depression, and physical health in menopausal women. Additionally, incorporating a stretching routine at least five days per week, particularly before bedtime, may improve sleep quality and have positive effects on menopausal and depressive symptoms (Ngamprasertwong et al., 2017).

The stretching program holds particular benefits for busy women, considering the increasing number of working middle-aged women globally. Women are reported to have a twofold higher risk of depression compared to men, and work-related stress and other environmental factors can exacerbate menopausal and depressive symptoms. Therefore, addressing menopausal and depressive symptoms is crucial for promoting health among middle-aged working women. Despite the mental and physical benefits of exercise, women in menopause often engage in low levels of physical activity due to perceived time constraints. Encouraging adherence to a stretching program is important for working women with limited time availability. Another effective method to promote physical activity among busy middle-aged working women is to incorporate physical activity during work by tracking and aiming to achieve a minimum of 10,000 steps per day. This can contribute to maintaining mental health, reducing depression and anxiety, and improving self-esteem. Employers can also support employees by allowing rest times during work, which can positively impact both mental health and work quality [18] (Takahashi et al., 2019).

Furthermore, women who perform domestic housekeeping activities such as cleaning, cooking, and laundry engage in daily physical activity. These activities can be classified as low physical activity (LPA) or moderate to vigorous physical activity (MVPA) based on the nature of the tasks. Both LPA and MVPA have been found to have a positive effect on depression, with MVPA being significantly associated with reduced anxiety symptoms [18] (Takahashi et al., 2019).

Incorporating nutrition education along with a 12-week program of moderate-intensity aerobic exercises has shown additional benefits in improving early menopausal symptoms and QoL. This combination has been found to reduce hot flashes, develop a positive attitude toward exercise, and enhance the overall well-being of women aged 40–60 years (Huang et al., 2011; Su et al., 2014).

Moreover, inactive women aged 40–62 who participated in a 12-week yoga program experienced improvements in their quality of life, including reduced hot flushes, better sleep quality, and fewer depressive symptoms. This intervention may be particularly suitable for women with a high socioeconomic status (Orr et al., 2010).

These findings highlight the importance of exercise, stretching, and physical activity in improving the QoL and overall well-being of menopausal women, providing various options that can be tailored to individual preferences and time constraints. By incorporating these interventions into daily routines, women can experience positive effects on their mental and physical health, leading to a better quality of life.

For menopausal women who have time during the day, engaging in physical activities such as walking, aerobic exercises, and line dancing (12 weeks of physical activity or three sessions per week for 6 months) along with regular stretching before bedtime, combined with a program of nutrition education, can significantly improve sleep quality and depressive symptoms. However, for women with limited time or work commitments, focusing on stretching before bedtime alone can still be beneficial compared to a 12-week exercise program. Additionally, increasing physical activity during work or daily housekeeping tasks, such as cumulative logging of step count and aiming for at least 10,000 steps per day, as well as engaging in activities like cleaning and cooking, can contribute to improving menopausal symptoms and overall quality of life. These strategies are particularly relevant for women with insufficient time or demanding work schedules.

It is important to note that physical activity can be of moderate-to-vigorous intensity or light intensity, both of which can alleviate depressive symptoms [17]. Therefore, women can choose the intensity level that suits their preferences and circumstances, with a reminder that engaging in moderate-to-vigorous physical activity or a combination of intensities may yield greater benefits compared to light intensity alone.

Overall, these steps aim to improve the overall physical and mental well-being, enhance the quality of life, and promote a positive attitude toward menopausal symptoms among women in the menopausal age group. Implementing these strategies for a minimum of 12 weeks can initiate long-term lifestyle changes [14], [15]. Furthermore, these approaches offer time and cost-saving advantages, making them suitable for individuals in low and moderate socioeconomic areas. By providing education and promoting positive attitudes, individuals can experience a reduction in menopausal symptoms. Increasing knowledge levels about menopause is associated with decreased symptom frequency, while maintaining a positive attitude helps mitigate the impact of menopausal symptoms [14].

Physiotherapy is a safe, non-invasive non-pharmacological intervention for improving sleep quality and depression during menopause. Exercise including aerobic exercise, stretching, strengthening, warming up, and cooling down exercises, yoga, walking, reflexology, and massage may reduce insomnia and depression in perimenopausal, menopausal, and post-menopausal women. Moreover, adding aromatherapy to the therapeutic massage found to be more effective than massage without aromatherapy.

However, more evidence is needed regarding the effects of Pilates, footbath, craniofacial massage, acupressure, and adding nutrition education to exercise on sleep quality and depression. There are also insufficient findings on the effects of walking on reducing insomnia. Thus, we recommend conducting more studies to support the findings of these modalities’ impact on sleep and depression in menopausal women.