Menopause and-physical-therapy-role-for-its-related-disorders (1)

MOHAMED GAMALABOUELYAZEED
ASSISTANT LECTURER OF PHYSICAL
THERAPY FOR WOMEN’S HEALTH
SOUTH VALLEY UNIVERSITY

Menopause
and
Physical Therapy
for Its Related
Disorders

*Menopause is the time at which a woman permanently stops
menstruating, usually between 45 and 55 years of age, and is diagnosed
after 12 months of amenorrhea in the absence of any other
pathological or physiological causes.
*Menopause occurs due to depletion
of the ovarian primordial follicles due to
their consumption since menarche.
*Climacteric is the phase of aging process during which a woman
passes from the reproductive stage to the non-reproductive stage.
*Perimenopause refers to the part of climacteric before
menopause (2-8 years prior to the final menstrual period) in which
there is a transition from normal ovulatory cycles to the permanent
amenorrhea of menopause, It is also known as Menopausal transition.

*Perimenopause physiological changes:
-Irregular menstrual cycles with
some of the symptoms associated
with the menopause as: hot flushes,
night sweats and mood swings.
-During this period, inhibin-B
secretion from granulosa cells falls
due to diminished follicular number
and as a result FSH levels rise and
progesterone levels become low.
-Ovarian estradiol secretion is preserved until late perimenopause.

Classification of menopause
1)Natural menopause: occurs due to intrinsic ovarian failure that
usually occurs between 45-55 years with a median age of 51 years in
non-smokers and 49 years in smokers. It is characterized by complete
or near complete ovarian follicular depletion, with subsequent
cessation of ovarian estradiol secretion
- Late menopause: menopause occurring after 55 years
- Premature menopause: menopause occurring between 40-45 years
2)Induced menopause: menopause can be artificially induced
-Surgically: as after bilateral oophorectomy
-Ablation of ovarian function: as pelvic irradiation or chemotherapy
-Medically: as in long acting GnRH agonist medications

*Premature menopause: occurring at 40-45years and it may be:
-Premature ovarian insufficiency: due to congenitally deficient
number of ovarian follicles at puberty, leading to their early
exhaustion at a relatively young age.
-Idiopathic: no underlying etiology
-Gonadal dysgenesis: as in mosaic turner syndrome
-Induced: due to some surgeries, irradiation and chemotherapy
before age of 40-45 years.

Endocrinal changes characteristic of
menopause
-Decreased serum inhibin-B levels that started at perimenopause.
-Marked & persistent decrease in levels
of ovarian estradiol and progesterone.
-Marked increase in serum LH and
FSH levels as a result of increased
GnRH levels due to loss of negative
feedback.
-Decrease in levels of sex hormone binding globulin (SHBG).
-Increased free testosterone levels.
-Persistent production of ovarian testosterone.

Changes in body systems associated with
menopause
*Changes start at climacteric period and continue gradually and
persistently after cessation of menstruation and they are almost related
to estrogen deficiency. These changes may be:
-Vagina: becomes smaller, thinner, increased vaginal PH, decreased
vascularity and gradual loss of its rugae
-Cervix: becomes gradually flushed with vaginal fornices
-Endometrium: becomes thin and atrophic
-Uterus: becomes smaller in size and if fibroids are present they
undergo atrophy
-Pelvic ligaments: become weaker predisposing to pelvic organ
prolapse
-Pelvic floor muscles: become weaker and less elastic

-Bladder and Urethra: show loss of elasticity and stress urinary
incontinence
- Breast: becomes smaller and progressive fatty replacement and
atrophy of active glandular element
-Skin: gradual decrease in thickness and its collagen content
-Androgenic symptoms: increased facial hair and androgenic alopecia
-Gradual changes in cognitive functions
and mood swings
-Decreased bone mineral density that
leads to osteopenia or osteoporosis
*Diagnosis of menopause:
1-Amenorrhea for 1year after LMP.
2-Elevated FSH levels > 30 mIU/ml.
3-Low estradiol levels < 25 mIU/ml.
4-Menopausal symptoms as : hot flushes, cold sweats, insomnia,
weight gain and irritability.

Clinical features of menopause:
1)Vasomotor symptoms:
Hot flushes and cold sweating:
*Recurrent waves of heat over the neck, face and chest followed by
cold sweating.
*A flush may last from 1 to 5 min. and may be associated with
palpitation, dizziness or headaches.
*Flushes affect at least 50% of menopausal women but with variable
grades of severity.
*Flushes start in the perimenopause and become more aggressive in
the menopause.
*Suggestive cause of flushes may be inappropriate stimulation of
the thermoregulatory centers in the hypothalamus with
vasodilatation of the skin over the head, neck and chest causing a
skin temperature rise although core temperature does not change.

2)Nervous and psychological symptoms:
*Anxiety, irritability, insomnia, mood swings and lack of
concentration are common with variable grades of severity.
3)Gastrointestinal symptoms:
*Constipation, abdominal distension and tendency of weight gain.
4)Urinary symptoms:
*Frequency, dysuria and stress urinary incontinence may occur
alone or in association with pelvic relaxation and genital prolapse.
5)Dyspareunia:
*Due to vaginal atrophy, dryness and senile vaginitis.
6)Tendency towards pelvic organ prolapse:
*Uterine and vaginal prolapse are more common due to atrophy and
weakness of pelvic and cervical ligaments.

7)Androgenic symptoms:
*Increased facial hair and male pattern baldness with variable
degrees.
8)Remote health hazards related to menopause:
-Cardiovascular changes:
*Increased risk of ischemic coronary heart disease (ICHD),
myocardial infarction (MI), atherosclerosis, hypertension (HTN)
and cerebrovascular strokes due to estrogen deficiency as estrogen is
very essential for maintaining good cardiovascular health and its
marked decrease plays a role in hypercholesterolemia with increased
LDL and reduced HDL.
-Bone mineral density changes:
*estrogen deficiency results in accelerated bone mineral calcium loss
and increased osteoclastic activity (Bone destroying cells) as estrogen
beside calcitonin and parathyroid hormones are critical for bone
hemostasis.

*Clinical manifestations of bone mineral density changes: Bone
demineralization is usually a silent disease that manifests years after
menopause with :
-Decreased height
-Increased curvature of
the spine (Kyphosis)
-Silent fractures of
vertebrae (wedge fractures)
, femoral neck, distal radius
and calcaneus bone on
exposure to mild trauma.

*Risk factors of osteoporosis after menopause:
-Premature menopause, inappropriate nutrition, low body weight,
heavy smoking, lack of exercise together with genetic factors.
*Diagnosis of osteoporosis after menopause:
- Dual energy x-ray absorptiometry
(DEXA) to estimate bone mineral
density to detect the early signs of
osteoporosis.
*Findings:
-T-score of -1.0 or above is
normal bone density.
-T-score from -1.0 to -2.5
means the patient has low bone density or osteopenia.
-T-score of -2.5 or below is a diagnosis of osteoporosis.
*DEXA should be confirmed by other tests to diagnose
osteoporosis in postmenopausal women.

*Prevention of osteoporosis after menopause:
-Balanced diet with rich calcium intake of 1500 mg. daily.
-Vitamin D 600-800 IU/day.
-Healthy life style: weight bearing exercises, stop smoking, indirect
exposure to sunlight and avoid long term corticosteroid therapy.
-Physical therapy modalities such as: PEMFT.
*PEMF may be useful in the prevention of osteoporosis resulting from
ovariectomy and that PGE2 might relate to these preventive effects
(Chang K and Chang W, 2003).
*Treatment of osteoporosis:
(A)Drugs that slow bone breakdown:
-Biphosphonates: orally once per week, decrease non-vertebral
fractures.
-Calcitonin: nasal spray, decrease vertebral fractures.

(B)Drugs that stimulate bone formation:
-Teriparatide: IM injections over a period up to 18-24 months, it
decreases non-vertebral and vertebral fractures.
(C)Hormonal Replacement Therapy:
-Hormonal Therapy: is rarely used as a
primary therapy except in cases need to
control postmenopausal hot flushes or in
cases of premature menopause because of its risk in endometrial and
breast cancer however, it is effective in prevention and treatment of
osteoporosis
-Selective estrogen receptor modulators: has a combined estrogen
effect on bone and anti-estrogen effect on breast and uterus. It is
approved for prevention of osteoporosis but may induce hot flushes.
-Phytoestrogens: plant substitutes that have a weak estrogen action.

Physical Therapy for Menopausal Disorders
1)Postural problems (Kyphosis)
2)Osteoporosis
3)Pelvic floor dysfunction
4)Metabolic disorders as (obesity)
5)Cardiovascular symptoms (HTN)
6)Postmenopausal depression
7)Hot flushes
8)Balance disturbance

1)Postural problems (Kyphosis):
*There is a lack of efficacious medical interventions for hyperkyphosis.
Physical therapy should be a first-line approach, particularly because
many of the causes of hyperkyphosis are of musculoskeletal origin.
Recognition and treatment of hyperkyphosis could contribute to
reduced risk of falls, fractures and functional
limitations.
A-Therapeutic exercises:
*The relative risk for compression fracture was 2.7 times greater in
the control group than in the back exercises group after 1 year of
intervention and even after 2 years and 10 years of follow up there
was significant reduction of risk of vertebral fractures. To our
knowledge, this is the first study reported in the literature demonstrating
the long-term effect of strong back muscles on the reduction of
vertebral fractures in estrogen-deficient women (Sinaki et al., 2002).

*Application of kinesiotaping may have short-term positive effects
on pain, but is unlikely to have significant effects on kyphosis angle
or balance in patients with postmenopausal osteoporosis-associated
thoracic kyphosis. Positive changes seen in kyphosis angle and
balance 30 min after taping are short-lived (Bulut et al., 2019).
B-Kinesiotaping:
*The exercise methods consisted of 4 sub-exercises including 5
minutes of breathing correction, 15 minutes of thorax mobility, 20
minutes of thorax stability, and 10 minutes of thorax alignment
reorganization exercise twice a week for 8 weeks developed in the
present study can be recommended for improving the mobility of
the rib cage and postures through specialized exercises focused on
thorax posture correction in elderly women with hyperkyphosis
(Jang et al., 2015).

*Three months of rehabilitation with manual
mobilization (18 sessions including gentle manual
mobilization, taping and exercises) can attenuate
thoracic kyphosis in elderly postmenopausal
patients with osteoporosis (Bautmans et al., 2010).
D-Bracing:
*Applying weighted kypho-orthosis (WKO) with
a harness and a 2-pound pouch, which centers its
weight on the posterior of the spine at T10 to L4
together with back extensor strengthening
exercises in postmenopausal women with
osteoporosis leads to improvement in functional balance test which
can be translated to decreased risk of fall-in real life in this
population (Raeissadat et al., 2014).
C-Mobilization techniques:

2)Postmenopausal osteoporosis:
*There are two phases of bone loss in women:
-The first phase occurs predominantly in
trabecular bone and starting at menopause.
It results from estrogen deficiency, and leads to a disproportionate
increase in bone resorption as compared with formation. This phase
could be defined as menopause related bone loss.
-After 4–8 years, the second phase exhibits a persistent, slower loss of
both trabecular and cortical
bone, and is mainly attributed
to reduced bone formation.
This is age related bone loss,
which is the only phase that
also happens in men.

*Exercise training, especially resistance exercise (RE) is
important for the maintenance of musculoskeletal health
in an aging society. Resistance exercises exerts a
mechanical load on bones consequently leading to increase
in the bone strength. Based on the available information, RE, either
alone or in combination with other interventions, may be the most
optimal strategy to improve the muscle and bone mass in
postmenopausal women (Hong and Kim, 2018).
-Strength training determines an increase in specific site bone density,
in particular at the neck of the femur and at the lumbar spine, which is
maintained in the short to medium term. At least 3 sessions a week for a
year are recommended.
-Progressive resistance training for the lower limbs is the most
effective type of exercise intervention on bone mineral density (BMD)
for the neck of femur (Benedetti et al., 2018).
A-Resistance exercises:

*Clinicians can safely recommend moderate intensity
aerobic exercises alone or in combination with
strengthening exercises to their premenopausal or perimenopausal
clients in efforts to offset the anticipated excess bone losses and
osteoporotic- related hip fractures and others commonly
experienced by postmenopausal women (Marks, 2012).
*Four hundred post‐menopausal women were randomized
to either 150 min/wk (MODERATE dose group) or 300 min/wk
(HIGH dose group) of aerobic exercise (eg, running, walking, and
cycling) 5 d/wk reaching 65%‐75% of heart rate for a 12‐month
intervention and 1 year follow up and findings suggest that
post‐menopausal women could delay some of the loss in total bone
mineral density by performing a greater volume of aerobic exercise,
especially if this exercise has a weight‐bearing component with high
dose women gained significant improvement in BMD than
moderate dose women after12 and 24 months (Encabo et al., 2019).
B-Weight bearing aerobic exercises:

*Our results suggested that a course of PEMFs treatment with
specific parameters (field frequency of 8 Hz, intensity of magnetism
of 3.82 mT and 40 min/treatment, 1 treatment session/day, 6
treatment sessions/week) was as effective as vitamin D supplements
in treating postmenopausal osteoporosis within 6 months (Liu et
al., 2015).
*In this systematic review, a number of
recent reports suggest that PEMFs have
a positive impact on the balances between osteoblast and osteoclast
activity as well as the balance between osteogenic differentiation
and adipogenic differentiation of bone marrow mesenchymal stem
cells which plays an important role in the process of osteoporosis
(Wang et al., 2016).
C-Pulsed electromagnetic field therapy:

*Low frequency pulsed electromagnetic field therapy (LFPEMFT)
and low level laser therapy (LLLT) are useful therapeutic
procedures to increase BMD in osteoporotic elderly. Furthermore,
LFPEMFT with a very low frequency of 33 Hz and a very low
intensity of 40 Gauss, with the rectangular waveform and for
30 min/session, 3 sessions/week for 3 months. is more effective
than LLLT in increasing BMD in the elderly with primary
osteoporosis (Abdelaal et al., 2017).

*LIPUS could partially attenuate the decrease in bone mass and
deterioration of bone microarchitecture caused by estrogen
deficiency by accelerating bone formation and suppressing bone
resorption. This suggests that pulsed ultrasound low intensity (150
mW/cm2 = 0.15 W/cm2 ), 1.5 MHZ, 20% duty cycle and duration
of 20 min. 6 days per week for 6 weeks may be more effective than
lower intensity (0.015W/cm2) in mitigation of osteopenia and
osteoporosis in ovariectomized rats (Sun et al., 2020).
D-Low intensity pulsed ultrasound :
*low intensity pulsed ultrasound is
effective modalities in increasing bone
mineral density (BMD) of lumbar
vertebrae in osteoporotic postmenopausal
women (Ali et al., 2019).

*The use of LLLT (GaAlAs) of 1000 HZ,
5 watts for 30 seconds with a total dose
15 m joule/cm2 and was performed
5 times a week for 8 weeks was found to
be effective in enhancing bone formation,
Decreasing bone resorption in the osteoporotic ovariectomized
rats. Bone morphological results revealed increase in calcium
deposition and alkaline phosphatase of femoral bones of LLLT
exposed group in comparison to sham-operated and OVX rats. Using
software image analysis showed increased osteoblast numbers,
decreased osteoclast numbers and increased compact bone
thickness in LLLT exposed group. Significant positive correlations
were obtained between osteoblast numbers and serum Ca, Pi, ALP,
and osteocalcin in LLLT group (Saad et al., 2009).
E-Laser Therapy :

*Laser for 6 weeks is an effective method can be used for management
of osteoporosis to improve bone mineral density in postmenopausal
women, with recommendation from this study to use HILT than LLLT
(Ali et al., 2011).
-High Intensity Laser Therapy (HILT) was introduces to the field of
physical therapy is relatively recent and this technology is in constant
evolution and approved by FDA in 2004.
-HILT was delivered in two different
phases, initial phase and terminal phase.
-Initial phase: three sub-phases of fast manual scan (every10 cm
scanned in about 1.5 second) was performed to lumbar region with
increasing fluences (710 -910 -1530 mJ/cm2 ) and decreasing
frequencies (30-20-15 Hz) with total energy of 2000 joules.
-Terminal phase: is the same but with slow scan.

*low-level laser therapy can activate osteoblasts, promote bone
repair, enhance the bone structure of peri-menopausal rat models,
and increase bone density, which can be used as an effective
intervention for osteoporosis in middle-aged and elderly women (Li
et al., 2018).
-LLLT was irradiated to the lumbar vertebrae
(L1-5) using the lasers used for treatment was
continuous red (He-Ne Laser with wavelength
of 632.8 nm and power 12 mW) and
Pulsed IR (Ga-Al-As Laser with wavelength
904 nm and power 25 mW)
and Beam Diameter 1.5 mm.
The delivery technique for this group was
automatic scanning with energy density of 4 J/cm2.

F-Extracorporeal Shockwave Therapy (ESWT) :
-ESWT will enhance the expression of growth factors.
-ESWT can activate the mesenchymal stem cells, promoting their
differentiation towards osteoblasts.
-ESWT is also involved in neovascularization.
-ESWT with appropriate energy will lead to
the consequences of improved bone
micro-architecture and mechanical properties.
*This study shows that bone microarchitecture can be affected by
radial (unfocused) shock waves, and indicates that unfocused
ESWT might be useful for the treatment of osteopenia and
osteoporosis (Jagt et al., 2009) .

*This study showed that single session of ESWT is a quick and
efficient noninvasive technique for the local BMD improvement in
postmenopausal women; high dosage of ESWT (0.28 mJ/mm2,
4 Hz, total 4000 impulses) 500 shots for every site in 8 points on
the femoral neck and greater tuberosity is rather effective than
low dosage of ESWT (0.15 mJ/mm2, 3 Hz, total 4000 impulses) .
Therefore, this physical therapy can be used to reduce the risk of
osteoporotic fractures (Shi et al., 2017).

G-Whole Body Vibration (WBV):
-According to the piezoelectric theory, pressure induces
bone formation in the electrical potential difference,
which acts as a stimulant of the process of bone formation.
A stronger stimulator of osteogenesis is the effort
performed in the upright position than in the horizontal,
which explains the good effects of the vibration therapy.
Whole-body vibration increases the level of growth
hormone in serum, preventing osteopenia and osteoporosis.
*This meta-analysis, 10 randomized controlled trials demonstrated that
WBV with frequency 20-50 HZ for 12-52 weeks is a safe potential
nonpharmacological intervention for improving bone mass in
postmenopausal and older women, particularly on lumbar spine,
which was shown the most sensitive area. In addition, significant
differences were found between intervention and control groups in BMD
of the femoral neck in postmenopausal women younger than 65 years
(Marín-Cascales et al., 2018) .

3)Postmenopausal pelvic floor dysfunctions:
*There is clear evidence of the
presence of estradiol receptors
(ERs) in the female lower
urinary and genital tract.
Furthermore, it is a fact that
estrogen deficiency after
menopause may cause
atrophic changes of the urogenital tract as well as various urinary
symptoms.
*Based on this study, there were similar positive results for
treatment with the vaginal cone and pelvic floor muscle training for
urinary leakage, pelvic floor muscle pressure and quality of life
for postmenopausal women with stress urinary incontinence after
6 weeks (Pereira et al., 2011).

*In a study published in APTA in 2016: 24 Canadian postmenopausal
women underwent 12 PT sessions over 3 months. The sessions
included education on UI, pelvic floor muscle retraining using
electromyography biofeedback, motor control exercises, functional
pelvic floor muscle exercises, bladder habit retraining, dietary
recommendations, and audio recordings for use at home and after 3
months, the women who had completed physical therapy experienced
75% fewer leakage episodes compared with baseline, and had
significantly improved scores, and at 1 year, the physical therapy group
maintained their previous improvement in leakage episodes and had
significantly better results on the 24-hour pad test and the UDI.

4)Postmenopausal obesity:
-In fact, it is well known that obesity and metabolic syndrome are
found in women in this period of their life (Menopause) three times
more often than before menopause (Kwaśniewska et al., 2012).
-Estrogens in women are responsible for the accumulation of fat in
the subcutaneous tissue, particularly in the gluteal and femoral
regions while androgens promote the accumulation of abdominal fat.
Hence, the development of obesity with metabolically unfavorable fat
redistribution from gynoid to abdominal
location observed during menopause is
caused by the relative hyperandrogenemia.
-Moreover, activity of ghrelin – the strongest orexigenic peptide,
derived mainly from the stomach, but also produced locally in the
hypothalamus – is reduced by estrogens (Dafopoulos et al., 2010)
and estrogens are involved in central regulation of energy balance,
and act on the CNS to reduce appetite.

*A 1-year aerobic exercise (intervention included
45 min of moderate-to-vigorous aerobic exercise
(warm up for 5 min, cool down for 5–10 min and stretch.
The prescription ramped up over the first 3 months starting with
three weekly sessions of 15–20 min at 50–60% of the heart rate
reserve then at 70–80% of the heart rate reserve five times per
week consistent with current public health guidelines resulted in
reduced adiposity levelsin previously sedentary postmenopausal
women at higher risk of breast cancer (Friedenreich et al., 2011).
A-Aerobic exercises:
*Cavitation ultrasound therapy of
30-35 KHz, 70-80 % of maximum power 3 W/cm2 for 20-30 min.
twice times per week for three months is an additional useful
physical therapy method in reducing of visceral adiposity in
perimenopausal obese women (Sabbour et al., 2009).
B-Cavitation Ultrasound:

C-Cryolipolysis and Electrolipolysis:
*From the results of this study it can be concluded that Cryolipolysis
(3 sessions, once every 4 weeks, for 3 months)
on the abdomen which is divided into 3 segments
every segment take 60 min. and temperature
gradually lowered until it gets to a predetermined
temperature of about –7 or –8 degrees Celsius,
thereby slowly freezing the fat cells causing
cold ischemic injury of the targeted adipocytes
that induce apoptosis of these cells and a
Pronounced inflammatory response, resulting in
their eventual removal within the following weeks
and Electrolipolysis (24 sessions, twice per week, for 3 months) are
effective in reducing abdominal adiposity in post-menopausal
women (Mohamed et al., 2018).

5)Postmenopausal Hypertension:
-In women after natural or surgical
menopause, estrogen levels decrease
gradually or drop suddenly.
-The menopause status in women can
increase the risk of cardiovascular disease and metabolic
disturbances. Especially, cardiovascular risks are more prevalent
and highly influenced in those undergoing surgical menopause.
-Cross-sectional data show a fourfold increase in the incidence of
hypertension occurring in postmenopausal women compared to in
premenopausal women.
-These increased levels of NO after exercise training may enhance
endothelial-dependent dilation, improve arterial stiffness, reduce
vascular resistance, and decrease vascular tone in peripheral arteries
and consequently may contribute to reductions in BP.

*Overall, the studies reviewed here in support the therapeutic concept
to promote physical activity and to achieve physical fitness, and the
essential conclusion is that moderate (50-60% of MHR) aerobic
exercise (as walking or swimming) for 60 min., 3-5 times/week and
for 2-3 months may be superior for eliciting cardiovascular benefits
in hypertensive postmenopausal women (Lin and Lee, 2018).
*WBV exercise training with frequency 25-35 HZ
for 12 weeks improves systemic and leg arterial
stiffness, BP, and leg muscle strength in postmenopausal women
with prehypertension or hypertension (Figueroa et al., 2014).
B-Whole Body Vibration (WBV):

C-Acupuncture:
*The study findings may help develop
evidence for the effectiveness and safety of
acupuncture at 8 points (bilateral GB20,
LI11, ST36, SP6 - 30min./session , 2-3
sessions/week and for 4-8 weeks) for diastolic
blood pressure control in postmenopausal
women (Kim et al., 2014).
-Acupuncture reduce renin, aldosterone and norepinephrine
while improve production of beta endorphins and enkephalins.
-In several studies, acupuncture showed a BP-lowering effect in men
and women in the prehypertension and hypertension stages (Du et al.,
2017) , (Liu et al., 2015) , (Li et al., 2014).
-The use of acupuncture in combination with
pharmacological therapy is effective in decreasing arterial BP in
patients with prehypertension or hypertension (Cevik and Iseri, 2013).

6)Postmenopausal depression:
-some studies suggesting postmenopausal depression
an estimate as high as 45%.
-Estradiol affects levels of serotonin, which involved in depression.
-Depression post menopause is likely due to fluctuating and
declining estrogen levels and psychosocial stressors so, regulation
of serotonin, dopamine and norepinephrine may change as
estrogen levels fluctuate leading to depression.
-Some evidence suggests that exercise positively
affects the level of certain mood through enhancing
neurotransmitters in the brain such as endorphins, release tension in
the muscles, help better sleep and reduce levels of cortisol (the stress
hormone) (Schmdit et al., 2000) and physical activity also stimulates
the release of dopamine, oxytocin, norepinephrine and serotonin.

*The results of present study demonstrated that regular aerobic
exercise training program including walking three times a week, for
3 months, decrease depression symptom in postmenopausal women
(Aghamohammadi et al., 2013).
*Regular physical activity (walking on a treadmill) started for 30
minutes at 60-70% of target heart rate (THR) for 4 weeks 3
times/week, after that the exercise was increased till 40 minutes for
the next 4 weeks appears to be an alternative method to decrease
depression and insomnia that occur during postmenopausal period
(Emara et al., 2013).
*A meta analysis for 16 quantitative studies confirmed that
acupuncture for perimenopausal depression is safe and effective.
Moreover, it has more stable long-term effects than antidepressants and
hormone replacement therapy (HRT). We recommend acupuncture as a
clinical treatment of perimenopausal depression (xiao et al., 2020).
B-Acupuncture:

7)Postmenopausal hot flushes:
A-Lifestyle changes:
1- Environmental manipulations to keep body
Temperature as cool as may reduce hot flushes
2-Behavioral changes :
*Regular sustained aerobic exercises (swimming or running)
*Avoid hot flushes triggers as:
smoking, caffeine, alcohol, high temperature and stress
*Weight reduction
*Paced respiration (slow and deep) during episodes of hot flushes
B-Aerobic exercises:
*Eight week program of an aerobic exercises with 3 times per week
at 60–70% HR max yields improvement in FSH, LH, and decrease
in severity of hot flushes assessed by hot flush dairy card than laser
acupuncture in the treatment of postmenopausal hot flashes
(Elhosary et al., 2018).

*The standardised and brief acupuncture treatment on acupuncture
points CV-3, CV-4, LR-8, SP-6 and SP-9 with single session per
week for 5 weeks produced a fast and clinically relevant reduction
in moderate-to-severe menopausal symptoms as hot flushes during
the intervention (Lund et al., 2019) .
*Acupuncture significantly reduced the severity of nocturnal hot
flashes compared with placebo. Given the strength of correlations
between improvements in sleep and reductions in nocturnal hot
flashes (Huang et al., 2006).
D-Acupuncture:
*A 15-week resistance-training program three times/week contained
exercises: chest press, leg press, seated row, leg curl, latissimus dorsi
pull-down, leg extension, crunches and back extensions
decreased frequency of moderate and severe hot flushes among
postmenopausal women it is effective and safe treatment
option to alleviate vasomotor symptoms (Berin et al., 2019).
C-Resistance exercises:

8)Postmenopausal disturbed balance:
-Postmenopausal women may have postural changes such as:
forward head, rounded shoulders, increased kyphosis,
decreased lumbar lordosis and flexed hips and knees.
-These changes may be due to loss of elasticity in
connective tissues, diminished ability to counteract gravitational
forces and decline of muscles strength as well as, endurance.
-All of these postural changes affect daily living activities, balance
and gait, hence; increase the risk of falling.
-Low estrogen may be involved in the microcirculatory disturbance
of the inner ear, affecting the occurrence and development of
meniere’s disease (Jian et al., 2018) and hormonal fluctuation in
menopause may increase the tendency to develop benign
paroxysmal positional vertigo (Ogun et al., 2014).

*In this mini review of 25 studies among older adults and
postmenopausal women , Balance and coordination exercise
programs have been found to improve both static and dynamic
stability, as well as a number of aspects in the quality of life.
Recently, they have also been found to improve cognitive functions
such as memory and spatial cognition (Dunsky, 2019).
*It could be concluded that balance
training using Biodex Balance
System, 3 sessions/week for 6 weeks
is an effective, safe and easy to
perform modality that can be used for
improving postural balance and
decrease the risk of falling in obese
postmenopausal women
(El-Mekawy et al., 2007).
A-Balance and coordination exercises:

-Epley maneuver:
1- The patient started in the long sitting with
the head rotated45 degrees to affected side.
2- The patient next rapidly reclined to the
supine position with the neck slightly extended. This position was
held for 30 seconds, or until nystagmus and dizziness subside.
3- The patient's head was rotated 90 degrees to the opposite side.
held for 20 seconds, or until nystagmus and dizziness subside.
4- The patient's head was turned another 90 degrees, requiring the
patient to go from the supine to side-lying position. This position was
held for 20 seconds, or until dizziness and nystagmus subside.
5- The patient was brought up to the short sitting position.
*Epley and semont maneuvers can be applied
to control symptoms of Benign Paroxysmal
Positional Vertigo in postmenopausal women
with a significant reduction in favor to Epley
maneuver group (Abdelatif and Yehia, 2017) .
B- Vestibular rehabilitation:

*we conclude that elderly
patients with high risk of falling
as in postmenopausal women
should begin vestibular
rehabilitation in this study the
design was (1session daily,
five/ week for 2weeks CDP,
1session daily, five/ week for
2weeks Optokinetic and 2weeks
home exercises)
as soon as possible in order to
avoid the potential harm of
falls, mainly injuries and
psychological consequences due
to fear of falling again
(Izquierdo et al., 2017).
*Computerized dynamic posturography & Optokinetic technology:

Menopause and-physical-therapy-role-for-its-related-disorders (1)

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