Abstract
This habilitation thesis presents research on the role that physical activity plays in
enhancing psychological wellbeing during the menopausal transition. The work presented is
interdisciplinary, intersecting the fields of health psychology, psychology of physical activity,
women´s health, and adult development and aging, viewing behavior and the menopausal
transition from a lifespan, developmental perspective. The number of women aged 40-60 has
been increasing as a result of the aging trends in most Western societies. This period of life
brings for women a transition from reproductive to nonreproductive status, which is
accompanied by volatile changes in hormonal levels. Changing of the hormonal mileu
consequently alters the health risk profiles of women, increasing their risk for cardiovascular
disease, osteoporosis, depression, or weight gain. The psychological disturbances that
accompany the menopausal transition are often linked to the experience of bothersome
menopausal symptoms, which has a negative impact on women´s wellbeing and quality of
life. Vasomotor symptoms, in particular, are experienced by the majority of women and often
serve as an impetus for women seeking healthcare services at this stage of life. While
sociodemographic factors, premenopausal health status, and psychosocial stress act as
important determinants of wellbeing as women transition through menopause, lifestyle
factors, namely physical activity, also play a vital role. Physical activity brings about
numerous health benefits to the menopausal women but its effects on menopausal symptoms
and wellbeing have been understudied. In this thesis, seven distinct published studies are
presented to unveil how physical activity impacts menopausal symptoms and wellbeing (both
long-term as well as acutely in the context of daily life), and to characterize individual
differences in how women may benefit from physical activity in terms of symptom and
wellbeing outcomes. A variety of methodologies were applied ranging from experimental,
intensive longitudinal, ecological momentary assessment, and single case designs to
demonstrate that (1) physical activity impacts psychological wellbeing and quality of life
indirectly through its effects on more proximal outcomes such as affect; (2) menopausal
symptoms can be impacted by physical activity but also have a direct influence on wellbeing;
(3) vasomotor symptoms are not triggered by acute exercise in most healthy women but that
low-fit women may perceive worsening of symptoms as a result of increased daily physical
activity; (4) substantial between- as well as within-person variability exist in both daily
physical activity and symptom reporting but enhancing perceived control, positive affect, and
coping efficacy may help women cope with symptoms effectively, suggesting a need for
intervention approaches that contain multiple components (cognitive, behavioral), are tailored
to subgroups of women based on their personality, fitness profiles, and are dynamic, adopting
to women´s changing needs and being delivered in the moment when most needed.
Table of contents
Introduction................................................................................................................................7
Defining menopause, menopausal health and well-being......................................................7
Determinants of health and well-being across the MT ..........................................................8
Socio-demographic factors.................................................................................................8
Premenopausal health.........................................................................................................9
Menopausal symptoms. ......................................................................................................9
Psychosocial stress. ............................................................................................................9
Physical activity................................................................................................................10
The focus, innovation and significance of the present research...........................................11
List of Original Publications....................................................................................................14
Author’s contribution...........................................................................................................15
Summary of Research Questions.............................................................................................16
Research aims of presented studies......................................................................................16
Methods....................................................................................................................................17
Data sources .........................................................................................................................17
Study I ..................................................................................................................................17
Study II.................................................................................................................................18
Study III................................................................................................................................18
Study IV ...............................................................................................................................18
Study V.................................................................................................................................19
Study VI ...............................................................................................................................19
Study VII..............................................................................................................................19
Study I: Physical Activity and Mental Health Outcomes During Menopause ........................20
Method .................................................................................................................................22
Participants .......................................................................................................................22
Measures...........................................................................................................................22
Procedure..........................................................................................................................24
Exercise intervention ........................................................................................................25
Statistical analysis.............................................................................................................26
Results..................................................................................................................................26
Intervention effects relative to mental health outcomes.......................................................27
Discussion ............................................................................................................................29
Figure 1.............................................................................................................................33
Table 1..............................................................................................................................34
Table 2..............................................................................................................................35
Table 3..............................................................................................................................36
Table 4..............................................................................................................................38
References ............................................................................................................................39
Study II: Physical Activity, Menopause, and Quality of Life: The Role of Affect and SelfWorth
Across Time..................................................................................................................42
Method .................................................................................................................................44
Participants .......................................................................................................................44
Measures...........................................................................................................................44
Procedure..........................................................................................................................46
Statistical analysis.............................................................................................................46
Results..................................................................................................................................47
Discussion ............................................................................................................................49
Figure 1.............................................................................................................................52
Table 1..............................................................................................................................53
Table 2..............................................................................................................................54
References ............................................................................................................................55
Study III: Personality, Menopausal Symptoms, and Physical Activity Outcomes in MiddleAged
Women ...........................................................................................................................58
Methods................................................................................................................................60
Participants .......................................................................................................................60
Procedures ........................................................................................................................60
Measures...........................................................................................................................61
Data Analysis....................................................................................................................62
Results..................................................................................................................................63
Discussion ............................................................................................................................64
Table 1..............................................................................................................................68
Reference..............................................................................................................................69
Study IV: Effects of Physical Activity on Vasomotor Symptoms: Examination Using
Objective and Subjective Measures .....................................................................................71
Method .................................................................................................................................72
Participants .......................................................................................................................72
Study Design.....................................................................................................................72
Measures...........................................................................................................................73
Statistical analysis.............................................................................................................75
Results..................................................................................................................................77
Discussion ............................................................................................................................79
Figure 1.............................................................................................................................83
Figure 2.............................................................................................................................84
Table 1..............................................................................................................................85
Table 2..............................................................................................................................86
Table 3..............................................................................................................................87
Table 4..............................................................................................................................87
References ............................................................................................................................88
Study V: Daily Physical Activity and Menopausal Hot Flashes: Applying a Novel WithinPerson
Approach to Demonstrate Individual Differences .......................................................91
Methods................................................................................................................................93
Participants .......................................................................................................................93
Measures...........................................................................................................................93
Procedures ........................................................................................................................95
Data Analysis....................................................................................................................95
Results..................................................................................................................................97
Discussion ............................................................................................................................99
Table 1............................................................................................................................103
Table 2............................................................................................................................104
Table 3............................................................................................................................105
Table 4............................................................................................................................106
References ..........................................................................................................................107
Study VI: Concurrent and Lagged Relations between Momentary Affect and Sedentary
Behavior in Middle-Aged Women.........................................................................................111
Methods..............................................................................................................................112
Participants and Procedures............................................................................................112
Measures.........................................................................................................................112
Data Analysis..................................................................................................................113
Results................................................................................................................................114
Discussion ..........................................................................................................................115
References ..........................................................................................................................117
Study VII: Daily Physical Activity Enhances Resilient Resources for Symptom Management
in Middle-Aged Women ........................................................................................................119
Methods..............................................................................................................................122
Participants and Procedures............................................................................................122
Measures.........................................................................................................................123
Data Analysis..................................................................................................................124
Results................................................................................................................................126
Discussion ..........................................................................................................................129
Table 1............................................................................................................................132
Table 2............................................................................................................................133
Table 3............................................................................................................................134
Table 4............................................................................................................................135
Table 5............................................................................................................................135
Figure 2...........................................................................................................................135
References ..........................................................................................................................137
General Discussion ................................................................................................................140
Future Directions................................................................................................................148
References ..........................................................................................................................151
7
Introduction
Defining menopause, menopausal health and well-being
There are nearly one million women over age 50 living in the Czech Republic,
representing one of the fastest growing segments of the population 1
. The United States, Europe,
and populations worldwide are experiencing the same aging trends with more and more women
reaching menopause each year 2,3
. Menopause refers to cessation of ovarian follicular activity
and is manifest by the cessation of menstrual flow lasting at least 12 months. Perimenopause
encompasses the time immediately before menopause (i.e., after menstrual cycles become
irregular) and the first year after menopause, representing a transitional period when
physiological, hormonal, and clinical changes commence, which lasts on average 3.5-4 years 4
.
The menopausal transition (MT) is defined as the time before the final menstrual period when
variability in menstrual cycle is usually increased 5
; however, the term is often used more
broadly to denote the transition from reproductive to non-reproductive years of women’s lives
(also referred to as such throughout this thesis).
Although the MT is part of a normal aging process, the hormonal changes occurring at
this stage of life alter the health-risk profile of women, increasing the risk of cardiovascular
disease (CVD) 6
, osteopenia and osteoporosis, contributing to weight gain and leading to
increases in central adipose tissue 7
, risk factors for diabetes. In menopause-related studies health
outcomes are generally operationalized along three dimensions: (1) as self-rated or self-defined
health; (2) as health status (often assessed as health history, some aggregate measure of different
health indicators, or as health-related quality of life); and (3) in terms of specific health/disease
end-points (e.g., cardiovascular risk factors). There are also more “acute” manifestations of the
MT in the form of different types of symptoms which cluster into three factors: vasomotor,
somatic, and psychological 8
. However, only vasomotor symptoms, such as hot flashes and night
sweats, and urogenital symptoms, such as vaginal dryness or atrophy, have been linked to the
endocrinological changes occurring during menopause 4
. To denote the more positive aspects of
health as women transition through menopause the term menopause-related well-being has been
used and is most typically operationalized as subjective or psychological well-being 9
.
8
Determinants of health and well-being across the MT
Although some women appear to be more susceptible to the adverse outcomes of
menopause 10,11
, the idea of a universal menopausal syndrome has been refuted 12
, with the
majority of women viewing menopause as a neutral event in their lives 13,14
. Several longitudinal
studies have identified important determinants of health and well-being across the MT (Health
Women’s Study 15
; Massachusetts Women’s Health Study 16
; Melbourne Women’s Health
Project 17
; Seattle Midlife Women’s Health Study 18
; Penn Ovarian aging Study 19
; Women’s
Health Australia Study 20
; Study of Women’s Health Across the Nation 21
; with several larger
studies focusing on postmenopausal and older women only, e.g., Women’s Health Initiative),
pointing at four inter-related primary factors contributing to health and well-being as women
transition through menopause: premenopausal health, menopausal symptoms, psychosocial
factors (mainly stress), and lifestyle factors (mainly physical activity) 22,23
.
To understand the impact of the MT on health and wellbeing of women, one must view
the MT in a broader context with multidimensional causal influences, extending from distal
social and built environmental factors to proximate, individual level factors 24,25
. A brief
overview of the most relevant covariates of menopausal health and wellbeing follows.
Socio-demographic factors. Chronological age is associated with health status as is age
at menopause 26
. Socio-demographic factors such as social class, marital status, parity, and
race/ethnicity may impact menopausal health and well-being by modulating age at menopause or
by influencing stress exposures, lifestyle behaviors linked to age at menopause or specific health
outcomes. For example, lower level of education, single status, not being employed, and AfricanAmerican
27
and Latina 28
race/ethnicity have been associated with earlier age at menopause 29,30
.
Higher parity, especially in women of higher socio-economic status, prior use of contraceptives,
and Japanese race/ethnicity have been linked to later menopause 30–32
. More African-American
and Latina, but fewer Chinese and Japanese women also report vasomotor symptoms as
compared to White women, and fewer women with postgraduate education report vasomotor
symptoms 33,34
. Additionally, childless women express more negative attitudes toward
menopause compared with parous women but are half as likely to report vasomotor symptoms 35
.
Socio-economically disadvantaged women also display more negative health behaviors (e.g.,
smoking, alcohol consumption, body mass index, stress, diet, physical activity) 36
, all of which
have been shown to impact age at menopause and/or health outcomes 37–39
. Socio-economic
9
status and race also contribute to health disparities more generally, resulting in uneven
distribution of health 40,41
.
Premenopausal health. Premenopausal health is the most important predictor of any
health outcome following the final menstrual period. In the Melbourne Women’s Health Project,
changes in self- rated health have been monitored across a 9-year period in middle-aged women
progressing through the MT. In a longitudinal analysis, modeling simultaneously multiple
influences on self-rated health and well- being, premenopausal self-rated health emerged as the
most potent indicator of any other health and well-being outcome over time 23
. This finding is
consistent with other reports suggesting that women with a history of physical or mental health
problems are the most likely to have a distressful MT 42
.
Menopausal symptoms. Among the most common symptoms reported by menopausal
women are hot flashes, night sweats, irritability, moodiness, tension, anxiety, low self-esteem,
and emotional instability 4
. However, the term “menopause management” is typically
constrained to the management of vasomotor symptoms such as hot flashes and night sweats.
These symptoms represent a heavy socioeconomic burden on society 43
and they are the primary
reason for middle-aged women visiting a physician 44
. Interestingly, women with menopausal
complaints display lower bone mineral density 45
and a less favorable cardiovascular risk profile
46
, including higher risk for hypercholesterolemia, hypertension 47
, and higher body mass index
48
, pointing to a possible overlap in etiology of both CVD and vasomotor symptoms 49,50
and
suggesting a potential role of vasomotor symptoms as a sub-clinical marker of health. In the
U.S., higher reporting of menopausal symptoms (vasomotor in particular) has been associated
with late perimenopausal and early postmenopausal status, specific endocrine changes, African
American race, lower educational attainment or socio-economic status, higher body mass index
or body fatness, smoking, history of pre- menstrual complaints, stress, anxiety, depression, and
sleep problems 34,50–54
. Recently, environmental context has been linked to menopausal symptom
reporting but few systematic investigations of the role of context exist. The limited evidence
available suggests that social networks, social support, and familial relationships influence how
women deal with menopause 55,56
, and that women residing in rural environments may be
experiencing a more distressful menopause and more frequent or severe vasomotor symptoms,
even after controlling for health status and socio-economic factors 57
.
Psychosocial stress. The most consistent psychosocial predictor of health and well-being
10
during the MT is stress. Both acute (e.g., interpersonal relationships or daily hassles) and chronic
stressors (e.g., history of child abuse or victimization) have been linked to adverse health
outcomes, more menopausal symptoms, and poorer well-being in middle-aged women. There is
a reciprocal relationship between stress and the MT as stress may exacerbate menopausal
symptoms and menopausal experiences may, in turn, influence the perception, experience of, and
coping with stressful life events 58
. Women who experience longer MT and increased symptoms
have higher stress, and were found to be at increased risk for depression 59
. Menopause-related
distress (i.e., experiencing symptoms) increases levels of inflammatory cytokines 60,61
, and
psychosocial stress in general has been associated with the development of hypertension,
metabolic syndrome, and faster progression of CVD 62
. Interestingly, women in early
perimenopause report the highest rate of psychological distress as compared to premenopausal
and postmenopausal women 63
, and postmenopausal women respond more intensely to stress
than premenopausal women 64,65
. Perceived stress has been associated with subsequent dysphoric
mood and recently also, stressors such as chronic or childhood stress, abuse, and victimization
have been associated with increased reporting of vasomotor symptoms 58,66
. A recent
observational study described longitudinal changes in the level of perceived stress in relation to
MT and although stress levels tended to decline in postmenopause, factors such as employment,
history of sexual abuse, depressed mood, and poor self-perceived health were associated with
higher levels of stress. Improvement in role burden, social support, and income adequacy was
associated with significantly lower perceived stress 67
.
Physical activity. Physical activity is a key lifestyle factor that can influence menopausal
wellbeing and women across the menopausal spectrum can derive the numerous health benefits
of physical activity 68
. Menopause has been associated with a decrease in energy expenditure and
increase in total body fat and visceral adipose tissue 69
, and CVD risk factors, but maintaining or
increasing participation in regular physical activity may prevent or attenuate any such increases
in midlife women . In 2004, the North American Menopause Society (NAMS) recommended
lifestyle changes such as regular physical activity as the first line of defense against the adverse
consequences of menopause, including the management of mild to moderate menopausal hot
flashes 70
, although the evidence from quality randomized control trials remains limited, leading
NAMS to remove exercise as well as yoga from their list of proven hot flash treatments 71
.
Unfortunately, women who experience vasomotor symptoms spend less time on exercise per
11
week than do those who do not have hot flashes 72
, and only approximately half of middle-aged
women engage in any leisure-time physical activity on regular basis, with less than 25% meeting
the public health recommendations of at least 30 minutes of accumulated moderate physical
activity on most days of the week 73
. One 4-year prospective study documented that physical
activity decreased significantly two years before menopause and remained low thereafter 69
, but
other longitudinal studies reported relatively stable physical activity levels on average in middleaged
women across the menopausal stages 22,74
, albeit with a significant portion (>50%) of the
women reporting insufficient or no regular activity. This is unfortunate given the numerous
health benefits of physical activity. Cross-sectionally, physical activity has been associated with
less nervousness and fewer menopausal symptoms 75–78
, enhanced mood, well-being 9
, and
quality of life 79
, but some experimental 80–82
and population-based prospective studies have
provided inconsistent findings when it comes to the relationship of physical activity to
vasomotor symptoms in particular 33,36,83,84
.
It has been proposed that one of the ways physical activity impacts health and well-being
across the menopausal transition is by attenuating the adverse effects of stress on these
outcomes. Physical activity has been associated with lower levels of stress generally 85,86
and
during ovarian aging 87
. Other literature (animal and human) supports the role of physical
activity in attenuating the adverse effects of stress on health 88
. For example, animal studies have
supported the physiological effects of exercise on reducing stress through reductions in
behavioral depression and immunosuppression brought about by different stressors 89,90
. In
human studies, physical activity has been shown to impact health through different pathways
depending on the outcomes under study. Physical activity may have a direct impact on health and
well-being (i.e., regardless of stress levels) for example by improving cardiovascular and bone
health 68
or mood 22
. It may however also affect health and well-being indirectly by either
mediating 91,92
or moderating the stress-health relationship 93,94
.
The focus, innovation and significance of the present research
My program of research stems from my previous work involving studies examining the
effects of physical activity on quality of life (QOL) during the aging process 75,95,96
. Although the
menopausal transition is part of a normal aging process, the hormonal changes occurring at this
stage of life alter the health-risk profile of women and bring about more “acute” manifestations
12
of the menopausal transition in the form of vasomotor symptoms such as hot flashes and night
sweats. These are perceived as especially bothersome and disruptive and represent the primary
reason for women seeking health care services at this stage of life. The menopausal transition
may also be a source of psychological distress or instability and there is growing evidence that
certain subgroups of women may be more vulnerable to such adverse outcomes than others. For
example, overweight and obese women are more likely to experience vasomotor symptoms 54
and consequently may be more vulnerable to experiencing sleep and other health problems.
Symptomatic menopausal women in general are also more vulnerable to developing depressive
symptoms or clinically defined depression and perimenopause has been identified as a period of
transitional vulnerability for depression and other mental health problems 97,98
. Collectively,
these adverse physical and mental health changes may negatively impact wellbeing as women
transition through menopause.
Although physical activity may attenuate many of the adverse outcomes associated with
menopause, including different types of symptoms, few studies have investigated the effects of
physical activity on physical and mental health (and subsequent impact on QOL and wellbeing)
during menopause. Existing studies have focused either solely on symptom reporting or
physiological outcomes primarily in pre- and post-menopausal women and have generally
confounded the neuroendocrine, fitness, body composition, and psychological effects of physical
activity. Consequently, the psychological and physiological responses to physical activity have
not been well characterized in peri-menopausal women, and little is known about how the
psychological and physiological systems interact to impact health and wellbeing at this stage of
life. Additionally, the majority of existing research has focused on between-group comparisons,
providing little understanding of the sources of individual differences in the way women
experience menopause and how they may respond to behavioral interventions including physical
activity in terms of health and wellbeing endpoints. In this work, I take an interdisciplinary
biopsychosocial approach to characterize the role of physical activity in enhancing wellbeing as
women transition through menopause by illuminating the mechanisms of the physical activitywellbeing
relationship and identifying relevant individual difference characteristics and other
sources of variability in responses to physical activity among middle-aged women.
This work is timely and important given the increasing trend towards using
complementary and alternative medicine strategies for menopause management 99
, and the fact
13
that menopause is viewed by many women as a time of life when preventive healthcare and
health behavior changes are critical 100
. Additionally, there is a critical need for longitudinal and
experimental studies with strong measurement and innovative designs, given the inherent
methodological challenges in research on menopause-related outcomes which to date has been
dominated by epidemiological approaches 101
. Although such studies are useful in providing
information about prevalence and incidence rates, trends, and trajectories, they are limited in
their ability to unveil the processes that underlie the effects of various behavioral modalities on
menopause-related outcomes. The majority of existing studies have typically relied on subjective
and mostly retrospective assessments of vasomotor symptoms and physical activity (known to be
subject to recall and social desirability biases), lacked detailed physiological and psychological
assessments, and focused on between-person comparisons, ignoring intra-individual variability
and within-subject associations among physical activity and wellbeing outcomes.
Recently, ecological momentary assessment methods (EMA) have been gaining
popularity and have been advocated for the assessment of momentary psychological processes in
the context of daily experiences 102,103
. Studies applying these methods conduct frequent “inreal-time”
measurements and provide rich data for the study of patterns in intra-individual
variability in outcomes of interest. The inclusion of objective measures and within-person
replicated time-series design may also enhance our understanding of individual differences in
physical activity behavior, menopausal symptoms, and wellbeing outcomes. For example, sternal
skin-conductance monitoring is considered the gold standard in objective ambulatory assessment
of hot flashes 4
. This technique has been shown to have high agreement (95-100%) with selfreport
data in laboratory settings. However, substantial under-reporting rates (43-65%) have been
found in ambulatory assessment studies. It is unclear what contributes to these discrepancies with
possible explanations ranging from different symptom interpretations or perceptions (potentially
driven by aspects of introspective personality), affective, contextual, or lifestyle influences.
Adopting a within-person methodology along with EMA allows for the characterization of the
patterns of subject responses over "time" while allowing for investigation of the effects of
important covariates (non-time or time-varying) on these patterns. The ultimate goal of
employing these novel methodological approaches is to form person-specific recommendations
regarding avoidance of behaviors and contexts that trigger symptoms and developing effective
coping strategies to minimize the impact of bothersome symptoms on normal daily functioning.
14
Findings from such studies also help inform the design of interventions by allowing for
individualization of treatment options or program design, ultimately optimizing their
effectiveness.
Consequently, this habilitation thesis presents work that could be characterized as
interdisciplinary, and it terms of classification of study fileds, lies at the intersection of health
psychology, psychology of physical activity, women´s health, and adult development and aging.
Research questions regarding psychosocial outcomes, symptom reporting and health behavior
fall within psychology of health and physical activity. The study of physiological and
psychosocial outcomes during reproductive transitions such as menopause also fall witin the
realm of women´s health. Understanding and approaching menopause as a developmental,
transitional period with important consequences for the aging process, also reflects a lifespan
perspective, a cornerstone of adult development and aging fields 104,105
. Notwithstanding the
interdisciplinary, biopschosocial nature of this work, standard (and novel) methodology from
within general and developmental psychology form the basis of this research, thus, general or
developmental psychology should be used as the interpretation framework of the whole thesis.
List of Original Publications
This habilitation thesis presents a series of original publications investigating the role that
physical activity plays in enhancing menopausal wellbeing. The publications are ordered
chronologically but the order is also consistent with the conceptual underpinnings of the studied
theme, starting with the results of a large-scale randomized controlled trial that demonstrated
individual differences in response to physical activity, followed by an examination of long-term
effects of physical activity on quality of life in middle-aged women, and culminating in a series
of studies aiming to unveil the individual characteristics and within-person variability in physical
activity and menopause-outcomes using intensive longitudinal designs and EMA methodology.
The presented studies do not represent the entire body of work on the subject, rather they have
been selected to provide a meaningful glimpse into the topic and types of methodologies utilized
in my work.
15
Study I
Elavsky, S., & McAuley, E. (2007). Physical activity and mental health outcomes during
menopause: A Randomized controlled trial. Annals of Behavioral Medicine, 33(2), 132-142.
Study II
Elavsky, S. (2009). Physical activity, menopause, and quality of life: the role of affect and selfworth
across time. Menopause, 16(2), 265-271.
Study III
Elavsky, S., McAuley, E. (2009). Personality, menopausal symptoms, and physical activity
outcomes in middle-aged women. Personality and Individual Differences, 46(2), 123-128.
Study IV
Elavsky, S., Gonzales, J.U., Proctor, D.N., Williams, N.I., & Henderson, V.W. (2012). Effects of
physical activity on vasomotor symptoms: Examination using objective and subjective measures.
Menopause, 19(10), 1095-1103.
Study V
Elavsky, S., Molenaar, P., Gold, C.H., Williams, N.I., Aronson, K.R. (2012). Daily physical
activity and menopausal hot flashes: Applying a novel within-person approach to demonstrate
individual differences. Maturitas, 71(3):287-93.
Study VI
Elavsky, S., Kishida, M., & Mogle, J. (2016). Concurrent and lagged relations between
momentary affect and sedentary behavior in middle-aged women. Menopause, 23(8), 919-923.
Study VII
Kishida, M., & Elavsky, S. (2015). Daily physical activity enhances resilient resources for
symptom management in middle-aged women. Health Psychology, 34(7), 456-64.
Author’s contribution
Study I-VI: The author conceptualized, designed and directed the studies and data collection and
processing, wrote 100% of the first drafts of the papers, collaborated on data analyses (studies
IV-VI) and on paper revisions (studies I-VI).
Study VII: The author helped conceptualize the study and supervised the study design and
conduct, wrote 10% of the first draft of the paper and collaborated on data analyses, paper
16
revisions. This study was conceptualized to fit thematically with other presented work but also
represents an example of mentored doctoral research.
Summary of Research Questions
Research aims of presented studies
The overall theme of presented studies is to characterize how physical activity impacts
wellbeing across the menopausal transition. In Study I, a large-scale randomized controlled trial
(the second largest trial in existence at the time) was conducted to test the effects of physical
activity on mental health, symptom, and wellbeing outcomes in middle-aged women.
Community-dwelling women across the menopause spectrum were recruited for a study
(LifePAQ) comparing the effects of aerobic exercise (supervised walking program), yoga, and a
control group. Additionally, differences in response to the interventions were probed to identify
possible moderators of treatment response. In Study II, women previously enrolled in the
LifePAQ study were followed two years after the trial end to evaluate the long-term effects of
physical activity on QOL and the underlying mechanisms of these effects. In Study III,
individual differences in menopausal symptom reporting were evaluated in the context of the
LifePAQ trial to identify personality characteristics that explain these differences. As part of
Study IV, a 15-day daily diary study with ecological momentary assessment (EMA) methods
was conducted to examine the relationship between chronic (habitual) physical activity and acute
exercise and vasomotor symptoms. This study utilized both subjective and objective measures of
physical activity and vasomotor symptoms (the first study at the time to do so). Study V applied
a novel approach, a single case longitudinal time-series analysis to demonstrate individual
differences in the relationship between physical activity and menopausal symptom reporting. In
this study within-person associations between physical activity and symptoms were analyzed
over time across one menstrual cycle or a period of 30 days if postmenopausal. Study VI
examined the role of inactivity (sedentary behavior) on affect in middle aged women. On data
obtained from Study III, associations between inactivity and affect were analyzed at the
momentary level to unveil both concurrent and lagged effects. Study VII used a 21-day daily
diary design to evaluate the direct and indirect associations between physical activity and
17
menopausal symptoms and test mediational pathways involving sources of resilience such as
positive affect and coping efficacy.
Methods
Data sources
A range of different methodological approaches were used to address the questions under
study, all however involved quantitative data analyses. Study I was a 4-month randomized
control trial (LifePAQ) with 3 (group) by 2 (time) design involving 164 community-dwelling
middle-aged women. Study II was a 2-year prospective examination of participants enrolled in
the LifePAQ study. Study III examined the contribution of personality characteristics to the
reporting of menopausal symptoms in the context of the LifePAQ randomized controlled trial.
Study IV was a 15-day daily diary study with ecological momentary assessment of 121
community-dwelling women reporting menopausal symptoms upon enrollment into the study.
Additionally, the women completed an acute bout of aerobic exercise in the lab to investigate
acute effects of exercise on the reporting of vasomotor symptoms which were assessed
subjectively as well as objectively through sternal skin conductance monitoring. Study V used a
novel single subject design with person-specific time series analyses to identify individual
differences in the relationship between daily physical activity and symptom reporting in 24
middle-aged women followed intensively across an entire menstrual cycle or a 30-day period.
Study VI used data from the 15-day daily diary study (Study IV) to examine how inactivity
(sedentary behavior) influences momentary affect in middle-aged women. Study VII utilized a
daily diary study design with 21 daily online assessments of 103 community-dwelling middleaged
women to investigate sources of resiliency in the relationship between physical activity and
menopausal symptoms. A brief overview of the specific methodologies and statistical approaches
used in these studies follows.
Study I
This study investigated the effects of a 4-month randomized controlled exercise trial on
mental health and wellbeing outcomes in 164 previously low-active middle-aged women (M age
= 49.9; SD = 3.6). Participants completed body composition (DXA) and fitness assessment (VO2
max test) and a battery of psychological measures at the beginning and end of a 4-month
18
randomized controlled exercise trial with three arms: walking, yoga, control. A series of mixed
model) repeated measures Univariate and Multivariate Analyses of Variance (ANOVAs and
MANOVAs) and Covariance (ANCOVAs and MANCOVAs) were conducted to evaluate the
effects of the intervention on outcomes of interest.
Study II
This study examined the long-term effects of physical activity on menopause-related
quality of life (QOL) and tested the mediating effects of physical self-worth and positive affect
in this relationship. Middle-aged women previously enrolled in a 4-month randomized controlled
trial involving walking, yoga, and a control group completed a follow-up mail-in survey two
years following the end of the trial. The survey included a battery of psychological and physical
activity measures, including measures of menopausal symptoms and menopause-related quality
of life. Longitudinal linear panel analysis was conducted within a covariance modeling
framework to test whether physical self-worth and positive affect mediated the physical activity quality
of life relationship over time.
Study III
This study examined the contribution of personality factors to the reporting of
menopausal symptoms in the context of a 4-month randomized controlled exercise trial.
Symptomatic middle-aged women (N = 164 M age = 49.9, SD = 3.6) completed measures of
menopausal symptoms, personality, physical activity, fitness and body composition assessment
at the beginning and end of a 4-month randomized controlled trial involving walking and yoga.
Study IV
The purpose of this study was to assess the effects of acute aerobic exercise and daily PA
on menopausal vasomotor symptoms. Community-dwelling midlife women (N=121; age range
40-60 years) not on hormone therapy were recruited for a 15-day daily diary study with
ecological momentary assessment. Women completed psychological, cardiorespiratory fitness
(VO2 max test), body composition (DXA), and hormonal status screening (urine and blood
samples), followed by a 15-day prospective assessment in a “real-life” setting using a personal
digital assistant device. Participants also completed a 30-minute moderate-intensity aerobic
exercise bout on a treadmill between days 5-8. Daily PA was assessed objectively through
accelerometry and all symptomatic women (n=92) completed two 24-hour Biolog sternal skin
conductance recordings of hot flashes (HFs), one at baseline and one immediately following
19
treadmill exercise.
Study V
This study applied a longitudinal within-person design through a prospective daily diary
study which applied experience sampling methods. Time series modeling techniques
investigated, at the within-person level, the relationship between objectively measured daily
physical activty of varying intensities and self-reported menopausal hot flashes (HFs) in 24
symptomatic middle-aged women (M age = 50.4; SD = 4.9). All women completed fitness, body
composition and hormonal status screening, and reported on daily HFs using an electronic
personal digital assistant (PDA) device across one menstrual cycle or for 30 days (if
postmenopausal). Daily physical activity and physical activity intensity was measured using
accelerometry and subjects completed a battery of psychological measures.
Study VI
The purpose of this study was to investigate the reciprocal relationship between sedentary
behavior (SB) and momentary affect in the context of daily experiences in a sample of
community-dwelling midlife women (N = 121; age range 40-60 years) recruited for a 15-day
daily diary study. The women rated their positive and negative affect when prompted on a PDA
device four times per day and wore an accelerometer for objective assessment of SB. Multilevel
models were estimated to test concurrent and lagged associations between momentary estimates
of SB and affect.
Study VII
The aim of this study was to evaluate the direct and indirect associations between
physical activity and menopausal symptoms in 103 community-dwelling middle-aged women
(age range 40-60 years) who completed daily Internet surveys at the end of the day and wore an
accelerometer for the objective assessment of physical activity for 21-days. 1-1-1 multilevel
meditational models were estimated to test whether resilient resources (i.e., positive affect and
coping efficacy) mediated the association between physical activity and symptom burden at both
the between- and within-person level.
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General Discussion
My scholarship focuses on accumulating scientific evidence that a physically active
lifestyle is central to successful and healthy aging, and that physical inactivity presents one of
the most prominent public health challenges of our time. As a scholar I aim to engage in, and
foster greater awareness of, physical activity research from the public health perspective,
while investigating and integrating scientifically relevant issues to the concrete concerns of
real people in terms they can make sense of and benefit from. The overarching long-term goal
of my research is to understand how best to harness the power of physical activity to enhance
health and wellbeing as we age. Specifically, I have made substantive contributions in three
areas: (1) understanding the role that physical activity plays in improving quality of life
(QOL) across populations (with a particular focus on the wellbeing of the menopausal
woman); (2) integrating objective and subjective methods to study clinical issues; and (3)
using within-person methodology to reveal the intra-individual dynamics of motivational
processes linked to physical activity and its psychological consequences. The work is
interdisciplinary in nature drawing on the knowledge framework across different fields
including psychology of health and physical activity, women´s health, and adult development
and aging. The methods and theories applied however stem from mainstream psychology,
resulting in largely psychological research with potential public health relevance.
Specifically, my work on wellbeing helped establish psychosocial influences such as selfefficacy,
social support, affect, and self-worth as important determinants of physical activity
behavior and as mediators of physical activity effects on quality of life in young, middleaged,
and older populations. One of the main thrusts of my research focuses on women in
midlife and menopause, as a transitional period with important implications for successful
aging. Fourteen publications have specifically aimed to illuminate the mechanisms of
physical activity effects on wellbeing in women as they transition through menopause.
These studies advanced the field by addressing notable shortcomings of previous research
which relied on self-reported measures and failed to adequately account for between-person
differences in physiological and psychological factors linked to menopausal symptom
reporting. Specifically, these were the first studies to: (1) incorporate both objective and
subjective measures of physical activity (accelerometry) AND vasomotor symptoms (sternal
skin conductance); (2) carefully characterize fitness levels, body composition, hormonal
status, and psychological profiles of women to take into account these important correlates of
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141
menopausal symptom experiences; and (3) employ longitudinal within-person designs to
examine how changes in physical activity impact menopausal outcomes while ruling out the
potential influence of established (and unknown) individual difference variables.
Parts of this research, also recognized by the biomedical menopause community (2011
New Investigator Award from the North American Menopause Society), are presented in this
habilitation thesis. Across seven different studies, this thesis attempts to address some of the
major issues in the study of physical activity behavior and its effects on mental health and
psychological outcomes in women as they transition through menopause. This work also
reflects a variety of different methodologies in an effort to address some of the shortcomings
of previous research. As a matter of summarizing these findings and general discussion, I
would like to emphasize several key themes or messages of this work.
1. The menopausal experience is idiosyncratic and individual differences exist in
how women benefit from behavioral modalities such as physical activity during
menopause.
Although from a public health perspective, one might desire to draw a simple message
regarding health behaviors and their positive effects on health and wellbeing, that would also
apply to populations broadly, the message regarding physical activity during menopause must
be nuanced. From the standpoint of physical and mental health status, women can derive the
same health benefits from physical activity as the population at large, nonetheless for
menopause management, which is usually akin to management of symptoms, some women
stand to benefit more than others. In Study I 81
, it was demonstrated that walking and yoga
were effective in enhancing positive affect and menopause-related QOL and reducing
negative affect. Nonetheless, the treatment response varied significantly based on changes in
menopausal symptoms across the trial. Women who experienced decreases in menopausal
symptoms across the trial benefited more from the interventions, experiencing more
pronounced improvements in all positive mental health and QOL outcomes and greater
reductions in negative mental health outcomes. Whether menopausal symptoms increased or
decreased across the trial appeared to be determined in part by whether there were increases
or decreases in cardiorespiratory fitness, suggesting that cardiorespiratory fitness may
represent a factor modifiable by interventions.
In Study III 106
, additional individual difference variables were identified as contributors
to the differential responses in menopausal symptoms. Specifically, after controlling for
baseline values, psychological symptoms at the end of the 4-month trial were associated with
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142
trait anxiety (β = .47, p < .001) and changes in fitness (β = -.20, p < .01); vasomotor
symptoms with optimism (β = -.18, p < .05) and changes in fitness (β = -.15, p = .053); and
sexual symptoms were associated with changes in fitness (β = -.16, p < .05). These findings
support previous suggestions that aspects of personality play a role in the experience of
menopausal symptoms 42,107
. This individual variability also predisposes women to benefit
differently from physical activity, suggesting that personalized multimodal intervention
strategies may be required to minimize the impact of bothersome symptoms in women.
Other research also indicates that different women experience different clusters of
symptoms and that symptom experiences are dynamic and change over time, only further
underscoring the need for personalized and adaptive interventions. For example, in the Seattle
Midlife Women’s Health Study, three latent classes representing broad categories of
symptoms were identified: Class 1 with observations of low severity levels for all symptoms
(e.g., vasomotor, psychological, somatic), class 2 with low-severity hot flashes and moderateseverity
levels for all other symptom factors, and class 3 with high severity hot flashes with
lower severity levels of all other symptom factors 108
. While profiling women from the late
postmenopausal stage only, more specific profiles were also identified: group 1 experiencing
low severity for all symptoms except for joint ache (65%); group 2 high severity for all
symptoms except for hot flashes (13%); group 3 with high severity for hot flashes, joint ache,
and awakening at night (12%); and group with high severity for problem concentrating and
joint ache (10%) 109
. Although symptom clusters changed somewhat across the different
stages of the menopausal transition, they were best predicted by symptom clusters from a
previous stage, suggesting some consistency in the types of symptoms women exhibit as they
transitions from early perimenopause to late postmenopause 110
. From a clinical translational
perspective, identifying subgroups of women with different symptom clusters and personality
dispositions that may make them more vulnerable would allow for tailoring of intervention
approaches to maximize their effectiveness.
It should also be noted that different types and intensity of physical activity are likely to
affect women differently and that individual differences exist in how women may respond to
different physical activity modalities. In Study I 81
, there were differences in the effects of
walking versus yoga on different types of symptoms and mental health outcomes with
walking having largely stronger effects than yoga. Although yoga impacted the sexual QOL
domain more and had different pattern of impact on psychological outcomes such as selfesteem
(shown in a separate study 111
). Study IV 112
demonstrated that acute aerobic exercise
may have different effects on vasomotor symptoms than habitual physical activity and that
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143
personal characteristics such as fitness level moderate this relationship. Study V 113
delineated in greater detail the person specific effects of daily physical activity of different
intensities, pointing to affect and perceived control as factors modifying this relationship.
Consequently, when it comes to optimizing management of menopausal symptoms, physical
activity recommendations should be tailored and combined with other behavioral and
cognitive strategies for most effective symptom management.
2. Physical activity enhances wellbeing and quality of life during menopause, both
directly and indirectly through its effects on more proximal outcomes such as
affect, self-worth, or coping resources.
Study II 114
tested whether physical activity enhanced menopause-related quality of life
(QOL) across a 2-year period in middle-aged women previously enrolled in a 4-month
randomized trial involving walking and yoga. There was an indirect relationship between
physical activity and QOL such that increases in physical activity and decreases in
menopausal symptoms over the 2-year period were related to increases in physical self-worth
(βs = .23 and -.52) and for symptoms also to decreased positive affect (β = -.47), and both
physical self-worth (β = .34) and affect (β = .43) directly influenced enhancements in QOL
(R2
= .775). The findings support the position that physical activity effects on QOL are in part
mediated by intermediate psychological outcomes and that physical activity can have longterm
benefits for women undergoing the menopausal transition.
From a theoretical perspective, influences on wellbeing/QOL could be divided into
two general categories of top-down and bottom-up influences 115
. Top-down influences can
be seen as time-invariant or slow-changing phenomena such as individual difference
characteristics (demographics, personality factors, or health status). Bottom-up influences can
be viewed as different contextual or process variables that change over time and in shorter
timescales such as daily affect, symptoms or stress. Data from the studies presented here
support the position that physical activity can operate both as a top-down and bottom-up
influence on wellbeing/QOL in menopausal women whereby changes in physical activity
have been linked to changes in menopause-related QOL over time, albeit indirectly. The
more immediate effects of daily physical activity on outcomes such as symptoms, affect, and
coping resources (in Studies IV-VII 112,113,116,117
) at the daily and momentary levels would
support effects of physical activity on important bottom-up influences on wellbeing of
menopausal women. In other words, one would expect fluctuations in physical activity (i.e.,
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144
deviations from usual activity) to be reflected in changes in different physical, self-related,
and cognitive functional outcomes which are likely to impact domain-specific or global
wellbeing/QOL. The strength of the effects would then be expected to be greater at the level
of the intermediate (more proximal) outcomes than the more distal outcomes such as life
satisfaction, just as shown in my other work 96,118,119
and in Study II 114
. To maximize the
impact of physical activity on QOL/wellbeing, interventions should thus target activities that
are personally meaningful and that demonstrate measureable improvements in proximal
outcomes such as affect, self-efficacy and self-worth, enhancing sense of personal control,
competency and enjoyment.
3. Physical activity effects on menopausal symptoms, vasomotor in particular,
warrant further study, but acute exercise is unlikely to exacerbate hot flashes in
most healthy women.
There has been controversy regarding the role that physical activity plays with respect to
vasomotor symptoms such as hot flashes and night sweats. This controversy stems from
inconsistent and generally low quality research. Cross-sectional studies typically report
positive effects of physical activity on vasomotor symptoms and QOL 72,77,78
, while
prospective studies provide contradictory results 33,36,120
. Only few randomized controlled
trials evaluating physical activity effects on symptoms and QOL during menopause exist, and
these have provided inconsistent results and are often underpowered 121–123
. Aiello et al. 80
reported an increase in vasomotor symptoms in some women following a 12-month moderate
intensity exercise program and at least one study suggests that lifetime exercisers may report
more frequent or severe vasomotor symptoms during menopause 124
. Hot flashes are believed
to be caused by altered neurotransmitter release in the hypothalamus leading to altered
regulation of the thermoregulatory centre 125
and are triggered by small elevations in core
body temperature acting within a reduced thermoneutral zone (mainly due to a lowering of
the core body temperature threshold for sweating). It has been suggested that exercise may
acutely exacerbate or trigger hot flashes by increasing core body temperature 126,127
. A recent
Cochrane review of studies on the topic have failed to find sufficient evidence for physical
activity alleviating vasomotor symptoms 128
and the North American Menopause Society has
recently removed exercise from their list of recommended treatements for lack of evidence 71
.
In Study IV 112
both objective and subjective methods of assessment were applied to
study the effects of acute exercise and habitual physical activity on vasomotor symptoms.
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145
The results have shown that a single bout of acute exercise does not increase objectively or
subjectively assessed hot flashes (contrary to a pre-existing view, from a single study 126
, that
has influenced clinical recommendations for menopausal women), but that at the withinperson
level, increasing levels of moderate-intensity physical activity performed on a daily
basis may be associated with increased reporting of vasomotor symptoms, particularly in
women with low levels of cardiorespiratory fitness. Previously inactive low-fit women may
thus be at risk of perceiving their symptoms as intensifying when first initiating behavior
changes. For these women, increasing physical activity levels gradually is essential along
with other (behavioral, cognitive) strategies to help ease symptom burden. These results
along with demonstrated person-specific effects in Study V 113
may help explain why
demonstrating consistent effects of physical aktivity is difficult.
Clearly, more quality research is needed to further investigate the mechanisms of the
relationship between physical activity and vasomotor symptoms. Especially needed are
sufficiently powered randomized controlled trials as well as experimental studies to shed light
on the causal mechanisms involved in hot flashes, and also to increase our understanding of
when, why, and for whom there is a relationship between physical activity and vasomotor
symptoms 129
. Along with these efforts, there should be a greater acknowledgement of the
other effects regular physical activity may have on psychological outcomes that may help
build resiliency in the face of bothersome symptoms. The work of my doctoral student in
Study VII 117
has demonstrated that daily physical activity generates positive affect and
coping efficacy which may help women cope better with symptoms. Specifically, using daily
diary data from 21 days of reporting, multi-level mediational analyses demonstrated that on
days when a woman engaged in more physical activity than was typical for her, she also
reported more positive affect and higher coping efficacy both of which were assocated with
lower symptom burden. Importantly, these effects were non-significant at the betweenperson
level suggesting one way in which physical activity may help a woman to cope with
her symptoms is through the enhancement of positive affect and coping efficacy in the
context of daily experiences.
Finally, it should be noted that not all physical activity is created equal and that different
modalities may exert different effects. A recent review of mind-body intervention studies
indicated that different intervention approaches (which included physical activity and yoga)
impact different types of symptoms differentially. For example, physical activity was found
to reduce hot flashes and mood symptoms (though results were mixed), whereas relaxation
therapy with mindfulness-based stress reduction training was shown to reduce sleep and
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146
mood symptoms, and yoga to reduce hot flashes and improve cognitive, sleep, and pain
symptoms 130
. In Study I 81
, we also observed effects of differenct magnitude by exercise
modality on different types of symptoms. From a clinical translational perspective this means
that women with different symptom clusters would be expected to benefit differentially from
different interventions, highlighting a need for multi-component approaches that could be
tailored to subgoups of women with specific characteristics. Nonetheless, regardless of
vasomotor symptoms, given the well-demonstrated physical and mental health benefits of
physical activity, sustained physical activity participation through young adulthood into
midlife will remain key to optimizing health through the menopausal transition.
4. The use of within-person methodologies can meaningfully contribute to
increasing our understanding of physical activity behavior and its effects on
wellbeing outcomes.
The use of within-person methodologies in my work has provided additional meaningful
insights into individual differences in responses to physical activity in middle-aged women as
well as into the within-person dynamics in motivation linked to physical activity participation
and wellbeing outcomes in younger populations of adolescents and emerging adults (six
manuscripts to date). These studies have demonstrated that daily physical activity is regulated
by both automatic and controlled motivational processes and that it influences QOL at the
within-person level.
There are great individual differences in the way women experience menopause but little
is known about what underlies this variation. In Studies IV-VII 112,113,116,117
intensive
longitudinal designs were employed to unveil the dynamics of the physical activity –
symptom relationship at the within-person levels. Study V 113
specifically applied a personspecific
time series model to best describe the dynamic patterns underlying each individual
time series. Within-person analysis identified significant relations between physical activity
(PA) and hot flashes (HFs) in 50% of subjects, although the specific PA indicators that
predicted HFs varied, both in terms of direction and magnitude. Perceived control over HFs
was the variable that most consistently differentiated between women for whom more PA
was associated with fewer HFs as compared to those for whom more PA was associated with
more HFs, but other individual difference characteristics such as affect, depressive
symptoms, and anxiety were identified. In recent years, this methodology as well as
analytical approaches accomodating this methodology have gone through substantial
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development, allowing for sophisticated sub-group analyses of commonalities between
elements of sets of subject-specific state-space models, potentially helping to identify distinct
subtypes of symptom and physical activity experiences (e.g., for women with personality
profiles indicative of increased somatization or by residential/occupational status).
Ultimately, such analyses can be done dynamically in real time through data collected in real
life settings on an ongoing basis (e.g., through smartphones or wearable sensors). The
promise of combining technology with understanding of individual and contextual factors
that contribute to health behaviors and health outcomes lies in the possibility of designing
effective “just-in-time” or ecological momentary interventions (EMIs) 131
that could help
individuals cope “in the moment” with acute symptoms or aid in behavior change.
5. Inactivity and sedentary behavior deserve attention as intervention targets for
optimizing wellbeing during menopause along with the exploration of
complementary intervention modalities involving cognitive restructuring,
mindfulness or other contemplative practices.
The results of Study VI 116
demonstrated detrimental effects of inactivity on affect.
Specifically, using EMA data across 15 days, in models that controlled for day of week,
number of hot flashes, and total minutes of accelerometer wear time, greater concurrent
positive affect was associated with fewer minutes spent being sedentary (β = -.31, p < .01).
Neither lagged positive nor negative affect predicted later SB, however, more sedentary
minutes predicted lower positive affect at the next occasion (β = -.04, p < .01). Affective
experiences may also predict future engagement in physical activity (as per hedonic theory of
motivaion) 132
, pathway which may place sedentary women into a vicious cycle of low
positive affect reinforcing inactivity. Additionally, as shown in Study VII 117
, positive affect
may serve as an important psychological resource when coping with symptoms during
menopause and is also related to QOL (Study II) 95,114
. Menopause has also been identified as
a window of vulnerability to psychological disturbances including negative mood, depressive
symptoms, or even increased risk of first-time onset depression 97
, all of which have been
linked to more severe menopausal symptoms. Women leading sedentary lifestyles (also
linked to obesity which is another risk factor for menopausal symptoms) may thus be
particularly at risk for a problematic menopausal transition. Future intervention efforts should
thus focus on reducing or interrupting sedentary behavior to lessen the detrimental effects
sedentary behavior appears to have on positive affect, along with efforts to promote physical
activity as key to enhancing wellbeing during menopause and successful aging beyond.
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Any intervention efforts to modify behavior should be accompanied by intervention
strategies for the management of menopausal symptoms, if symptomatic. These strategies
may be particularly important for women with high trait anxiety and neuroticism. Cognitive
behavioral therapy has been shown effective for the treatment of menopausal symptoms
including vasomotor symptoms such as hot flashes and night sweats 133,134
and could be easily
incorporated into physical activity programs or with the use of technology 135
. Similarly
promising for symptom management (as well as behavior change) have been mindfulnessbased
practices such as meditation or yoga 71,136
.
Future Directions
The findings presented in this thesis provide valueable, novel insights into the
dynamics of physical activity and wellbeing relationship in menopausal women, relevant to
the fields of health psychology, psychology of physical activity, women´s health, adult
development and aging. Most of what is known about the physical activity and menopausal
wellbeing relationship stems from studies that have examined between-person differences in
physical activity and wellbeing outcomes (e.g., epidemiological studies), whereby a woman´s
typical (average) level of physical activity is associated with typical (average) levels of
wellbeing (or symptoms). This approach is limited and may not be appropriate as betweenperson
variation does not always reflect individual-level process137,138
. Investigating
intraindividual variability in outcomes of interest, such as through the application of intensive
longitudinal designs and EMA methodologies, offers important insights into intraindividual
variability in outcomes over time and can also reveal psychological processes at play. Across
seven studies (four of which have utilized such methods), the idiosyncratic nature of physical
activity effects on menopausal wellbeing has been demonstrated, along with noteable
individual difference characteristics and plausible casual pathways for how physical activity
could be used or targeted to enhance wellbeing as women transition through menopause.
From a theoretical standpoint, the findings complement other work in the health and
physical activity psychology fields on the nature of intraindividual variability in psychosocial
outcomes and physical activity behavior. Intensive longitudinal designs and EMA methods
have exploded in recent years especially in the areas of affective outcomes, symptom
reporting, or cognitive functioning139–141
. Not only have these investigations helped
characterize individual differences in how affect, symptoms, or cognition change over time or
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149
in response to interventions, but they have highlighted the importance that context and the
person-by-context interactions play in determining health and wellbeing outcomes. In spite of
using EMA methods in studies presented here, the design (with random daily assessments)
did not lend itself ideally to more thorough investigation of the role that context plays in the
(in)activity-wellbeing relationship. Event- or context-congintent signals (as opposed to
random or symptom triggered) should be incorporated in future EMA studies to better
evaluate the role of context. Future work should also utilize EMA-derived data to test
suppositions of existing theories, most of which have been tested using between-person
approaches only. For example, the transactional theory of stress and coping views coping as a
process best studied in the moment and as it unfolds over time and across differing
situations142,143
. By applying EMA methods one can accomplish assessment of within-subject
factors and the intraindividual variability in experiences and behaviors as they unfold in reallife
settings and over time, allowing for testing of casual pathways hypothesizing the links
between behaviors, coping, and stress. Similarly, the suppositions of theories of health
behavior such as the social cognitive theory or theory of planned behavior could be tested in a
more rigorous fashion applying intensive data methods. That is, one could test in a dynamic
fashion whether changes in cognitions (e.g., self-efficacy, intentions) drive changes in
behaviors and whether the underlying processes operate as hypothesized by these theories.
Such testing could lead to refinement of exising theories and their greater practical utility144
.
From a developmemtal, lifespan perspective it will be important to conduct
longitudinal studies that could accomodate investigations of both short-term and long-term
(between- and within-person) variability in outcomes such as measurement burst designs145
.
Acknowledging that development (and aging) is the result of multiple co-acting influences
which are sensitive to context and thus inherently person-specific138
, person-oriented theories
and single-subject designs should be incorporated into the study of menopause and wellbeing.
In social psychology and behaviroal science more broadly, there is also an increasing
awareness of the need to consider systems level approaches such as dynamical systems
theories given that behavior and behavior change is nonlinear and involves interaction of
multiple levels of influences across different timescales146
. These trends are partially fueled
by advancement in behavior tracking technologies that allow for passive, continuous, and
intensive data capture. Approaches utilizing such data will require application of advanced
statistical methods that span subject-specific data analysis methods, mixture modeling,
multilevel structural equation modeling, or time-varying effect models.
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150
From a practical standpoint, the research presented suggests that „one size fits all“
types of interventions will not be the most effective for enhancing wellbeing during the
menopausal transition, especially in women who experience a range of menopausal
symptoms. Given that 85% of women will experience symptoms at some point during their
menopausal transition70
, intervention strategies that are tailored to the needs of different
women are called for. These strategies should also include multiple components to maximize
both fitness effects and symptom management. Any such intervention should be based on a
good understanding of the factors involved in symptom experiences, the casual pathways
linking physical activity behavior, symptoms and wellbeing, as well as the context within
which it is to be applied. To this end, future research must incorporate methods of intensive
monitoring in everyday life to accurately evaluate symptoms experiences across different
contexts and over time, and to allow for intervening in the moment, in the best way possible,
and at the right time.
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151
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