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This is to certify that the
thesis entitled

THE RELATIONSHIP BETWEEN THE FREQUENCY OF EXERCISE AND
NUMBER AND LEVEL OF BOTHER OF MENOPAUSAL SYMPTOMS.

presented by

Luanne M. Robarge Kraus

has been accepted towards fulfillment
of the requirements for

Master of Science . Nursing
degree in

 

 

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THE RELATIONSHIP BETWEEN THE FREQUENCY OF EXERCISE AND
NUMBER AND LEVEL OF BOTHER OF MENOPAUSAL SYMPTOMS.

By

Luanne M. Robarge Kraus

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING
College of Nursing

1997

ABSTRACT
THE RELATIONSHIP BETWEEN THE FREQUENCY OF EXERCISE AND
NUMBER AND LEVEL OF BOTHER OF MENOPAUSAL SYMPTOMS.
by

Luanne M. Robarge Kraus

This study analyzed the relationship between exercise and the symptoms
of menopause: hot flashes, weight gain, difficulty sleeping, flooding, vaginal
dryness, irregular periods, depression, fluid retention, mood swings, headaches,
fatigue and tender breasts. This secondary analysis, included 200 women, 40 to
65 years of age and used data from the Decision Making in Menopause Study
(Rothert, 1990). Participants identified their frequency of exercise, the number
and level of bother of menopausal symptoms utilizing a questionnaire. The
conceptual framework for this study was Newman’s System Model. A
relationship was found between the frequency of exercise and the number of
menopausal symptoms the women reported, and with the level of bother that

they reported experiencing menopausal symptoms.

To Ken, Michael, Lisa and Dad

iii

ACKNOWLEDGMENTS

I would like to extend my appreciation to my thesis chair, Marilyn Rothert
for her support. In addition, I would like to thank Barbara Given and Geraldine
Talarczyk for their time and effort as members of my committee.

I thank my family for their support and patience throughout the course of
my graduate study and especially during the long hours spent on this thesis. I
look fowvard to spending time with them, instead of with Nike and the computer.
Thanks to my dad who ran countless errands with the kids and supported me
more than he will ever know.

Thanks to my special friends, Dorothy and Pam, and to our thesis support
group (Andi, Jan, Kathy, Debbi, and Sandy). Without their support and
encouragement I would never have completed my thesis.

Thanks also, to Betty Marshall for her assistance in literature searches

and for obtaining literature and miniature roses that no one else could find.

iv

TABLE OF CONTENTS

LIST OF TABLES ............................................... vii
LIST OF FIGURES .......................................... viii
INTRODUCTION ................................................ 1
Summary of Conceptual Definitions of Variables .................. 14
Research Question ........................................ 16

Study Relevance .......................................... 17
CONCEPTUAL FRAMEWORK .................................... 18
REVIEW OF LITERATURE ....................................... 23
METHOD OF STUDY ............................................ 26
Study Design ............................................. 26
Sample ................................................. 26
Variable Operational Definitions and Instruments of Measurement . . . . 27

Data Collection ............................................ 29

Data Analysis ............................................. 30
HUMAN SUBJECT PROTECTION .................................. 32
RESULTS ..................................................... 32
Study Sample ............................................ 32
Findings ................................................. 38
Question 1 ............................................ 38
Question 2 ............................................ 38
DISCUSSION .................................................. 41
Assumptions ............................................. 44
Limitations ............................................... 44
Implications for the Advanced Practice Nurse .................... 45
Further Studies ........................................... 46
APPENDICES ................................................. 47
Appendix A: Measure for Menopausal Status .................... 49
Appendix B: Measure for HRT ............................... 50

Appendix C: Decision Making in Menopause Study Menopausal

Symptoms Instrument ........................... 51
Appendix D: Decision Making in Menopause Study Symptom
Management and Self-Care Instrument .............. 53
Appendix E: UCHRIS Approval ............................... 54
LIST OF REFERENCES .......................................... 55

vi

LIST OF TABLES

Table 1 - Frequency of Demographics Variables of Participants ........... 33

Table 2 - The Level of Bother That Participants Identified They Experienced
with Menopausal Symptoms .................................. 36

Table 3 - Number of Menopausal Symptoms Participants Identified as
Experiencing .............................................. 37

Table 4 - Multiple Regression Analysis of Menopausal Symptoms
and Exercise with Control for HRT ............................. 40

vii

LIST OF FIGURES

Figure 1 -The Rothert List of symptoms for menopause compared to three
symptom Checklists used most consistently in previous menopausal
studies. ................................................. 13

Figure 2 - Neuman’s System Model ................................. 19

Figure 3 - Neuman’s System Model as It Relates to Menopause and
Exercise ................................................. 22

viii

INTRODUCTION

Menopause is a natural occurrence in all women as they age. It is the
time when a decreasing number of ovarian follicles produce less of the female
hormones, estrogen and progesterone. Menstrual periods change in
characteristic and finally cease completely (Walsh 8 Schiff, 1990). It usually
occurs between 40 to 55 years of age with the average age being 51.4 years
(Uphold & Graham, 1994). Greenblatt stated in 1966 that "the life history and
destiny of each woman are dependent to a great degree on the intensity and
duration of her ovarian function." In the 1990's many women are looking at
menopause not as the end of youth, but as the beginning of new opportunities
(Friedan, 1993; Jacobowitz, 1993; & Sheehy, 1992).

There has been a Change in age distribution of US. females. In 1900
only 14.9% of the female population were 40 and 64 years of age (US. Bureau
of Census, 1975). By 1970 26.8% of the female population were between 40
and 64 years of age (US. Bureau of Census, 1975). It is projected that by the
year 2000, 39% of the female population will be of the ages 40 to 65 years (US.
Bureau of Census, 1994). This includes the female "baby boomers" born
between 1946 and 1964 who are now entering the menopausal years. Over the
next decade approximately 16 million American women will enter menopausal

years (Scharbo-DeHaan, 1994).

2

With the life expectancy of a woman at 79.7 years of age, about one third
of a woman's life will occur after menopause (US. Bureau of Census, 1994). An
increase in the life expectancy of a woman does not ensure good health in a
woman's later years. The quality of life She experiences in these later years may
be affected by the lifestyle Choices she makes at menopause. One important
choice is to live a sedentary lifestyle or to be physically active through exercise.

After menopause, women have an increased risk of cardiovascular
disease, osteoporosis and deterioration of glucose tolerance (Skouby, 1994).
Bush (1990) reports that nearly 53% of deaths in women over fifty years of age
are due to cardiovascular disease. Obesity is one of the risk factors for
cardiovascular disease (Gorodeski & Utian, 1994). Exercise can lead to
decreased weight.

Osteoporosis can be found in half of the women in the United States over
50 years of age (Paganini-Hill, 1994). Osteoporosis results from calcium loss in
bones which occurs at a rate of 2%-4% per year for the first three years following
menopause and then 1% each year after that (Wren, 1984; Carlucci, 1991).

This loss of bone mass leaves a woman susceptible to fractures such as a
femoral neck fracture or vertebral fracture (Lindsay, Hart, Abdalla and Dempster,
1986). Studies show that hormone replacement therapy prevents or slows bone
loss (Weiss, Ure, Ballard, Williams & Daling, 1980; Notelovitz, 1990). Exercise
not only prevents loss, but when exercise is continued, a modest increase in
bone mass can be achieved (Forward & Burr, 1993; Caplan & Ward, 1993;

Grove & Londeree, 1992, Notelovitz; 1986).

3

Not all the adverse side effects of menopause are long term. The
symptoms of menopause can be felt at the early stages of menopause. The
symptomatology of menopause varies with each woman. Kronenberg (1990)
uses the estimates that 75% of American women experience symptoms of
menopause and that 15% of these women are affected severely. The symptoms
of menopause come from a progressive decrease in hormones that leads to
vasomotor instability and target tissue atrophy. Common symptoms of
menopause include hot flashes, night sweats, difficulty Sleeping, headaches,
irregular periods, heavy menstrual flow, vaginal dryness, swelling, fluid retention,
tender breasts, and weight gain. This study will focus on the relationship
between the frequency of exercise to the number of menopausal symptoms, and
to the level of bother of the menopausal symptoms women report.

Elm

In spite of a growing body of evidence supporting the health benefits of
exercise, less than half of the American population exercise at least three times
per week for 20 minutes or more (US. Department of Health and Human
Services, 1994). Exercise is defined in The Webster’s Dictionary (1981) as
"bodily or mental exertion designed for training, developing or keeping in
condition." The American College of Sports Medicine states that exercise, to be
of health benefit, needs to involve repetitive use of large muscle groups at a
moderate intensity for at least 20 minutes or more, three to five times per week
(US. Department of Health and Human Services, 1994).

The effects of exercise on health are the foci of many studies (Pronk,

4
Crouse, & Rohack, 1995; Kottis, Rosen, Cosgrove, Shindler, & Wilson, 1994;

Maroulakis & Zervas, 1993; Pronk, Crouse, & Rohack, 1995; Choi, VanHom,
Picker, & Roberts, 1993; Thomas, Londeree, Lawson, Ziogas, & Cox, 1993).
These studies on exercise used a specific training program for a limited time.
The problem with this approach is one of practicality. In order for exercise to be
of long term benefit, it must become part of a person's lifestyle (US. Department
of Health and Human Services, 1994). An exercise program, therefore, must be
enjoyable, convenient and realistic. If the exercises are found to be fun and
enjoyable a person is more apt to incorporate them into his/her daily activities,
than exercises that are tedious and/or difficult. A barrier to exercise can be
inconvenience. If an exercise program requires expensive equipment, high-
priced health Club fees or long, time consuming commutes, the person is less apt
to continue with the program. The exercise program needs to fit the person's
present level of fitness. A program that is too physically demanding will cause
frustration and lead to defeat. The focus Should be on the enjoyment and the
benefits of the exercise, not on the preparation, expense or pain.

In this study each participant designed the exercise program that fit her
lifestyle. If, after starting her exercise program, the participant found it did not
work as she planned, she was allowed to revise the program. Exercise was
defined as any aerobic physical activity that involves the repetitive use of large
muscle groups. The exercises did not need to be weight bearing for this study.
The level of exercise was defined by the number of times per week the

participant identified she was involved in the planned exercise.

Menopause

The terms menopause, perimenopause, and climacteric have been used
interchangeably (Hargarten, 1994 and Notelovitz 8 van Keep, 1986), although
they do have different meanings. Menopause is the permanent cessation of the
menstruation. It results from the loss of ovarian response to gonadotropic
hormone stimulation and leads to a decrease in estrogen and progesterone
production. Surgical menopause occurs with the removal of both ovaries.
Natural menopause occurring before the age of forty years is considered
premature menopause (Notelovitz 8 van Keep, 1986 and Walsh 8 Schiff, 1990).

The perimenopausal or climacteric years can be divided into three
phases, premenopausal, perimenopausal and postmenopausal. Premenopausal
is the time prior to the menopause, when follicular activity is decreased enough
to cause some hormonal change. Menstrual periods may become irregular in
timing and Character. This usually occurs between the ages of 35 and 45 years
(Bachmann, 1991; Diczfalusy, 1986 and Hargarten, 1994). Perimenopause is
the time immediately prior to the cessation of menstruation and continues for one
year following the menopause (Speroff, 1994; Notelovitz, 1986).
Perimenopause usually occurs between the ages of 45 and 55 years.

Postmenopausal years continue after the cessation of menstruation to 65
years old. After 65 is traditionally considered the "geriatric years" (Notelovitz,
1986). Cessation of hormone production becomes evident with the cessation of
menstruation. Postmenopausal years follow the perimenopausal time and

usually occur between the ages of 55 and 65 years of age. Long term side

6

effects resulting from a loss of estrogen may begin to become evident, such as
an increase risk of cardiovascular disease, osteoporosis, and glucose
intolerance (Bachman, 1991; Diczfalusy, 1986; 8 Hargarten, 1994).

In summary, menopause is the permanent cessation of menstruation.
The symptoms of menopause can occur, however, in the premenopausal years
and continue through the postmenopausal years. The premenopausal years can
begin as early as 35 years of age with menopause, itself, occurring after the age
of 40 years. Postmenopausal years may last beyond the age of 65 years,
however, the years after the age of 65 are traditionally considered the “geriatric
years.” Women between 40 and 65 years of age were included in this study.
Using this age group eliminated women experiencing premature menopause.
H91; Flashes And Exercise

The hallmark symptom of menopause is the hot flash or flush.
Kronenberg (1994) reports the prevalence of hot flashes increases throughout
the time of the menopause. Of premenopausal women, 6% to 63% will
experience hot flashes, while the percent of women reporting hot flashes during
the time of postmenopause is 58% to 93%. A hot flash is an unpredictable,
recurring episode where a woman has the feeling of warmth starting in her upper
torso and sweeping upward to her head. It may or may not be preceded by an
aura. The woman's face may turn red and she begins to sweat. Some women
sweat to the point of soaking their garments. This sweating is followed by the
body cooling down causing the woman to feel Chilled and to even shiver. This

can be embarrassing and intrusive. It is reported that hot flashes can affect

7

sleep (Kronenberg, 1994). Hot flashes can cause the woman to sweat to the
extent of requiring a change of bedding and may occur several times in one night
(Erlik, Tatartyn, Meldrum, Lomax, Bajorek 8 Judd, 1981). This interference with
sleep leads to daytime fatigue, irritability, impaired memory, and poor
concentration (Walsh 8 Schiff, 1990).

The exact cause of hot flashes is not known. Estrogen therapy is
currently the most effective treatment (Kronenberg, 1994). Campbell and
Whitehead (1977) found estrogen therapy to decrease hot flashes by 40 to 50%.
There is a paucity of studies on treatments for hot flashes other than hormone
replacement therapy (HRT). In a study by Hammar, Berg and Lindgren (1990) it
was found that physically active women enrolled in a gymnastic club reported
less frequent hot flashes than the sedentary control group. Hammar included
postmenopausal women with natural menopause who did not use hormone
replacement therapy.

In summary, hot flashes can occur throughout the menopausal years. Hot
flashes can be not only embarrassing, but lead to difficulty sleeping, fatigue,
irritability, impaired memory and poor concentration. HRT is the current Choice
of treatment. There has been a paucity of studies on treatment for hot flashes
outside of HRT. This study will look at the relationship of exercise to hot flashes
for women who use HRT as well as for those women who do not use HRT.

i rin S m ms And Ex rci
Bachman (1990) states that the genitourinary mucosa can be affected by

menopause and become dryer, less elastic, and thinner. These changes can

8

cause an increase in discomfort and an increase in incidence of infections. As
the vaginal walls become smoother, dryer and less elastic, the menopausal
woman is more susceptible to vaginal infections. The vagina Shortens and
narrows. Vaginal discharge can cause irritation and burning or intense itching.
This irritation can interfere with sleep (Bachman, 1994). The vaginal dryness
can lead to a decrease in libido. Hormone replacement therapy is currently the
most effective treatment (Bachman, 1994).

Changes in the urinary tract can lead to an increase in urinary tract
infections as well as irritation and burning on urination or even bladder
dysfunction. The effects of hormone replacement therapy on the female urinary
tract are being studied (Formosa, Brincat, Cardozo, 8 Studd, 1994). There were
no studies found demonstrating that strenuous exercise leads to uterine, rectal
or vaginal prolapse.

Strengthening the pelvic muscles, with Specific pelvic muscle exercises,
can eliminate or at least decrease urinary stress incontinence in some women
(US Department of Health and Human Services, 1992; Burns, Pranikoff,
Nochajski, Desotelle 8 Hanrvood, 1990). Pelvic muscle exercises called Kegel
exercises are performed by contracting the pubococcygeus muscle.

In summary, hormone replacement therapy is currently the most effective
treatment for the genitourinary symptoms of menopause. Specific exercises,
such as pelvic muscle exercises have been Shown to have a positive effect on
urinary stress incontinence. No other studies were found regarding the effects of

exercise on the genitourinary symptoms of menopause.

Wsight Gain Ans Exersiss

Women tend to gain weight at a rate of .8 kg/year in the perimenopausal
years. It is questioned if weight gain is a result of aging or directly related to
menopause (Gorodeski 8 Wulf, 1994). Weight is gained when the caloric intake
exceeds the calories expended by the body. An increase in weight, especially in
the abdominal area is associated with an increased risk for cardiovascular
disease, hypertension, impaired glucose tolerance, and diabetes. One of the
Side effects of estrogen is weight gain (Kuhn, 1991).

Caloric restriction will lead to weight loss. The weight loss results from a
loss of fat and muscle (Shangold, 1994), As women age, their bodies naturally
lose lean muscle mass and gain fat (Kart, Metress 8 Metress, 1992). Increasing
physical activity by exercising can burn calories, increase muscle strength, raise
resting metabolism and decrease the appetite (Kart, Metress 8 Metress, 1992).

In summary, women tend to gain weight during the menopausal years.
HRT can lead to further weight gain. Exercise can have a positive effect on the
weight gained during the menopausal years by burning calories, increasing
muscle strength, raising resting metabolism and decreasing the appetite.
Esyshslogical Symptoms And Exsrciss

The psychological symptoms of menopause are more controversial than
the physical symptoms of menopause. It has been argued that psychological
symptoms such as anger, rage, anxiety, depression, nervousness, mood swings
and difficulty sleeping are a result of life events. Life events that a woman may

experience during menopause include children leaving home, death or illness of

10

a spouse or parent, Changes in job roles and the perceived loss of her own
youthfulness. Several studies have failed to document any change in
psychological symptomology during the time of menopause (Neugarten 8
Kraines, 1965; McKinlay, Brambilla 8 Posner, 1992). Other studies have shown
that the majority of women seeking medical assistance related to menopause
demonstrate psychological symptomatology (Ballinger, 1975; Anderson,
Hamburger, Lui 8 Rebar, 1987; Montgomery, Bincat, Tapp, Appleby, VerSi,
Fenwick 8 Studd, 1987). The data from these studies Show that not all women
experience noticeable psychological symptomatology, but that the majority of
women who are seen by a health care professional for menopause do exhibit
psychological symptoms. Menopause is the result of changes in the body.
These changes cause stress in the body. A woman will, therefore, have less
tolerance of sources of stress outside of the body (Cobb, 1990).

Caplan, Ward and Lord (1993) studied postmenopausal women and
exercise. They found women who voluntarily enrolled in an exercise program,
consisting of exercise three times per week scored significantly higher on the
"Life Satisfaction Index" than the control group who did not join the exercise
program. Exercise as simple as walking can reduce anxiety, depression, and
fatigue (Carlucci, Goldfine, Ward, Taylor 8 Rippe, 1991; Hargarten, 1994).

In summary, the psychological symptoms, whether caused by a reaction
to life events or directly by menopause may be decreased by regular exercise.
In this study the psychological symptoms included were: depression, mood

swing, difficulty Sleeping, and fatigue.

1 1
Sympggms Chssklisg

Just as the symptomology of menopause varies with each woman, so do
the lists of symptoms used in research differ with each study. The problem with
the symptoms of menopause is that the majority of symptoms are subjective.
Very few menopausal symptoms lend themselves to the objectivity of Clinical
tests.

Three menopausal symptoms checklists have been used most
consistently in menopause research: the Blatt Menopausal Index (1953) called
the BMI, the Neugarten and Kraines Checklist (1965), and the International
Health Foundation Index (1975). Researchers have adapted these lists to their
studies. Rothert et al. (1990), in The Decision Making in Menopause Study did
not use the BMI, the Neugarten and Kraines Checklist or the International Health
Foundation Index. The list of menopausal symptoms used for this study were:
hot flashes or flushes, weight gain, difficulty Sleeping, flooding (heavy menstrual
flow), vaginal dryness, irregular periods (bleeding), depression, swelling or fluid
retention, mood swings, headaches, fatigue-tiredness, and painful or tender
breasts. This list was derived from a previous study by Rothert et al. (1990), The
Women’s Use of Information Regarding Hormone Replacement Therapy Study.
The original symptom list included 55 items. These 12 symptoms were found to
be the most bothersome.

A summary comparison to the BMI, the Kraines and Neugarten Checklist
and the International Health Foundation Index can be found in Figure 1. Nine of

the symptoms on the Rothert menopausal symptom list (hot flashes, weight gain,

12

difficulty sleeping, heavy menstrual flow, depression, mood swings, headaches,
breast pain and fatigue) are common to the other checklists. Vaginal dryness,
irregular periods and fluid retention were not found on the other Checklists.
These symptoms were among the symptoms women reported as most
bothersome in The Women’s Use of Information Regarding Hormone
Replacement Therapy Study (Rothert et al., 1990). These three symptoms are
also Cited in literature as symptoms of menopause (Bachman, 1990; Walsh 8
Schiff, 1990). In this study, the Rothert Checklist of menopausal symptoms was

employed.

13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Symptoms Blatt Neugarten International Health Rothert
(1953) 8 Kraines Foundation Index (1990)
(1965) (1975)

Vasomotor flashes/night

sweats/perspiration x x x x
Weight gain x x
Difficulty sleeping x x x x
Heavy menstrual flow x x
Vaginal dryness x
Irregular periods x
Depression x x x x
Fluid retention x
Mood swings x x
Headaches x x x
Breast pain x x
Fatigue x x x x

 

Figure 1. The Rothert List of symptoms for menopause compared to three

symptom Checklists used most consistently in previous menopausal studies.

 

14
Summary of Conceptual Dsfinitipns pf Variablas
Menopausal years

Menopausal years for this study was defined by age. Women between 40
and 65 years of age, regardless of menopausal status or use of HRT were
included. Using this age group eliminated women experiencing premature
menopause (Notelovitz 8 van Keep, 1986; 8 Walsh 8 Schiff, 1990).

Menopausal status was defined using the same terms as used by Wilbur,
Dan, Hedricks and Holm (1990):

Premenopausal: still having natural menstrual periods or last menstrual

period was less than 3 months ago.

Perimenopausal: last menstrual period was 3 to 12 months ago.

Postmenapausal: last menstrual period was more than 12 months ago or

had both ovaries removed.

n I m tom

Menopausal symptoms included: hot flashes, weight gain (over 10 lbs),
difficulty Sleeping, flooding (heavy menstrual flow), vaginal dryness, irregular
periods, depression, swelling or fluid retention, mood swings, headaches,
fatigue-tiredness, and painful or tender breasts (Rothert et al., l990).
W

Bother is a subjective feeling. Webster (1981) defines bother as an
annoyance or causing a disturbance. In a study by Hammar in 1990 the degree
to which menopausal symptoms affected the participants was measured using

the term “severity.” Severity was defined by the participant as “no symptoms,

15

mild, moderate and severe symptoms.” Webster defines severity as the state of
being in extreme distress. For this study the term bother was considered less
subjective.
Exercise

Exercise can involve both physical and/or mental exertion for the purpose
of training (Webster, 1981). Exercise in the original study included mental
activities, such as meditation, as well as physical activities. For the purpose of
this study exercise followed the guidelines of the American College of Sports
Medicine. Exercise was defined any aerobic physical activity that involves the
repetitive use of large muscle groups (US. Department of Health and Human
Services, 1994).
W

Exercise can be measured by numerous methods, including physical
measurements, i.e. heart rate, or by a set of defined activities, i.e. walking on a
treadmill. The original study encouraged each participant to design an exercise
program to fit her individual lifestyle, therefore strict Clinical measurements were
not possible. The American College of Sports Medicine states that exercise, to
be of health benefit, needs to involve repetitive use of large muscle groups,
three to five times per week (US. Department of Health and Human Services,
1994). In keeping with this guideline, this study measured the number of times

per week the participant identified she was involved in aerobic physical activity.

16
R r h ti n

For most of history menopause was looked at as a natural and
unfortunate occurrence in women (Wilson, 1966; Utian, 1990). With the advent
of hormone replacement therapy, menopause was looked at in a new light. It
was now being described as an endocrine problem, a hormone deficiency
(Wilson, 1966). Wilson (1953) stated that women no longer had to suffer the
effects of estrogen deprivation which were "physically and emotionally
devastating." Menopause had a "cure." The cure was hormone replacement
therapy.

Hormone replacement therapy does not completely eliminate menopausal
symptoms. Some women still report symptoms such as hot flashes,
genitourinary problems and psychological symptoms (Kronenberg, 1994).
Women on hormone replacement therapy who are still experiencing symptoms
of menopause may also need to find methods to further decrease their
symptomatology. Many women do not use hormone replacement therapy.
Kronenberg found that only 10 to 15% of women eligible for hormone
replacement therapy use hormone replacement therapy. For some women
hormone replacement therapy is contraindicated. Hormone replacement therapy
is contraindicated in women with a history of breast cancer, recent endometrial
cancer, vaginal bleeding of unknown etiology, acute liver disease or acute
vascular thrombosis. (Shoupe 8 Mishell, 1994). This leaves a large group of
women who are not receiving the benefits of hormone replacement therapy

and need an alternative method of managing their menopausal symptoms

17

and preventing the long term effects. Exercise may be of benefit to those
women not using hormone replacement therapy. It may also benefit women
using hormone replacement therapy who may or may not be experiencing
menopausal symptoms.

The research question for this study is:

IS there a relationship between the frequency of exercise reported by
women during the menopausal years to:

a. the number of menopausal symptoms identified by these women?

b. the level at which these women describe menopausal symptoms

bothersome?

It is hypothesized that there is a relationship between the level of exercise
and the number of menopausal symptoms identified by women. It is further
hypothesized that there is a relationship between the frequency of exercise and
the level at which women describe menopausal symptoms bothersome.

l v e

Hormone replacement therapy is presently the treatment of Choice for
menopausal symptoms. Many women, however, do not use hormone
replacement therapy . Exercise may be able to help these women to decrease
or alleviate menopausal symptoms. It may also be of use to those women who
use hormone replacement therapy and may or may not be still experiencing
menopausal symptoms.

By employing the nursing process, the Advanced Practice Nurse (APN)

would be able to assess those women who would benefit from exercise. The

18

APN would also assess the patient for the type and amount of exercise most
appropriate for each patient and evaluate the effectiveness of the exercise plan.

Cost containment is very important in the plan of care for the patient. An
exercise program can be designed to fit within economic restraints. An exercise
program can be designed to be Simple and inexpensive.

With proper assessment and planning an exercise program has few, if
any, negative side effects. Research has demonstrated that the benefits of
exercise can be far reaching to include reducing long term risk factors such as
cardiovascular problems, osteoporosis and impaired glucose tolerance and
diabetes.

CONCEPTUAL FRAMEWORK

The conceptual framework for this study was Neuman's Systems Model
(Neuman, 1995). Neuman uses a holistic approach to the patient, whom she
calls the client. The Client's health or wellness is described as system stability.
A client's wellness is protected by lines of defense beginning with a central core.
Neuman uses concentric rings to diagram this idea (Figure 2). The central core
of a person consists of basic survival factors common to all human beings.
Surrounding this core Neuman describes three levels of defense. The rings
Closest to the core are the lines of resistance. At this level the person's system
attempts to stabilize the system and return to the normal level of resistance. The
next group of rings represent the normal lines of defense and lie between the
lines of resistance and the flexible lines of defense. This level represents the

person's normal level of wellness or system stability. It is the level of wellness

19

 

 

 

 

 

 

 

 

 

 

 

.5 a .82 .5385 .282 cmanz 9: m 2:9“.

 

 

 

 

 

20

that the person has developed over their lifetime to this point. This is the level at
which a standard of wellness can be used to compare any subsequent changes
in system stability. The outer rings represent the flexible lines of defense and
are the lines that protect the person's normal lines of defense. This is the first
line of defense a person has against the stressors encountered. The flexible
lines of defense are the most dynamic. They can be altered over a short period
of time. Its effectiveness can be decreased by negative factors, such as lack of
sleep or poor nutrition. Its effectiveness can be strengthened by positive factors
such as adequate sleep, balanced nutrition, or exercise (Ross 8 Bourbonnais,
1980; Cross, 1990).

The client interacts with the environment on a continuous basis. The
relationship between the client and the environment is reciprocal. The
environment and the person are continuously influencing each other. Neuman
divides the environment into the internal and the external components. The
internal component consists of all the forces that are contained within the
person. The external component consists of all the forces that are contained
outside of the client.

Stressors can come from either the internal or external environment or
from both. Stressors are divided into intrapersonal, interpersonal and
extrapersonal. The intrapersonal stressors are those stressors found within the
person. This could include factors such as physiological, psychological or
developmental stressors. The interpersonal stressors are those that occur

between the Client and another individual or group of people. This could include

21

the relationship with family members or social groups. The extrapersonal
stressors are those that occur outside of the individual system. This would
include social norms, laws, or job status.

In the Neuman Systems Model the goal is system stability, which can be
threatened by stressors. These stressors are resisted by person's lines of
defense. The stronger the flexible lines of defense, the more resistant to
stressors the client will be.

Following the Neuman Systems Model, wellness in this study was defined
as being free of menopausal symptoms (Figure 3). The intrapersonal stressors
would be the decrease in estrogen and progesterone and possibly a perceived
loss of youthfulness. Interpersonal stressors can involve changes in family
relationships, Spouse relationships and midlife events such as Children leaving
home, job changes, illness or death of a spouse, or aging parents.
Extrapersonal stressors, those occurring outside the individuals’s system, include
cultural expectations of women of menopausal age and world events. A
symptom occurs when stressors break down the normal lines of defense. This is
a felt response to the invading stressor (Meleis, 1991). In Neuman’s System
Model, the relationship between the client and the environment is reciprocal.
Using this framework, when a woman experiences menopausal symptoms she
will react with her environment. This reaction will affect her relationship with
others as well as herself and may further increase her stressors.

Strong flexible lines of defense can prevent stressors from reaching the

normal lines of defense, thereby, preventing or stopping symptoms from

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23

occurring (Cross, 1990). The flexible lines of defense can be strengthened with
exercise (Ross 8 Bourbonnais, 1980).

It is hypothesized that the menopausal woman can strengthen her flexible
lines of defense with exercise and thereby decrease or eliminate menopausal
symptoms.

REVIEW OF LITERATURE

Although numerous studies have been conducted on menopause and
exercise, the majority of these have been on the long term effects of
menopause, such as cardiovascular disease and osteoporosis (Bush, 1990;
FonNard 8 Burr 1993; Grove 8 Londeree, 1992). Only three studies on the
relationship between exercise and the acute symptoms of menopause were
found. Hammar (1990) studied 79 women who were going through natural
menopause. The participants had no history of using hormone replacement
therapy. A self-selected group of women participated in physical exercise at a
gymnastics Club an average of three hours per week. Physical activity for the
control group was not monitored. The control group consisted of women who did
not want to join the gymnastics club. The percentage of women reporting no hot
flashes was higher in the physically active group than in the control group. The
most significant difference was in the severity of the hot flashes. The physically
active group reported less severe and less frequent hot flashes than the control
group. The weakness of this study was the failure to monitor the physical activity
of the control group. It is difficult to determine if the decrease in frequency and

severity of hot flashes was actually due to physical activity or to social interaction

24
at the gymnastics club.

A second study on exercise and acute menopausal symptoms was
conducted by Wilbur, Dan, Hedricks and Holm (1990). The study of 386 women
looked at menopausal status, menopausal symptoms, energy expenditure and
aerobic fitness. Menopause was defined as:

"Premenopausal: normal menses during the 12 months preceding

the study.

Perimenopausal: irregular or infrequent menses over the past 12 months.

Postmenopausal: no menopause over the past 12 months and

self-description as postmenopausal.

Hysterectomy: uterus removed and at least one ovary intact." (p. 69).

Menopausal symptoms were defined using the Kaufert and Syrotuik
Symptom Index. The menopausal symptoms in this scale are: hot flashes, night
sweats, fatigue, irritability, nervousness, depression, headaches, and trouble
sleeping. Weight gain, menstrual flow, vaginal dryness, fluid retention or breast
pain were not included in the study. Energy expenditure was measured using an
"intensity code” (p.70). This was an estimated amount of energy expended
relative to the resting metabolic rate. Included in this study was energy
expended during occupational activities, leisure time, and household activities.
Aerobic fitness was measured by the "submaximal heart rate exercise test on a
bicycle ergometer” (p.70). American Heart Association guidelines were used to
control for age effects.

Wilbur et al. (1990) did not find a change in hot flashes or night sweats

25

related to physical activity. Exercise, however, was found to decrease the non-
vasomotor symptoms: fatigue, irritability, nervousness, depression, headaches,
and trouble sleeping. This supports the findings of others related to exercise
having a positive affect on the psychological health (Blair, Kohl Paffenbarger,
Clark, Cooper, 8 Gibbons, 1989; Taylor, Sallis, 8 Needle, 1985).

The third study was conducted by Wallace, Lovell, Talano, Webb and
Hodgson (1982). Wallace studied pre-menopausal women (mean age 43.1 1|;
2.8 years) and post-menopausal women (mean age 53.7 i 3.7 years). Blood
samples were drawn before and after a physical conditioning program to
measure hormone levels. It was found that exercise Significantly increased
estradiol for both pre-menopausal and post-menopausal. The conclusions drawn
were that exercise:

"1) appears to change climacteric symptomatology in post-menopausal

women
2) may delay the onset of menopause in pre-menopausal women"
(p. 154).

The weakness of this study was the short report did not give enough
detail. It is, therefore, impossible to evaluate appropriateness of the research
process. The strength of this research project was the objective method of
measuring the effect of exercise, a blood test.

In summary, a review of the literature found three studies on the
relationship between exercise and the symptoms of menopause. All three

studies found exercise to have a positive affect on the symptoms of menopause.

26

Exercise was most reported to affect the non-vasomotor such fatigue, mood
swings, depression, sleep difficulty and headaches. None of these studies,
however, examined the affect of exercise on weight gain, menstrual flow, vaginal

dryness, fluid retention or breast pain.

METHOD OF STUDY
u D i n

This study was a secondary analysis using the data from the Decision
Making in Menopause Study (Rothert et al., 1990), funded by National Institute
of Health, National Center for Nursing Research, grant number NR 0124-04A2.
The overall objective of the study was to develop and test an educational
intervention to inform women about hormone replacement therapy and empower
them to interact positively with the health care system. The purpose of this study
is to describe the relationship between the frequency of exercise reported by
women during the menopausal years, the number of menopausal symptoms
identified and the level at which these symptoms were rated as bothersome.

Sample

The original study used a non-probability convenience sample. Three
hundred women over the ages of 40 years were recruited from a moderate sized
Michigan City by using newspaper, radio, and television announcements. Letters
were sent to those women who were interested in participating in the study. Of
the 300 women recruited, 252 completed the study. For this secondary analysis,

complete data were available on 200 participants. Participants were primarily of

27

the white race (193 or 96.5%), three (1.5%) were African-American and one
(.5%) was Hispanic. Over ninety-Six percent had incomes of $15,000 or above.
Most of the participants (198 or 99%) had a high school or higher education.
The demographics of race and education were not reflective of the community.
The participants included in this study were: 1) female, 2) 40 years of age or
older, 3) able to read and speak English. Menopausal status or use of
medications were not included as participation criteria.
Vri bl O r i naID flniti fM

The original study used a self administered questionnaire. The
instruments used were tested in a pilot study (Rothert, et.al., 1990). Measures
were taken four times during twelve months: pre-intervention (T1), 3 months
post-intervention (T2), 6 months post-intervention (T3), and 12 months post-
intervention (T4). In this study, only the items on the original questionnaire
collected at T4 and related to menopausal symptoms and exercise were utilized.

n us I a

The participants were asked to identify when their last natural menstrual
period occurred using the following scale: 1 = still having Dalila! menstrual
period; 2 = less than 3 months ago; 3 = 3 to 12 months ago; 4 = more than 12
months ago; and 5 = not sure (Appendix A). Only those answering 3 or 4 were
considered to be menopausal.

rm n R la m n Th r T
To identify those who were using HRT, the women were asked to describe

their present experience with HRT as 1 = currently taking; 2 = have never taken;

28

3-7 = have taken in the past but discontinued for various reasons (Appendix B) .
Only women currently taking estrogen or estrogen/progesterone at Time 4 were
considered as using HRT.
m tom f Meno ause

Each participant was asked to rate the menopausal symptoms she was
experiencing using the Decision Making in Menopause Study Menopausal
Symptom Instrument. This instrument listed the following twelve menopausal
symptoms: hot flashes or flushes, weight gain (over 10 lbs.), difficulty sleeping,
flooding (heavy menstrual flow), vaginal dryness, irregular periods, depression,
swelling or fluid retention, mood swings, headaches, fatigue-tiredness, and
painful or tender breasts (Appendix C). These twelve symptoms were found to
be the most frequently identified as bothersome in the Use of Information
Regarding Hormone Replacement Therapy Study (Rothert et al., 1990).
W

Each participant was asked to rate how much she was bothered by each
one of the twelve menopausal symptoms on a scale of 1 to 5, with 1 = She was
not experiencing this symptom or didn’t believe it was related to menopause;
2 = does not bother her at all; 3 = bothers her a little; 4 = bothers her somewhat;
and 5 = bothers her a great deal (Appendix C).

re nc of Exercise

Each participant was asked to identify her frequency of exercise.

Exercise was defined as any aerobic physical activity that involves the repetitive

use of large muscle groups. The frequency of exercise was rated by the

29

participant on a scale of 1 to 5 with 1 = never; 2 = sometimes but less than once
a week; 3 = 1-3 times per week; 4 = 4-6 times per week and 5 = everyday.
(Appendix D). There were two ways that the participants were asked about
exercise frequency. The first, asked if the participant exercised for health
promotion and the second, if she exercised for menopausal symptoms. The
results of both of these items were analyzed.

Data Cpllestian

The women recruited for the Decision Making in Menopause Study were
given a questionnaire to complete. The questionnaire included the Decision
Making in Menopause Study Symptom Index and the Self Care Instrument. The
participants met at the university to complete the questionnaires. A member of
the research team was present to describe the purpose of the study, obtain an
informed consent, give instructions on completing the questionnaire, answer
questions, and to collect the completed questionnaires. It is the data collected
from the Decision Making in Menopause Study Symptom Index and the Self
Care Instrument at Time 4 that were used in this study.

In the original study, the participants were randomly divided into three
groups. All three groups received the same intervention, but the method and
intensity of delivery varied. The intervention was educational in nature. The first
group (Group A, N=88) received a written brochure describing menopause,
menopausal symptoms, long term postmenopausal risk factors, hormone
replacement therapy and methods to improve their health. The brochure

encouraged the participant to eat balanced meals which included 800 to

30

1000 mg. of calcium daily and to perform "regular weight bearing exercises such
as biking or yoga...for at least 20 minutes....three times per week" (p. 4). The
second group (Group B, N=81) was given the same brochure as the Group A,
plus participated in a lecture/discussion program. The third group (Group C,
N=83) was also given the same brochure as Group A, and participated in
interactive sessions designed to support the participant’s decision making
process. All three groups were given similar information regarding exercise and
its benefits. Knowledge scores for the three groups did not vary significantly
according to the intensity of the mode of delivery. For the purpose of this study
Groups A, B, and C, were combined and only the participants with complete data
were included (N=200).
D I i

Data collected from the 200 participants in the Decision Making in
Menopause Study Symptom Index and the Self Care Instrument at Time 4 were
utilized. Using SPSS for Windows program, the data were analyzed to
determine the relationship between exercise and the number of menopausal
symptoms and the relationship between exercise and the level of bother of
menopausal symptoms as identified by the participants. The effect of HRT was
controlled. The level of statistical significance was set at .05. Descriptive
statistics were utilized to show the demographic characteristics of the
participants. The demographic characteristics included age in years, ethnicity,
education, marital status, employment, household income, menopausal status,

and use of HRT.

31

The relationship between the experimental groups and the level of
exercise was examined using one-way ANOVA. The analysis of variance
revealed no significant differences between Group A, B, or C (F Prob. = .7551,
2-tail Significance = .750). For the purpose of this study the three groups were
combined (N=200).

Multiple regression was used to determine the relationship between the
variables and to accept or reject the null hypothesis with the significance level
set at p 5 .05. The null hypotheses are:

Ho1 = There is no relationship between the frequency of exercise and the
number of menopausal symptoms the participants report.

Ho2 = There is no relationship between the frequency of exercise and the
level of bother of menopausal symptoms the participants report.

In analyzing exercise and the number of menopausal symptoms, HRT
was entered as the first independent variable and exercise as the second
independent variable. The number of menopausal symptoms was the
dependent variable. To test the second hypothesis, HRT was entered as the
first independent variable, with exercise entered as the second independent

variable. Level of bother was the dependent variable.

Introducing HRT as the first independent variable reduced the potential of

a Type I Error, that is, observing a significant relationship between exercise and
the dependent variables that actually were due to HRT. As discussed earlier,
HRT is the treatment of Choice for most women experiencing hot flashes and

vaginal dryness. Since HRT was entered as the first independent variable, the

32

variance shared in common by HRT and exercise were attributed to HRT.
HUMAN SUBJECT PROTECTION

The original study was approved by the University Committee on
Research Involving Human Subjects (UCRIHS) on 5l10/94. A letter of
permission to use the data from the Decision Making in Menopause Study for
this secondary analysis was obtained. This study was approved by UCRIHS on
6/3/96 (Appendix E). Protection of the rights of the participants was guaranteed
by following the protocol. Data utilized was in aggregate form. There were no
subject identifiers, thereby, maintaining confidentiality.

RESULTS
W

The study used a non-probability convenience sample. Of the 300
women recruited, 252 completed the study and complete data were available on
200 participants (N = 200). Demographic characteristics collected included: age
in years, ethnicity, education, marital status, employment, household income,

menopausal status, and use of HRT (Table 1).

33

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 1. Fraguanpy pf Demographic Variablss at Eafiisipants.
Characteristic 11 Frequency

Age 200 Number Percent
40 - 45 62 31
46 - 50 83 41.5
51 - 55 48 24
56 - 60 5 2.5
61 - 65 1
Race 200

African-American 3 1 .5
Hispanic 1 .5
American Indian 1 .5
White 193 96.5
Other 2 1
Education 200

High School Graduate 15 7.5
Greater than 12 years 53 26.5
Technical trade 25 12.5
Bachelor’s Degree 52 26
Master’s Degree 37 18.5
PhD/Professional Degree 16 8
Other 2 1
Marital Status 200

Married 136 68
Divorced 47 23.5
Single 15 7.5
Widowed 2 1

 

 

Table 1 (continued).

 

 

 

 

 

 

 

 

 

 

 

Employment 200

Full-time 125 62.5
Part-time 40 20
Retired 12 6
Not employed 19 9.5
Other 4 2
Household Income 200

Under $14,000 9 4.5
$15,000 - $29,999 21 10.5
$30,000 - $49,999 54 27
$50,000 - $99,999 92 46
$100,000 - $200,000 18 9
Over $200,000 4 2
Not answered 2 1
Using HRT 200

Yes 65 32.5
No 135 67.5
Menopausal Status 200

Premenopausal 1 15 57.5
Perimenopausal 20 10
Post-menopausal 65 32.5

 

 

35

Participants were primarily of the white race, between the ages of 40 and
55 years (N = 193), and married (N = 136). The sample was highly educated,
with the majority having completed greater than 12 years of education (N = 183),
and 26.5% (N = 43) had obtained a master's degree, Ph.D., or other professional
degree. Only 4.5% (N = 9) had household incomes under $14,000. The majority
had household incomes greater than $29,999 (N = 170; 85%).

Most of the participants were premenopausal (N = 115; 57.5%), or
post-menopausal (N = 65; 32.5%). This was reflected in the number of
participants who were using HRT at Time 4 (N = 65; 32.5%). The participants
identifying as post menopausal did not make up the entire group taking HRT.

When measuring the status of menopausal symptoms, a large number of
participants reported that they were not bothered or experiencing menopausal
symptoms (N = 98 to N = 141; 34% to 70.5%). This may be related to 115
(57.5%) of the participants being premenopausal. Weight gain was the symptom
identified as bothering most of the participants to the greatest degree (N = 33;
16.5%). Flooding or having heavy menstrual flow was identified as least
bothersome by the largest number of participants (N =141; 70.5%) (Table 2).

In evaluating the number of symptoms reported, a large number of
participants reported no symptoms (N = 45; 22.5%). Only two (1.0%)

participants reported experiencing all twelve symptoms (Table 3).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table2. l 0 Mr I ' I .04 0 0 I _.9‘|‘|;0.
MthencpausaLSxmptcms
Not Little Somewhat Great Bother
Variable Experiencing Bothered Bothered
or No Bother
Depression 124 (62.0%) 38 (19.0%) 23 (11.5%) 15 ( 7.5%)
Difficulty Sleeping 125 (62.5%) 30 (15.0%) 29 (14.5%) 16 ( 8.0%)
Flooding 141 (70.5%) 18 ( 9.0%) 27 (13.5%) 14 ( 7.0%)
Headache 125 (62.5%) 37 (18.5%) 22 (11.0%) 16 ( 8.0%)
Hot Flashes 124 (62.0%) 44 (22.0%) 13 ( 6.5%) 19 ( 9.5%)
Irregular Periods 133 (66.5%) 37 (18.5%) 21 (10.5%) 9 ( 4.5%)
Mood Swings 114 (57.0%) 43 (21.5%) 25 (12.5%) 18 ( 9.0%)
Breast Pain 129 (64.5%) 48 (24.0%) 20 (10.0%) 3 ( 1.5%)
Swelling 128 (64.0%) 42 (21.0%) 18 ( 9.0%) 12 ( 6.0%)
Tiredness 98 (49.0%) 48 (24.0%) 32 (16.0%) 22 (11.0%)
Vaginal Dryness 132 (66.0%) 32 (16.0%) 25 (12.5%) 11 ( 5.5%)
Weight Gain 125 (62.5%) 21 (10.5%) 21 (10.5%) 33 (16.5%)
Mean 124.83 36.5 23.0 15.67
Std. Dev. 9.79 8.95 4.86 7.07

 

 

 

 

 

 

[1:200

 

37

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 3. Numbar pf Menppausal Symptpms Eartisipants Idantifiag as

Number of Symptoms Responses Percentage
0 45 22.5%

1 14 7.0%

2 1 1 5.5%

3 15 7.5%

4 21 10.5%

5 14 7.0%

6 10 5.0%

7 18 9.0%

8 23 1 1.5%

9 10 5.0%

10 10 5.0%

11 7 3.5%

12 2 1.0%

Total 100.0%

 

 

 

 

 

[1:200 Mean=4.43 Std. Dev.=10.13

38

ti n

IS there a relationship between the frequency of exercise reported by
women during the menopausal years to the number of menopausal symptoms
identified by these women?

In analyzing the relationship between the frequency of exercise and the
number of menopausal symptoms reported, multiple regression was utilized. In
the multiple regression equation (N = 200), HRT was entered as the first
independent variable and exercise as the second independent variable. The
number of menopausal symptoms was the dependent variable. The R2 change
for exercise, controlling for HRT was .047, F Change (1,197) = 9.74 with p<.05,
at p = .0024, indicating that there was a relationship between exercise and the
number of menopausal symptoms. In summary, the hypothesis was supported.
QM

Is there a relationship between the frequency of exercise reported by
women during the menopausal years to the level at which these women describe
menopausal symptoms bothersome?

In analyzing the relationship between the frequency of exercise and the
level of bother for each of the twelve menopausal symptoms, HRT was again
entered first in the multiple regression equation. Exercise was entered as the
second independent variable in the equation. Twelve regressions were
performed. Each of the twelve symptoms was entered into a separate

regression equation as the dependent variable. The results of the regression

39

analysis indicated that R2 values and the associated p values for the variables;
flooding, headache, hot flash, irregular periods, breast pain, swelling, vaginal
dryness and weight gain were greater than the accepted .05 level of statistical
significance, and therefore were not statistically significant. However, for the
dependent variables; depression, difficulty sleeping, mood swing, and tiredness,
the R2 values and the associated p values of less than the .05 level
demonstrated statistical significance. Refer to Table 4 for the specific statistical

results of each symptom.

40

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table4. Itio-l R-o - ionAnI ' f n-u. - , moot
with Cpntrpl far HRT.
Symptom R2 Change Beta p
vahua

Depression .042 -.206 .0009
Difficulty sleeping .063 -.254 .0003
Flooding .0001 -.012 .8702
Headache .012 a112 .1142
Hotflash .014 A123 .150
Irregular period .006 -.077 .183
Mood swings .061 -.248 .0004
Breast pain .003 -.055 .744
Swelling .013 —.1 15 .105
'Tfiednessfiafigue .056 'n239 .0001
Vaginal dryness .007 -.087 .440
Weight gain .002 -.047 .505

 

 

p=200; pg .05

41
DISCUSSION

This study investigated the relationship between exercise and the number
of menopausal symptoms women reported and the level at which these
symptoms became bothersome. Previous studies demonstrated a potential
effect of exercise on the severity of hot flashes (Hammar et al., 1990). Wallace
et al., (1992) found that exercise increased estradiol both in pre-menstrual and
post-menstrual women. The results from this study indicated no significant
correlation between changes in the dependent variables; flooding, headache, hot
flashes, irregular periods, breast pain, swelling, vaginal dryness, or weight gain
and the independent variable; exercise. As HRT is the treatment of choice for
the physical symptoms of menopause, HRT was entered into the multiple
regression equation as the first independent variable and exercise as the second
independent variable. The variance, therefore, shared in common by HRT and
exercise were attributed to HRT.

Wilbur et al., (1990) also found a decrease in the non-vasomotor or
psychological symptoms: fatigue, irritability, nervousness, depression,
headaches, and trouble sleeping. This study did find a positive correlation
between the independent variable; exercise and the dependent variables;
depression, difficulty Sleeping, mood swings and fatigue. Difficulty sleeping,
mood swings and fatigue can be symptoms of depression (US. Department of
Health and Human Services, 1993). Using a Pearson Correlation between
depression and difficulty sleeping, mood swings and fatigue would have

demonstrated if these were related to menopause or more closely to depression.

42

This could mean that depression was measured twice, first as depression and
secondly by the symptoms of depression. Studies by Carlucci, Goldfine, Ward,
Taylor and Rippe (1991) and Hargarten (1994) found that exercise can reduce
psychological symptoms, irrelevant of the cause of the symptoms. This finding is
Clinically significant as earlier studies have shown that the majority of women
seeking medical assistance related to menopause demonstrate psychological
symptomalogy (Ballinger, 1975; Anderson, Hamburger, Lui 8 Rebar, 1987;
Montgomery, Bincat, Tapp, Appleby, Versi, Fenwick 8 Studd, 1987).

The results of this study may have been stronger with the elimination of
the 45 (22.5%) participants who identified experiencing no menopausal
symptoms. The mean number of symptoms reported in this study was 4.3
symptoms with a standard deviation of 10.13. With the removal of the 45
participants experiencing no symptoms, the mean number of symptoms
identified is 5.72 symptoms with a standard deviation of 5.65. Removing the 45
participants would improve the clarity of the results.

In summary, there was not a significant relationship between exercise and
the menopausal symptoms of flooding, irregular periods, headache, hot flashes,
breast pain, swelling, vaginal dryness or weight gain. The R2 for depression,
fatigue, mood swings, and difficulty Sleeping were very small after controlling for
HRT (.042, .056, .061, .063) but significant. This study supports using a
combination of HRT and exercise to decrease the number and level of bother of
menopausal symptoms.

The conceptual framework for this study was Neuman's Systems Model

43
(Meleis, 1991; Cross, 1990; 8 Fawcett, 1989). A client's wellness is protected

by lines of defense. The flexible lines of defense are the most dynamic. They
can be altered over a short period of time. Its effectiveness can be strengthened
by positive factors such as exercise (Ross 8 Bourbonnais, 1980; Cross, 1990).
This conceptual framework was supported by previous studies and by this study.
Wallace et al. (1982) studied the physiological effects exercise has on women's
hormone levels. An increase in the client's estradiol level resulted in a decrease
in the amount of intrapersonal stress exerted on the flexible line of defense.
Wilbur et al. (1990) and Hammar et al. (1990) found a correlation between
exercise and a decrease in the severity of menopausal symptoms. Hammar

et al. (1990) concluded that social interaction as well as exercise played a role in
the decrease in severity of menopausal symptoms. In relationship to Neuman’s
model, Wilbur and Hammar’s studies intervened at the flexible lines of defense.
A decrease occurred in the interpersonal and the extrapersonal stressors. This
resulted in the strengthening of the flexible lines of defense, thus protecting the
normal lines of defense.

In summary, this study indicated no significant relationships between
exercise and physical menopausal symptoms when controlling for HRT. It did
demonstrate a positive correlation between exercise and the psychological
symptoms of menopause. While HRT can decrease the physical symptoms of
menopause, exercise can improve a women’s psychological well-being. Her
lines of defense can be strengthened, thus enabling her to cope with all the

stressors of menopause.

44
Ammutieus.

1. The women participating gave accurate answers.

2. The women were literate and understood the questions on the
questionnaire.

3. This study was a secondary analysis of data from the Decision Making
in Menopause Study (Rothert et al., 1990). It is, therefore, assumed that the
data were handled and recorded properly.

1. This study was a secondary analysis of data from the Decision Making
in Menopause Study (Rothert et al., 1990). The original tool was not designed to
measure specifics of exercise. The definition of exercise needed to be more
clearly defined.

2. The duration and intensity of physical activity was not defined or
evaluated.

3. The convenience sample was not reflective of the community. The
results of this study cannot be generalized beyond the sample.

4. Using secondary analysis, it was not possible to correct or control
extraneous variables such as calcium intake, or diet.

5. As the study analyzed data from Time 4, it was the fourth time that the
participants had completed the questionnaire. It is possible that the participants
answers were influenced by the Hawthorne effect.

6. No menopausal symptoms were experienced or found bothersome by

22.5% of participants.

45

7. Co-Iinearity of depression may have occurred with mood swings,
difficulty sleeping and fatigue.

In summary, this study was limited by being a secondary analysis. The
study did support previous studies (Wilbur et al.,1990 8 Hammar et al, 1990) on
the positive relationship between of exercise and menopausal symptoms. The
conceptual framework of this study, Neuman’s System Model was supported by
this study.

ILilliflfiiltions for WW

By the year 2000, 39% of the female population will be between the ages
of 40 and 64 (US. Bureau of Census, 1994). Kronenberg (1990) uses the
estimate that 75% of American women experience symptoms of menopause.
This study demonstrated a positive correlation between exercise and the
psychological symptoms of depression, mood swings, difficulty sleeping and
fatigue. This is supported by previous studies (Wilbur et al.,1990; 8 Hammar et
al., 1990). Beyond these studies, exercise has been found to decrease the long
term results of menopause, such as the risk factors for cardiovascular disease,
osteoporosis, impaired glucose tolerance and diabetes.

Employing the nursing process, the Advanced Practice Nurse (APN) can
use history-taking and physical assessment skills to assess menopausal
symptoms and those women who would benefit from exercise as well as the type
and amount of exercise most appropriate for each patient. This creates an
opportunity for the APN to use patient counseling and teaching skills,

approaching the patient in a caring and non-judgmental manner. During

46

subsequent office visits the APN could evaluate the effectiveness of the exercise
plan with the patient.

Menopause is a complex phenomenon. The choices to use or not to use
HRT or other therapies can be very confusing for a women. The APN must
listen to the concerns of the women experiencing or questioning menopausal
symptoms. Using patient education, the APN can empower the patient to make
self care decisions that will promote positive health outcomes.

An exercise program is an important part of a woman's treatment plan.
Exercise plans can be designed to fit within economic constraints. An exercise
program can be designed to be simple and inexpensive. Health promotion prior
to permanent consequences is cost-effective and an important role of the APN.
With proper assessment and planning an exercise program has few, if any,
negative side effects but many potential positive effects.

The APN can also serve as a role model for the patient by participating in
health promoting activities, such as regular exercise. An exercise plan is
important for the individual APN as well as for the patient.

In summary, this study supports the role of the APN as a primary health
care provider, including the areas of a role model, patient advocate, counselor,
and as an educator for patients, their families and the community.

M

The area of exercise and menopausal symptoms needs further research.

Although HRT is the treatment of choice for most women with menopausal

symptoms, not all women can or chose to use HRT. This study found a positive

47

relationship between exercise and depression, difficulty sleeping, mood swings
and fatigue, however, it was unable to generalize this beyond a Similar
population of women.

Future research could be designed as longitudinal studies to specifically
measure the effect that the intensity and duration of exercise has on menopausal
symptoms. When designing such a study, the sample needs to reflect a larger,
more diverse population of women. The criteria for admission could be limited to
perimenopausal women or women presently experiencing menopausal
symptomology.

Future studies including longitudinal and clinical studies on defining the
symptoms of menopause are needed. The present lists of symptoms varies
among studies making comparison between studies or building on past studies
cumbersome. Depression or symptoms of depression could be used, but not
both. Participants could be screened for depression due to other underlying
causes.

As research continues to evaluate the appropriate hormone replacement
therapy most beneficial to women, alternative or conjunctive therapies need to
be further studied. Such studies could evaluate the effects of diet,
mineral/vitamin supplements, support groups, diversional activities or the effect
of employment, marriage, financial status or cultural on menopause.

In summary, this study only touched a small area of the needed research
on menopause. As more women enter the menopausal years, the impact of

appropriate health care choices will effect not only the health of the individual

48

woman, but this of this nation as a whole. Healthy women are better able to
contribute to this nation’s future than women compromised by the effects of

menopause.

APPENDICES

APPENDIX A

49
APPENDIX A

Measur r en 1 t

Check your answer sheet. You should now be filling in row number 9

10.

11.

12.

13.

HEALTH BACKGROUND

How many months ago was your last natural menstrual period (unrelated to hormone therapy)?

 

l = Still have natural menstrual period
2 = Less than 3 months ago

3 = 3 to 12 months ago

4 = more than 12 months ago

5 = Not sure

 

Using the scale below, indicate how severe you think your menstrual problems are or were prior

10 menopause.

l = No Problems

2 = Minor Problems

3 = Moderate Problems

4 = Severe Problems

5 = Very Severe Problems

Do you currently consider yourself to be experiencing menopausal symptoms?
I = No, have never experienced menopausal symptoms

2 = Yes, currently experiencing menopausal symptoms

3 = Not presently experiencing menopausal symptoms but have in the past

4 = Not sure

Have you had a hysterectomy (an operation where the doctor removed all or part of your uterus)?

I = Yes
2=No
3 =Not sure

Have one or both of your ovaries been removed?
I = Yes, both ovaries removed

2 = Yes, one ovary removed

3 = No

4 = Not sure

@1992 Michigan State University
College of Nursing
4

APPENDIX B

50
APPENDIX B

W

Check your answer sheet. You should now befitting in row number 14

For items 17-21, please indicate your experience with hormone replacement therapy by choosing
one of the following responses for each type of therapy listed.

17.

18.

19.

20.

21.

= I am currently taking this.
2 = I have never taken this.
3 = I have taken this in the past but discontinued it because of side effects.
4 = I have taken this in the past but discontinued it because I no longer needed it for symptoms.
5 = I have taken this in the past but discontinued it because I re-evaluated the safety of taking it.
6 = I have taken this in the past but discontinued it because my health care provider

recommended that I discontinue taking it.

7 = I have taken this in the past but discontinued it for reasons not listed above.

Estrogen pills and progestogen pills ( e.g., premarin and provera).
Estrogen patch and progestogen pills.

Progestogen pills alone.

Estrogen patch alone.

Estrogen pills alone (e.g., Premarin).

@1992 Michigan State University
College of Nursing
5

APPENDIX C

51
APPENDIX C

DECISION MAKING IN MENOPAUSE STUDY
MENOPAUSAL SYMPTOMS INSTRUMENT

We would like to know what menopausal symptoms you are experiencing and
how bothersome they are to you. Listed on the next few pages are a number of
symptoms which sometimes occur in women as they go through menopause.
Please read the list and identify which of these symptoms yap are experiencing.*

If you are not experiencing the symptom, because you are pre-
menopausal, on hormone therapy, past menopause or have had a hysterectomy,
PLEASE ANSWER “1".*

Ifyou are experiencing the symptom but you do not think it is relate to
menopause, PLEASE ANSWER “1".*

If you are currently experiencing the symptom AND you believe it is due to
menopause, please use the following scale to indicate how bothersome the
symptom is.*

We are interested in knowing only those symptoms which you believe are
caused by menopause or which you believe are diraptlyralatad to menopause.

Use the following scale to respond to items 50-61.

50.

51.

= I am NOT EXPERIENCIN G this symptom or I don't believe that it is related to

menopause.

2 = DOES NOT BOTHER ME AT ALL.
3 = BOTHERS ME A LITTLE.

4 = BOTHERS ME SOMEWHAT.

5 = BOTHERS ME A GREAT DEAL.

Hot Flashes or Flushes

Weight gain (over 10 lbs)

52. Difficulty sleeping

53. Flooding (heavy menstrual flow)

@1992 Michigan State University
College of Nursing
10

52
Check your answer sheet. You should now be filling in row 54
Use the following scale to respond to items 54-61.
Use the following scale to respond to items 50-61.
1 =1 am NOT EXPERIENCING this symptom or I don't believe that it is related to
menopause.
2 = DOES NOT BOTHER ME AT ALL.
3 = BOTHERS ME A LITTLE.
4 = BOTHERS ME SOMEWHAT.
5 = BOTHERS ME A GREAT DEAL.
54. Vaginal Dryness
55. Irregular Periods, Bleeding
56. Depression
57. Swelling or Fluid Retention
58. Mood Swings
59. Headaches
60. Fatigue-Tiredness

61. Painful or Tender Breasts

sc/l ZMOPOST
October 27, 1992

@1992 Michigan State University
College of Nursing
11

APPENDIX D

53
APPENDIX D

DECISION MAKING H\l MENOPAUSE STUDY
SYMPTOM MANAGEMENT AND SELF -CARE INSTRUMENT

Please choose the extent to which you use each of these for general health
promotion or disease prevention. Do not include items you are taking for a
specific disease or for occasional aches and pains such as headaches.

Use the following scale to respond to items 62-67.
1 = Never
2 = Sometimes but less than once a week
3 = 1-3 times per week
4 = 4-6 times per week
5 = Every Day
FOR HEALTH PROMOTION
62. I watch my diet
63. I do planned exercises

64. I take vitamins, mineral supplements or calcium supplements.

Please fill in the circle on your answer sheet that indicates the frequency of each of
these for helping with menopausal symptoms. Use the scale above.

FOR MENOPAUSAL SYMPTOMS

65. I watch my diet

66. I do planned exercises

67. I take vitamins, mineral supplements or calcium supplements

68. I take medications (prescription and non-prescription)

sc/ l ZMOPOST

Octobcr27. 1992 @1992 Michigan State University
College of Nursing
12

APPENDIX E

 

OFFICE OF
RESEARCH
AND
GRADUATE '
STUDIES

IInIversIty Commllm a
Research Involving
Iiuman Sub]
(UCRIHS)

Mld’ligan Stale University
232 Administration Building
East Lansing. Michigan
«undue

51 71355-21”
FAX 51 71432-1171

m Moan Sate mm
m s muaa'Dwsiiy,
turmnm.

ICU B M afimmmian.
anal-arming mam

    
  
  
  

54
APPENDIX E

CRlArI

MICHIGAN STATE
u N I v r. R s I T Y

June 5, 1996

TO: Luanne N. Kraus
1870 Crestwood Ln.
Muskegon, MI 49441
RE: IRB“: 96-352
TITLE: THE RELATIONSHIP BETWEEN FREQUENCY OF EXERCISE
AND THE NUBMER AND LEVEL OF BOTHER OF MENOPAUSAL
SYMPTOMS
REVISION REQUESTED: N/A
CATEGORY: 2-H
APPROVAL DATE: 06/03/96

The University Committee on Research Involving Human Subjects'IUCRIHS)
review of this project is complete.. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately

rotected and methods to obtain informed consent are appropriate.
Therefore, the UCRIHS approved this project and any reVisions listed
above. .

RKNEIAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown ve. Investigators planning to
continue a progect be ond one year must use the green renewal
form (enclosed with t e original approval letter or when a
project is renewed) to seek u ate certification. There.is a
maXimum of four_such expedite renewals SSible. Investigators
wishing to continue a progect beyond tha time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
1.:

subjects, rior to initiation of e change. If this is done at
the.time o renewal, please use the green renewal form. To
reVise an approved protocol at an 0 her time during the year,
send your written request to the. CRIBS Chair, requesting reVised
approval and referenCing the progect's IRB fl and title. Include
in your request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.
PROBLEMS]

CHANGES: Should either of the followin arise during the course of the

‘work, investigators must noti UCRIHS promptly: (l) roblems
(unexpected side effects, comp aints, e c.) involving uman
subjects.or (2) changes in the research environment or new
information indicating greater risk to the human sub ects than
eXisted when the protocol was previously reviewed an approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355o2180 or FAX ($1714 2- 171.

vid E. Wright. Ph

CRIBS Chair
DEW:bed

Sincerel

cc: Marilyn Rothert

LIST OF REFERENCES

55

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”IIIIIIIIIIIIIIIIIES