Yoga and Menopause

First published in What Doctor's Don't Tell You Magazine.

The menopause is a natural transition in a woman’s life cycle. It is not an illness, but a passing into a new phase, where we drop away from the more frenzied activity of earlier years and into a more relaxed approach. Hormone fluctuations and resultant symptoms accompany each female biological life stage and changes are felt on all levels; physically, emotional and spiritually as we take stock and prepare to move on.

Menopause follows puberty and childbirth - each is a phase where moving inwards to reflect can help us understand ourselves and make adjustments. Yoga is a system that asks us to be present and meet whatever is arising with kindness and curiosity. At a time where we may have a confused relationship with our bodies, yoga can help us move with, rather than against natural physical tides.

How our changing biology feels

Menopause is defined as the time when monthly periods have stopped for more than 12 consecutive months. Changes in hormonal levels and menstrual patterns begin about 6 years prior to the menopause and is called the perimenopause.  Symptoms may begin to appear during this time, including irregular menstrual patterns, hot flushes, night sweats, mood swings, vaginal dryness, reduced libido and sleeplessness.  A decrease in oestrogen is also associated with a loss of skin elasticity and skin dryness, including vaginal dryness. Symptoms often continue up to a year or more after a woman’s last period.

Before perimenopause begins, the menstrual cycle is governed by the hypothalamus, the ‘control centre’ for many bodily functions (including appetite and temperature) at the base of the brain. It tells the pituitary gland to produce many hormones, including those for reproduction from the ovaries. In perimenopause, the pituitary gland senses lowering oestrogen and progesterone in the ovaries and signals them to raise production. So there is a kind of hormonal tug-of-war resulting in (often wildly) fluctuating hormones. Many symptoms result from spikes of stimulating oestrogen to waves of slowing progesterone, which can affect sleep, mood and memory too.

The average age for the menopause in the UK is 51.  Post-menopause is defined as the time when ovulation no longer occurs and so a woman is no longer able to conceive, signifying a new female life phase where her body is adjusting to living with new (and normal) lowered hormone levels.

After the menopause the ovaries no longer produce progesterone and oestrogen levels dramatically decrease.  After a few years, oestrogen release from the ovaries stops completely. We still have oestrogen stores in fat cells and particularly in ‘female areas’ like bottom and thighs, which is why entering the menopause a little overweight can be healthier than underweight. Yoga can help us celebrate our own body shape and form as it is. Creating strength and flexibility can nurture an embodied mind and acceptance of a changing shape.

As well as its role in the menstrual cycle, oestrogen plays other roles in the body. It is important for the formation of new bone, which is why yoga’s weight-bearing effects play a key protective role in the post-menopause years.

Stress and the menopause

Reducing chronic stress and therefore levels of the stress hormone cortisol is a key consideration as post-menopausally, some oestrogen can still be produced in fat cells by conversion of testosterone from the adrenal glands. In cases of long-term stress and adrenal fatigue, this source of oestrogen may be affected. Protection of adrenal health is also supportive of the thyroid gland – lowered function is common around menopausal time and symptoms are similar. Yoga has a sound body of research to show stress and anxiety reduction, so can help address root causes to symptoms, but also long-term health through hormone support (Health Psychology Review, 2015; 15:1-18).

Protecting the Female Heart

After the menopause women are as at much risk of heart disease as men.  Oestrogen also contributes to lowered LDL (‘bad’) cholesterol, arterial and heart health, so dropping levels create higher risk factors.  Oestrogen also helps to keep skin supple and hair thick.  Many of the poses in the sequence here are inversions and forward bends, where the heart gets to rest and circulation is encouraged. Full breathing, with an emphasis on the relaxing out-breath also slows heart rate, increases oxygenation and encourages circulation out to the skin and follicles.

A focus on the heart is not just physical. Many women coming into the menopause bring years of looking after others over themselves; through children, family and care of others. The symptoms and lowered energy of this time can force a re-evaluation and show the need for self-care in the face of what is often referred to as ‘compassion fatigue’. An embodied and mindful practice can help foster the loving-kindness to self that allows us to continue to care for others.

Research on Yoga and the Menopause

Research reviews for yoga and menopausal symptoms remain inconclusive, with most promising results seen in supporting the psychological issues (depression, mood swings and anxiety) associated with this time (Evidence Based Complementary and Alternative Medicine, 2012; Epub). Other results have been less than expected, given that yoga has been used in India to support women through this transition for hundreds of years. The review cited showed that studies were carried out (with varying frequency) only over periods ranging from 8 to 12 weeks. For novices and particularly those starting the practice in later life, it is possible that the body and breathing changes may a little longer to see the deeper effects we tend to feel after 6 months, a year and longer of practice.

Another criteria for the studies was that women often needed to have no previous yoga experience as a control, so these time frames may be only the beginning. Of the total five RCTs (randomised control trials) meeting the criteria for review, only one included a longer-term follow-up for yoga compared to no treatment. At 20-week follow-up, this study reported significant group differences for psychological, somatic, and vasomotor symptoms.

A separate study on the effect of yoga therapy on the four domains - physical, psychological, vasomotor and sexual symptoms - of perimenopause showed that of 216 women with 12 weeks of intervention, “symptoms in all the four domains were improved by yoga therapy, thus significantly improving the overall Quality of Life compared to the control group” (Journal of Midlife Health, 2014; 5(4):180–185). Participants in this study practised daily for 45 minutes, demonstrating that a ‘little and often’ approach can have best outcomes as many teachers recommend.

Another review reported that “eight of the nine studies of yoga, tai chi, and meditation-based programs reported improvement in overall menopausal and vasomotor symptoms; six of seven trials indicated improvement in mood and sleep with yoga-based programs” (Maturitas, 2010; 66(2):135–149). Here vasomotor symptoms refers to the sudden blood flow increase that causes night sweats, hot flashes, and flushes. From a yogic perspective, the way in which a physical practice is approached ie whether heating or cooling for the body and brain, can make a huge difference to its effects.

Patricia Walden, yoga teacher and co-author with Linda Sparrowe of The Woman’s Book of Yoga and Health: A Lifelong Guide to Wellness, had a vigorous physical practice until perimenopause, when Yoga Journal reported that “unsupported inversions, strenuous poses, and backbends sometimes made her symptoms worse. When that happened, she turned to supported and restorative poses to calm her nerves.” For those with established practices, slower forms with more modifications may lend themselves to adjusting a practice according to new body states. Finding new paths and creative ways to explore is a continual part of a long-term practice.

For those coming to yoga to help met this changing phase, the specific needs at this time can help create a sensitive, introspective and compassionate practice – fundamental philosophical aims of yoga that we can take long into old age.

Yoga and the Menopause – Practices for Cooling, Calm and Self-care

The following sequences are designed to bring focus and circulation to the pelvic area, whilst cooling brain agitation and encouraging awareness of changing energy and temperature states. They can be followed as an entire practice or taken in portions when you need some respite from symptoms or as a physical meditation to connect with body changes.

Several of the poses are cooling alternatives to more heating postures, so can be introduced and played around with within an existing practice or in classes where you might feel the pace or effort may have become overwhelming. They are not lesser versions, but body intelligent variations; where we listen and honour our needs, rather than pushing our will or an idealised version of yoga postures into our practice. This can help us stay strong and flexible, rather than wearing out resources and inviting injury.

Anantasana (Heart Pose)

Starting on all fours, feel any movement through the hips, shoulders and spine to loosen and arrive into your body. From there, then walk your hands forward to bring your elbows down in their place, either bringing your forehead to the ground or bringing the floor to you with blocks. Breathe to let gravity open your heart and lengthen your spine.

This also provides an alternative to child pose for those who have knee issues and can be practised more dynamically with elbows lifted and pressing back from the hands as a spine-lengthening alternative to downward-facing dog. This gives a cooling forward bend and inversion combined to come back to whenever you need; during a more dynamic or passive practice.

This sequence focussing on strengthening through the legs to both support weight-bearing and also encourage apana vayu, the energetic ‘wind’ or energy tide that yogis believe rises up from the pelvic region and can diminish as we grow older. Many women feel weaker in the legs during menopause and stress can exacerbate that feeling, so slower movements held with long and spacious breath can help feel a gathering of power without the building of stress or strain.

Strengthening with right energy

From all fours, open the hands, tuck toes under and round the back to exhale up. Start with knees bent and heels up to give you the room to explore opening in the front body whilst drawing back tops of the thighs to open the hamstrings. Explore ‘figure-of-eights’ through the shoulders and hips to loosen and create a sense of playfulness.

From downwards-facing dog, walk the hands back with bent knees and parallel feet hip-width apart to fold fully forward and release the arms and head. This softer variation may be where you need to stay – always or just on some days – if you feel lower back pain, tight hamstrings or simply the need for a restful version. From here you can explore lifting up from the feet and through the inner legs to bring the legs towards straight, and you can explore this up and down as feels right and allows you to feel the cooling effects of forward bending.

Utthita trikonasana (Extended triangle pose)

The triangle is a potent female or divine symbol in many cultures and feeling the strength of its angles from the ground helps us feel and connect with the pelvic and abdominal region. With the back foot turned in and front foot parallel with the sides of the mat, lengthen out the bottom arm to come down only as far as you can still revolve the belly and chest upwards. This provides the space to open across the chest and lengthen then spine and neck.

Prasarita padottanasana (Spread-out-feet intense stretch pose)

With outer edges of the feet parallel and activated feet, you can feel the uplift through inner legs and drawing in of the belly that helps naturally draw up the pelvic floor and encourage circulation around reproductive organs and adrenals. Rise up through the legs to allow soft release into the upper body as you stay with full, releasing out-breaths. Putting a bolster, blocks or chair under the head can make this a more mind and body cooling pose.

Viparita Karani (Waterfall practice)

Inversions help to soothe the nervous system and brain by raising the legs above the heart, so blood can simply flow back to the heart via gravity. Supported versions means we can stay longer without the heat or strain of muscular effort and in viparita karani, the added backbend element opens the area between the navel and pubic bone, which with the inversion helps raise apana energy in menopause (hence contraindicated in menstruation). Stay in each variation for a good few minutes for full benefit.

With a bolster or folded blankets placed against a wall (with a little gap for your tailbone), bring your right hip up onto the right side of the bolster and swings your legs up the wall. Shimmy onto if you need and with tight hamstrings have the lift further from the wall. Settle down into the weight of the legs and rest into breathing the shoulders to drop and the heart to rise, with your arms wherever most comfortable
Open your legs wide to where you can sustain the opening into the inner thighs. Inverting with the pelvis open helps bring blood flow and energy to the pelvic organs. Stay until your body says you’re ‘cooked’, coming back to the first version to settle the lower back before rolling off the bolster to lie on your side before coming up.Viparita Karani – wide-legged

Restorative Menopause sequence

This is a simply practice at the end of any sequence or whenever you need to bring down heightened temperature, emotions or feeling overwhelmed. Laying on the ground creates a natural support and trust that there is nowhere to fall. Focus on drawing your breath in towards your pelvic and abdominal region with the inhale and out into your whole body and soft outer shell as you exhale. Allow the poses to unfold, staying present with each breath and offering compassion to your whole mind-body.

Let the floor hold you to feel length in the whole body and spine as you revolve around the core.Supta Matsyendrasana variation (Supine sage twist pose)

Supta Baddha Konasana (Supine bound-angle pose)

Place a lift under your back with enough freedom for your lower back to feel completely comfortable. Place folded towels or blankets under both thighs if any pulling or pinching into the lower back or knees. Support your head to lightly draw your chin into throat and soften the front brain and eyes.

Savasana (Corpse pose) with bolster

This pose can be a full practice in itself and with knees supported allows softness in the lower back and full resting of the thighs to support kindness and restoration around the lower abdomen.

If you'd like to discover more, Charlotte's Natural Health Webinar on the subject of Menopause Support covers this subject. The recording and a supporting recipe eBook is available to monthly subscribers of Yoga, Somatics & Meditation with Charlotte.