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Effect of programmed exercise on perceived stress in middle-aged and old women: A meta-analysis of randomized trials

  • Author Footnotes
    1 M.P. Nigdelis is a member of the EMAS Junior Mentorship Programme (JuMP).
    Meletios P. Nigdelis
    Footnotes
    1 M.P. Nigdelis is a member of the EMAS Junior Mentorship Programme (JuMP).
    Affiliations
    Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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  • Samuel J. Martínez-Domínguez
    Affiliations
    Facultad de Medicina, Universidad de Zaragoza and Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain
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  • Dimitrios G. Goulis
    Affiliations
    Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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  • Faustino R. Pérez-López
    Correspondence
    Corresponding author at: Facultad de Medicina, Universidad de Zaragoza and Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain.
    Affiliations
    Facultad de Medicina, Universidad de Zaragoza and Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain

    Department of Obstetrics and Gynecology, Lozano-Blesa University Hospital, Zaragoza, Spain
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  • Author Footnotes
    1 M.P. Nigdelis is a member of the EMAS Junior Mentorship Programme (JuMP).

      Highlights

      • Meta-analysis of randomized controlled trials on the effect of exercise on perceived stress in midlife and older women.
      • There was no significant effect of exercise on perceived stress in medium-term nor in long-term exercise interventions.
      • Medium-intensity programmed exercise had no effect on perceived stress.

      Abstract

      Objective

      To clarify the effect of programmed exercise (PE), performed for at least six weeks, on perceived stress (PS) in middle aged and old women.

      Methods

      A structured search was carried out in PubMed, Embase, Cochrane Library, Scielo, Web of Science and Scopus, from database inception through January 10, 2018, without language restriction. The US, UK, and Australian clinical trials databases were also searched. The search included a combination of the terms “programmed exercise”, “perceived stress”, “menopausal women” and “randomized controlled trial” (RCTs). PE was classified according to duration as “mid-term exercise intervention” (MTEI; mean duration 6 months), and “long-term exercise intervention” (LTEI; mean duration 12 months). Mean ± standard deviations of changes in PS scores, as assessed with different questionnaires, were calculated as standardized mean differences (SMDs) and used as effect size for meta-analysis. SMDs of PS after intervention were pooled using a random-effects model. Study quality and bias risk were assessed with the Cochrane tool.

      Results

      Five RCTs that studied midlife and older women (mean age 47.0 ± 1.7 years minimum to 71.8 ± 5.6 maximum) were included in the meta-analysis. There was no significant effect of PE on PS score (SMD: −0.16; 95% CI: −0.43 to 0.11). In subgroup analyses, there was no significant effect of PE on PS with mid-term interventions (SMD: − 0.17; 95% CI: −0.59 to 0.25) nor with long-term interventions (SMD: −0.02; 95% CI: −0.42 to 0.38) as compared with controls.

      Conclusion

      PE of low to moderate intensity does not improve PS in midlife and older women.

      Keywords

      1. Introduction

      Perceived stress (PS) is a defensive reaction against threatening environmental conditions, which is associated with activation of the sympathetic nervous system and other body systems responses. This status cannot be maintained for long periods, as the parasympathetic system restores equilibrium [
      • Cohen S.
      • Janicki-Deverts D.
      • Miller G.E.
      Psychological stress and disease.
      ,
      • Chrousos G.P.
      Stress and disorders of the stress system.
      ]. PS is experienced as a negative sensation and is associated with adverse health consequences, including increased cardiovascular risks, hypertension, cancer, social adversity, metabolic syndrome risk and insomnia [
      • Siegrist J.
      Adverse health effects of high-effort/low-reward conditions.
      ,
      • Albert M.A.
      • Durazo E.M.
      • Slopen N.
      • Zaslavsky A.M.
      • Buring J.E.
      • Silva T.
      • Chasman D.
      • Williams D.R.
      Cumulative psychological stress and cardiovascular disease risk in middle aged and older women: rationale, design, and baseline characteristics.
      ,
      • Suglia S.F.
      • Koenen K.C.
      • Boynton-Jarrett R.
      • Chan P.S.
      • Clark C.J.
      • Danese A.
      • Faith M.S.
      • Goldstein B.I.
      • Hayman L.L.
      • Isasi C.R.
      • Pratt C.A.
      • Slopen N.
      • Sumner J.A.
      • Turer A.
      • Turer C.B.
      • Zachariah J.P.
      • American Heart Association Council on Epidemiology and Prevention
      • Council on Cardiovascular Disease in the Young
      • Council on Functional Genomics and Translational Biology
      • Council on Cardiovascular and Stroke Nursing
      • Council on Quality of Care and Outcomes Research
      Childhood and adolescent adversity and cardiometabolic outcomes: a scientific statement from the American Heart Association.
      ,
      • Wiernik E.
      • Lemogne C.
      • Thomas F.
      • Perier M.C.
      • Guibout C.
      • Nabi H.
      • Laurent S.
      • Pannier B.
      • Boutouyrie P.
      • Jouven X.
      • Empana J.P.
      Perceived stress, common carotid intima media thickness and occupational status: the Paris Prospective Study III.
      ,
      • Steptoe A.
      • Kivimäki M.
      • Lowe G.
      • Rumley A.
      • Hamer M.
      Blood pressure and fibrinogen responses to mental stress as predictors of incident hypertension over an 8-Year period.
      ,
      • Gerber M.
      • Börjesson M.
      • Ljung T.
      • Lindwall M.
      • Jonsdottir I.H.
      Fitness moderates the relationship between stress and cardiovascular risk factors.
      ,
      • Yıldırım N.K.
      • Özkan M.
      • İlgün A.S.
      • Sarsenov D.
      • Alço G.
      • Aktepe F.
      • Kalyoncu N.
      • İzci F.
      • Selamoğlu D.
      • Ordu Ç.
      • Pilancı K.N.
      • İyigün Z.E.
      • Eralp Y.
      • Özmen V.
      Possible role of stress, coping strategies, and life style in the development of breast cancer.
      ].
      Women experience higher PS levels than men, even after adjustment for demographic and psychosocial factors [
      • Osmanovic-Thunström A.
      • Mossello E.
      • Åkerstedt T.
      • Fratiglioni L.
      • Wang H.X.
      Do levels of perceived stress increase with increasing age after age 65? A population-based study.
      ]. PS is highly prevalent among middle-aged and old women [
      • Cuadros J.L.
      • Fernández-Alonso A.M.
      • Cuadros-Celorrio A.M.
      • Fernández-Luzón N.
      • Guadix-Peinado M.J.
      • del Cid-Martín N.
      • Chedraui P.
      • Pérez-López F.R.
      • MenopAuse RIsk Assessment (MARIA) Research Group
      Perceived stress, insomnia and related factors in women around the menopause.
      ]. Lower education and financial difficulties are predictors [
      • Cohen S.
      • Janicki-Deverts D.
      Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009.
      ]. Higher PS levels correlate negatively with female age, and positively with lower psychological and uro-gynecological quality of life, insomnia and a partner’s premature ejaculation [
      • Cuadros J.L.
      • Fernández-Alonso A.M.
      • Cuadros-Celorrio A.M.
      • Fernández-Luzón N.
      • Guadix-Peinado M.J.
      • del Cid-Martín N.
      • Chedraui P.
      • Pérez-López F.R.
      • MenopAuse RIsk Assessment (MARIA) Research Group
      Perceived stress, insomnia and related factors in women around the menopause.
      ]. Cumulative stress in women is associated with race/ethnicity, divorced or separated marital status, obesity, diabetes, smoking, depressive symptoms and anxiety [
      • Albert M.A.
      • Durazo E.M.
      • Slopen N.
      • Zaslavsky A.M.
      • Buring J.E.
      • Silva T.
      • Chasman D.
      • Williams D.R.
      Cumulative psychological stress and cardiovascular disease risk in middle aged and older women: rationale, design, and baseline characteristics.
      ].
      Stress management is essential to prevent stress-related diseases. Different approaches have been recommended, including psychological techniques, relaxation, behavioral therapy and aerobic exercise. It is important to apply a specific physiological technique and not only a psychological approach. Physical activity and programmed exercise (PE) have been widely recommended to reduce PS, although some researchers have found that they have no effect [
      • Hansen C.J.
      • Stevens L.C.
      • Richard C.J.
      Exercise duration and mood state: how much is enough to feel better.
      ,
      • Bond D.S.
      • Lyle R.M.
      • Tappe M.K.
      • Seehafer R.S.
      • D’Zurilla T.J.
      Moderate aerobic exercise, t’ai chi, and social problem-solving ability in relation to psychological stress.
      ]. Since there are controversial results concerning the effect of PE on PS in post-menopausal women [
      • Elavsky S.
      • Gold C.H.
      Depressed mood but not fatigue mediate the relationship between physical activity and perceived stress in middle-aged women.
      ,
      • Cuadros J.L.
      • Pérez-Roncero G.R.
      • López-Baena M.T.
      • Cuadros-Celorrio A.M.
      • Fernández-Alonso A.M.
      Life satisfaction and related socio-demographic factors during female midlife.
      ], in the present study we aimed to systematically review randomized control trials (RCTs) investigating the effects of PE on PS in middle-aged and old women.

      2. Methods

      This systematic review followed the guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ]. Formal institutional review board approval was not required, because this analysis consisted of pooling published studies.

      2.1 Systematic search strategy

      The search included, but was not limited to, the following terms: “perceived stress”, “programmed exercise”, “menopausal women”, and “randomized controlled trial”. We searched PubMed-Medline, Embase, Cochrane Library, Scielo, Web of Science and Scopus, from database inception through January 10, 2018, without language restriction. We also conducted a manual search of systematic reviews and reports of RCTs to identify additional trials. In addition, the US Clinical Trials [

      US Clinical Trials, https://clinicaltrials.gov. (Accessed 30 January 2018).

      ], the UK Clinical Trials Gateway [

      UK Clinical Trials Gateway, https://www.ukctg.nihr.ac.uk/. (Accessed 30 January).

      ] and the Australian clinical trials [

      Australian Clinical Trials, https://www.australianclinicaltrials.gov.au. (Accessed 30 January 2018).

      ] databases were searched for related RCTs.

      2.2 Inclusion and exclusion criteria

      Articles reviewed were restricted to original RCTs published in any language that involved: (i) women living independently and aged >40 years without severe disease (cancer, heart disease), cognitive limitations, significant neuromuscular or skeletal diseases, or caring for other persons; (ii) PE for at least six weeks; (iii) an assessment of PS by validated questionnaires or similar tools that included a subscale for the quantitative evaluation of PS; (iv) control groups, defined as women who did not participate in PE.
      Publications were excluded for the following reasons: (i) non-RCTs; (ii) lack of PE for at least 6 weeks; (iii) lack of PS assessment with a validated instrument; (iv) lack of a control group; (v) sample size <20 women.

      2.3 Outcomes

      The primary outcome of interest was PS as assessed before and after PE with specific questionnaires, or tools with a subscale or subdomain for PS. Planned secondary outcomes of interest were hot flashes and other menopausal symptoms, quality of life, social support, self-efficacy, insomnia, muscle strength, body weight and body mass index (BMI).

      2.3.1 The Cohen Perceived Stress Scale (PSS)

      The original Cohen Perceived Stress Scale (PSS) is a 14-item tool to measure non-specific stress that correlates with objective biologic markers of chronic stress [
      • Cohen S.
      • Janicki-Deverts D.
      Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009.
      ,
      • Cohen S.
      • Kamarck T.
      • Mermelstein R.
      A global measure of perceived stress.
      ]. Scores are calculated by reversing seven positive items that are summed along with another seven negative items for a final score. For the 10-item PSS (PSS-10), four positive items are reversed and then all items are summed.

      2.3.2 The Depression, Anxiety and Stress Scale (DASS)

      The 42-item Depression, Anxiety and Stress Scale (DASS-42) are a screening tool to evaluate depressive, anxiety and stress symptoms in the general population [
      • Lovibond P.F.
      • Lovibond S.H.
      The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories.
      ]. The DASS-21 includes 21 items divided into three subscales: depression, anxiety and stress [
      • Henry J.D.
      • Crawford J.R.
      The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample.
      ,
      • Ng F.
      • Trauer T.
      • Dodd S.
      • Callaly T.
      • Campbell S.
      • Berk M.
      The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure.
      ]. The stress subscale assesses nervous tension, difficulty relaxing, irritability and negative affect. The DASS-21 has a better factor structure than the DASS-42 [
      • Clara I.P.
      • Cox B.J.
      • Enns M.W.
      Confirmatory factor analysis of the Depression anxiety Stress Scales in depressed and anxious patients.
      ].

      2.4 Study selection and data extraction

      After removing duplicates, papers were screened for eligibility by their title and abstract. Two authors independently screened the list of retrieved articles to choose potentially relevant papers, and then extracted relevant data (baseline characteristics and outcome variables) from each full-text included article to a previously designed (Microsoft Office Excel) data sheet. Disparities found within the extracted data were discussed by all the authors to reach a consensus.
      Menopausal status was categorized as pre-, peri- and postmenopausal in accordance to the Stages of Reproductive Aging Workshop (STRAW + 10) criteria [
      • Soules M.R.
      • Sherman S.
      • Parrott E.
      • et al.
      Executive summary: stages of reproductive aging workshop (STRAW).
      ].

      2.5 Risk-of-bias assessment

      The methodological quality of the selected RCTs was independently assessed by two authors (SJM-D, MPN) using the Cochrane Risk of Bias Tool [
      • Higgins J.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      ,
      • Higgins J.P.
      • Altman D.G.
      • Gotzsche P.C.
      • et al.
      The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
      ]. This instrument evaluates seven aspects: “random sequence generation” (selection bias); “allocation concealment” (selection bias); “blinding of participants and research staff” (performance bias); “blinding of outcome assessment” (detection bias); “incomplete outcome data” (attrition bias); “selective reporting” (reporting bias); and “any other biases”. Every assessed item was described for each RCT as having a “low”, “high” or “unclear” risk of bias. RCTs presenting bias for “randomization” or “blinding” were considered as having an overall high risk of bias.

      2.6 Data synthesis and statistical analysis

      Effect sizes with 95% confidence interval (CI) were calculated using Hedges’ method. Standardized mean differences (SMDs) and 95% confidence intervals (95% CIs) for PS scores were calculated for each study by the baseline and follow-up PS scores for cases and controls. Individual SMDs were pooled using a random-effects model. The magnitude of SMDs was considered “small” (0.20), “moderate” (0.50) or “large” (0.80) [
      • Deeks J.J.
      • Higgins J.P.T.
      • on behalf of the Statistical Methods Group of The Cochrane Collaboration
      Statistical Algorithms in Review Manager 5.
      ].
      We evaluated statistical heterogeneity using the Cochrane chi-square (X2), the I2 statistic, and the between-study variance using the tau-square (Tau2) [
      • Higgins J.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      ,
      • Deeks J.J.
      • Higgins J.P.T.
      • on behalf of the Statistical Methods Group of The Cochrane Collaboration
      Statistical Algorithms in Review Manager 5.
      ]. I2 values of 0–30% represented a low level of heterogeneity. A p-value < 0.1 for the chi-square defined the presence of heterogeneity; and a tau2 > 1 defined the presence of substantial statistical heterogeneity. Depending on availability of data, subgroup analyses were planned according to the type of exercise and/or the duration of exposure.
      For statistical analyses, we used the Review Manager software (RevMan 5.3; Cochrane Collaboration, Oxford, UK) [
      • Review Manager (RevMan)
      Computer Program]. Version 5.3.
      ].

      3. Results

      3.1 Eligible studies

      A total of 1074 records with stress-related physiological parameters were initially retrieved. After removing duplicates, 859 abstracts were evaluated. Of these, 108 abstracts fulfilled the inclusion criteria and remained for full-text assessment. One hundred and two papers were excluded for various reasons (Fig. 1). Therefore, six articles reporting information from five RCTs were qualitative and quantitatively assessed for the current systematic review and meta-analysis [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ,
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Simkin-Silverman L.
      • Wing R.R.
      • Hansen D.H.
      • Klem M.L.
      • Pasagian-Macaulay A.P.
      • Meilahn E.N.
      • Kuller L.H.
      Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ,
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ]. There were no RCTs in the US, UK and Australian clinical trials registries concerning the effect of PS on peri- or post-menopausal women.
      Fig. 1
      Fig. 1Flow diagram of study selection. RCTs: Randomized controlled trials.

      3.2 Characteristics of the included trials

      The sample characteristics of women included in this systematic review and meta-analysis are outlined in Table 1, Table 2. Age ranged from 47.0 ± 1.7 years [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Simkin-Silverman L.
      • Wing R.R.
      • Hansen D.H.
      • Klem M.L.
      • Pasagian-Macaulay A.P.
      • Meilahn E.N.
      • Kuller L.H.
      Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
      ] to 71.8 ± 5.6 years [
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ]. One RCT studying pre-menopausal women reported outcomes in two publications [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Simkin-Silverman L.
      • Wing R.R.
      • Hansen D.H.
      • Klem M.L.
      • Pasagian-Macaulay A.P.
      • Meilahn E.N.
      • Kuller L.H.
      Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
      ] and the remaining four RCTs reported results for post-menopausal women [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ,
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ].
      Table 1Baseline characteristics of the included randomized controlled trials, as reported by authors.
      First author, year [ref]Study location, CountryAge (years) [Mean ± SD]PopulationMenopause stageSample sizeBMI (kg/m2) [Mean ± SD]Perceived stress scales
      Imayama I, 2011
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      Seattle, USCG: 57.4 ± 4.4

      AEX: 58.1 ± 5.0

      AEX + DWL: 58.0 ± 4.5
      Overweight or obese, aged 50–75 years, <100 min per week of moderate or vigorous physical activity, no breast cancer, no-HT in the previous 3 months, no diabetes, cardiovascular or serious medical conditions.Post-MCG: 87

      AEX: 117

      AEX + DWL: 117
      All: ≥ 23.0

      CG: 30.7 ± 3.9

      AEX: 30.7 ± 3.7

      AEX + DWL: 31.0 ± 4.3
      PSS 14 items
      Klem ML, 1997
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      Pennsylvania, USMean: 47

      Range: 44–50
      Healthy women, aged 44–50 years, <3 months of amenorrhea in the previous 6 months, no-HT, no blood pressure, glucose or cholesterol alterations, no cancer in the previous 5 years, no participation in a commercial weight loss program.Pre-MCG: 275

      EX: 260
      All:20–34

      Average: 25.12

      20–24 (48%)

      >24 (52%)
      PSS 4 items
      Messier V, 2010
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      Montreal, CanadaCG: 58.0 ± 4.7

      EX: 57.2 ± 5.0
      Overweight or obese, 1 year without menstruation and FSH ≥30 U/l, no inflammatory disease, no diabetes, no cardiovascular disease.Post-MCG: 89

      EX: 48
      All: ≥ 27

      CG: 32.2 ± 4.6

      EX: 32.6 ± 4.9
      PSS 14 items
      Simkin-Silverman L, 1995
      • Simkin-Silverman L.
      • Wing R.R.
      • Hansen D.H.
      • Klem M.L.
      • Pasagian-Macaulay A.P.
      • Meilahn E.N.
      • Kuller L.H.
      Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
      Pennsylvania, USCG: 47

      EX: 46.9

      Range: 44–50
      Aged 44–50 years, <3 months of amenorrhea in the previous 6 months, no-HT, no blood pressure, glucose or cholesterol alterations, no cancer in the previous 5 years, no participation in a commercial weight loss program.Pre-MCG: 267

      EX: 253
      CG: 25.1 (24.7–25.5)

      EX: 25.0 (24.6–25.4)

      Mean (95% CI)
      None
      Toobert DJ, 2007
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      Lane County, USCG: 60.7 ± 7.8

      EX: 61.1 ± 8.0
      Women with type 2 diabetes mellitus >6 months, living independently, multiple chronic illnesses, <75 years.Post-MCG: 116

      EX: 163
      CG: 35.6 ± 8.8

      EX: 35.1 ± 7.7
      PSS 14 items
      Williams P, 1997
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      Sydney, AustraliaCG: 71.6 ± 5.2

      EX: 71.8 ± 5.6
      Women ≥60 years, included in the Randwick Falls and Fractures Study, no immobile, no significant neuromuscular, skeletal or cardiovascular diseases.Post-MCG: 93

      EX: 94
      Not reportedDASS 21 items
      AEX: Aerobic exercise group, BMI: Body Mass Index, CG: Control group, DASS: Depression Anxiety and Stress Scale, DWL: Dietary Weight Loss, EX: Exercise group, h: hour(s), FSH: Follicle Stimulating Hormone, HT: Hormone Therapy, Peri-M: Perimenopausal, Post-M: Postmenopausal, Pre-M: Premenopausal, PSS: Perceived Stress Scale, SD: standard deviation.
      Table 2Outcomes of the included randomized controlled trials, as reported by authors.
      First author, year [ref]Medical treatmentIntervention (exercise)Comparison groupDuration of intervention (months)Intensity of exerciseOther recommendationsOutcomesAssessment intervals (months)
      Imayama I, 2011
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      On antidepressant or anxiolytic:

      CG: 33.3%

      AEX: 35.0%

      AEX + DWL: 37.6%
      AEX: aerobic exercise

      AEX + DLW: diet + exercise
      Usual care12AEX: Moderate to vigorous, 45 min per session, 5 days per week.Diet: 1200–2000 kcal/day based on baseline weight, ≤30% calories from fat.PO: perceived stress

      SO: social support, general health, physical functioning
      0/12
      Klem ML, 1997
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      No psychotropic, insulin, thyroid or antihypertensive medications, no lipid lowering agents.Diet + progressive exerciseUsual care6Increasing gradually physical activity to expenditure 1000 calories per week.EX: women also followed a healthy diet and were instructed to use behavior change strategies.PO: perceived stress

      SO: weight fluctuation
      0/6
      Messier V, 2010
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      No medications affecting cardiovascular function and/or metabolism.Caloric restriction + resistance trainingCaloric restriction

      Maintained their usual physical activities
      63 days per week

      of leg press, chest press, lateral pull downs, shoulder press, arm curls and triceps extensions.
      Both groups met with the dietitian for nutrition classes 1–1.5 h.PO: perceived stress

      SO: quality of life, self-esteem, perceived benefits, BMI
      0/6
      Simkin-Silverman L, 1995
      • Simkin-Silverman L.
      • Wing R.R.
      • Hansen D.H.
      • Klem M.L.
      • Pasagian-Macaulay A.P.
      • Meilahn E.N.
      • Kuller L.H.
      Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
      No lipid lowering agents.

      No psychotropic, insulin, thyroid or antihypertensive medications.
      Diet + progressive exerciseUsual care6Increasing gradually physical activity to expenditure 1500 kcal per week.EX: healthy diet (total fat <25% of daily calories, saturated fat <7% of daily calories and total cholesterol <100 mg/day).

      Also, women were instructed to use behavior change strategies.
      PO: none

      SO: BMI, body weight
      0/6
      Toobert DJ, 2007
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      Lipid-lowering:

      CG: 40.5%

      EX: 38.9%

      Blood pressure lowering:

      CG: 47.4%

      EX: 46.3%

      HT:

      CG: 46.6%

      EX: 59.3%
      Exercise + Mediterranean diet + motivational techniquesUsual care from their physicians2430 min of moderate physical activity on most days of the week. Later 1 h per dayPO: perceived stress

      SO: social support, self-efficacy, quality of life
      0/6/12/24
      Williams P, 1997
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      Psychoactive:

      CG: 20.4%

      EX: 26.6%
      Aerobic exercise (also walking, stretching and relaxation)Usual care121 h twice weeklyDuring holidays, women were instructed to maintain the exercise regimenPO: perceived stress

      SO: muscle strength, reaction time
      0/12
      AEX: Aerobic exercise group, CG: Control group, DWL: Dietary Weight Loss, EX: Exercise group, h: hour(s), HT: Hormone Therapy, PO: Primary Outcome, SO: Secondary outcomes.
      The sample included young healthy women [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Simkin-Silverman L.
      • Wing R.R.
      • Hansen D.H.
      • Klem M.L.
      • Pasagian-Macaulay A.P.
      • Meilahn E.N.
      • Kuller L.H.
      Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
      ], overweight or obese early post-menopausal women (<60 years) without co-morbidities [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ], women in their sixth decade of life with chronic illness (including type 2 diabetes mellitus and obesity) living independently [
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ], and women in their seventh decade of life without significant neuromuscular or cardiovascular diseases [
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ] (Table 1). Medical treatments, programmed exercise interventions (duration, type, and intensity) and other recommendations (e.g., diet) are detailed in Table 2.
      Three RCTs measured the effects of PE on PS with the 14-item [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ] and one with the 4-item [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ] Cohen Perceived Stress Scale, and one RCT with the DASS-21 stress subdomain [
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ].

      3.3 Risk-of-bias assessment

      Risk-of-bias assessment is shown in Fig. 2. Participants were properly selected and both baseline and follow-up conditions were well described. The age, weight and comorbid conditions varied, although baseline characteristics were not significantly different between control and intervention groups in each RCT. The duration of follow-up ranged from 6 to 12 months. All studies used validated tools to assess PS.
      Fig. 2
      Fig. 2Assessment of risk of bias in included RCTs.
      Random-sequence generation and allocation concealment were of low risk of bias in one study [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ] and of unclear risk in four studies [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ,
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ]. One study had low risk [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ] and the remaining studies unclear risk [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ,
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ] for “blinding of participants and personnel”. All studies had an unclear risk for “blinding of outcome assessment” [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ,
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ,
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ], while two studies had an unclear risk for “incomplete data” [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ] and one had an unclear risk for “other bias” [
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ]. None of the authors reported conflicts of interest.

      3.4 Meta-analyses

      In five interventions [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ,
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ], PE of medium intensity had no effect on PS (SMD: −0.08; 95% CI: −0.33 to 0.17, p = 0.53, I2 = 74%). One study reported exercise of low intensity [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ] (Fig. 3).
      Fig. 3
      Fig. 3Association between programmed exercise and standardized mean difference of perceived stress. Upper figure: Exercise of medium intensity. Lower figure: Exercise of low intensity. Squares represent the SMD for each trial. Diamonds represent the pooled SMD across trials.
      In three studies [
      • Klem M.L.
      • Wing R.R.
      • Simkin-Silverman L.
      • Kuller L.H.
      The psychological consequences of weight gain prevention in healthy, premenopausal women.
      ,
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ], mid-term (6 months) PE had no effect on PS (SMD: −0.17; 95% CI: −0.59 to 0.25, p = 0.43, I2 = 89%). In four interventions [
      • Imayama I.
      • Alfano C.M.
      • Kong A.
      • et al.
      Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
      ,
      • Toobert D.J.
      • Glasgow R.E.
      • Strycker L.A.
      • Barrera Jr., M.
      • Ritzwoller D.P.
      • Weidner G.
      Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
      ,
      • Williams P.
      • Lord S.R.
      Effects of group exercise on cognitive functioning and mood in older women.
      ], long-term (12 months) PE had no effect on PS (SMD: −0.02; 95% CI: −0.42 to 0.38, p = 0.91, I2 = 88%) (Fig. 4).
      Fig. 4
      Fig. 4Association between programmed exercise and standardized mean difference of perceived stress. Upper figure: Mid-term exercise interventions (6 months). Lower figure: Long-term exercise interventions (12 months). Squares represent the SMD for each trial. Diamonds represent the pooled SMD across trials.
      Two RCTs [
      • Messier V.
      • Rabasa-Lhoret R.
      • Doucet E.
      • Brochu M.
      • Lavoie J.M.
      • Karelis A.
      • Prud'homme D.
      • Strychar I.
      Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
      ,
      • Simkin-Silverman L.
      • Wing R.R.
      • Hansen D.H.
      • Klem M.L.
      • Pasagian-Macaulay A.P.
      • Meilahn E.N.
      • Kuller L.H.
      Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
      ] reported secondary outcomes. BMI (SMD: −1.03; 95% CI: −2.55 to 0.50, p = 0.19, I2 = 93%) and weight (SMD: −2.76; 95% CI: −6.65 to 1.12, p = 0.16, I2 = 90%) were not significantly different after 6 months of PE (Fig. 5).
      Fig. 5
      Fig. 5Association between programmed exercise and BMI (Upper figure) and weight (Lower figure). Squares represent the SMD for each trial. Diamonds represent the pooled SMD across trials.

      4. Discussion

      This is the first systematic review and meta-analysis of RCTs focused on the effect of PE on PS in middle-aged and old women. The included studies applied a subjective assessment, obtained by two validated questionnaires. We found that PE, for 6 or 12 months, did not change PS in five RCTs with high risk of bias and high heterogeneity among them.
      Emotions are related to social and physical values, and life expectations [
      • Lazarus R.S.
      Emotions and interpersonal relationships: toward a person-centered conceptualization of emotions and coping.
      ]. PS is higher among women than men, and more prevalent in individuals with lower income and educational level [
      • Osmanovic-Thunström A.
      • Mossello E.
      • Åkerstedt T.
      • Fratiglioni L.
      • Wang H.X.
      Do levels of perceived stress increase with increasing age after age 65? A population-based study.
      ,
      • Cuadros J.L.
      • Fernández-Alonso A.M.
      • Cuadros-Celorrio A.M.
      • Fernández-Luzón N.
      • Guadix-Peinado M.J.
      • del Cid-Martín N.
      • Chedraui P.
      • Pérez-López F.R.
      • MenopAuse RIsk Assessment (MARIA) Research Group
      Perceived stress, insomnia and related factors in women around the menopause.
      ,
      • Cohen S.
      • Janicki-Deverts D.
      Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009.
      ,
      • Hansen C.J.
      • Stevens L.C.
      • Richard C.J.
      Exercise duration and mood state: how much is enough to feel better.
      ,
      • Warttig S.L.
      • Forshaw M.J.
      • South J.
      • White A.K.
      New, normative, English-sample data for the short form perceived stress scale (PSS-4).
      ,
      • Hedgeman E.
      • Hasson R.E.
      • Karvonen-Gutierrez C.A.
      • Herman W.H.
      • Harlow S.D.
      Perceived stress across the midlife: longitudinal changes among a diverse sample of women, the Study of Women’s health Across the Nation (SWAN).
      ]. Middle-aged and old women experience stressful life changes and insomnia, have increased body weight and more significant health worries, low life satisfaction and greater loneliness [
      • Osmanovic-Thunström A.
      • Mossello E.
      • Åkerstedt T.
      • Fratiglioni L.
      • Wang H.X.
      Do levels of perceived stress increase with increasing age after age 65? A population-based study.
      ,
      • Cuadros J.L.
      • Fernández-Alonso A.M.
      • Cuadros-Celorrio A.M.
      • Fernández-Luzón N.
      • Guadix-Peinado M.J.
      • del Cid-Martín N.
      • Chedraui P.
      • Pérez-López F.R.
      • MenopAuse RIsk Assessment (MARIA) Research Group
      Perceived stress, insomnia and related factors in women around the menopause.
      ,
      • Cohen S.
      • Janicki-Deverts D.
      Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009.
      ,
      • Cuadros J.L.
      • Pérez-Roncero G.R.
      • López-Baena M.T.
      • Cuadros-Celorrio A.M.
      • Fernández-Alonso A.M.
      Life satisfaction and related socio-demographic factors during female midlife.
      ,
      • Darling C.A.
      • Coccia C.
      • Senatore N.
      Women in midlife: stress, health and life satisfaction.
      ]. PE is associated with a higher prevalence of chronic conditions, multi-morbidity and worse health outcomes [
      • Stubbs B.
      • Vancampfort D.
      • Veronese N.
      • Schofield P.
      • Lin P.Y.
      • Tseng P.T.
      • Solmi M.
      • Thompson T.
      • Carvalho A.F.
      • Koyanagi A.
      Multimorbidity and perceived stress: a population-based cross-sectional study among older adults across six low- and middle-income countries.
      ]. Women included in the present meta-analysis had only minor co-morbidities that allow PE to be performed for 6 or 12 months without general negative consequences.
      Physical activity and PE are now considered as first-line interventions for the primary and secondary prevention and management of common chronic diseases [
      • Barry V.W.
      • Baruth M.
      • Beets M.W.
      • Durstine J.L.
      • Liu J.
      • Blair S.N.
      Fitness vs. fatness on all-cause mortality: a meta-analysis.
      ,
      • Arem H.
      • Moore S.C.
      • Patel A.
      • Hartge P.
      • Berrington de Gonzalez A.
      • Visvanathan K.
      • Campbell P.T.
      • Freedman M.
      • Weiderpass E.
      • Adami H.O.
      • Linet M.S.
      • Lee I.M.
      • Matthews C.E.
      Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship.
      ,
      • Warburton D.E.R.
      • Bredin S.S.D.
      Health benefits of physical activity: a systematic review of current systematic reviews.
      ,
      • Yeh M.L.
      • Liao R.W.
      • Hsu C.C.
      • Chung Y.C.
      • Lin J.G.
      Exercises improve body composition, cardiovascular risk factors and bone mineral density for menopausal women: a systematic review and meta-analysis of randomized controlled trials.
      ]. Previous systematic reviews and meta-analyses of RCTs reported that PE might improve insulin sensitivity and reduce insomnia, depressive and anxiety symptoms in peri- and post-menopausal women [
      • Bueno-Notivol J.
      • Calvo-Latorre J.
      • Alonso-Ventura V.
      • Pasupuleti V.
      • Hernandez A.V.
      • Pérez-López F.R.
      • Health Outcomes and Systematic Analyses (HOUSSAY) Project
      Effect of programmed exercise on insulin sensitivity in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials.
      ,
      • Rubio-Arias J.Á.
      • Marín-Cascales E.
      • Ramos-Campo D.J.
      • Hernandez A.V.
      • Pérez-López F.R.
      Effect of exercise on sleep quality and insomnia in middle-aged women: a systematic review and meta-analysis of randomized controlled trials.
      ,
      • Pérez-López F.R.
      • Martínez-Domínguez S.J.
      • Lajusticia H.
      • Chedraui P.
      • Health Outcomes Systematic Analyses Project
      Effects of programmed exercise on depressive symptoms in midlife and older women: a meta-analysis of randomized controlled trials.
      ,
      • Martínez-Domínguez S.J.
      • Lajusticia H.
      • Chedraui P.
      • Pérez-López F.R.
      • Health Outcomes
      • Systematic Analyses (HOUSSAY) Project
      The effect of programmed exercise over anxiety symptoms in midlife and older women: a meta-analysis of randomized controlled trials.
      ]. However, the effect of PE on menopausal symptoms was insufficient to control for vasomotor symptoms in middle-aged women [
      • Daley A.
      • Stokes-Lampard H.
      • Thomas A.
      • MacArthur C.
      Exercise for vasomotor menopausal symptoms.
      ].
      A large number of studies reporting benefits of PE on PS were obtained. Most were observational studies and, less frequently, prospective longitudinal studies [
      • Gerber M.
      • Pühse U.
      Review article: do exercise and fitness protect against stress-induced health complaints: a review of the literature.
      ,
      • Albert M.A.
      • Durazo E.M.
      • Slopen N.
      • Zaslavsky A.M.
      • Buring J.E.
      • Silva T.
      • Chasman D.
      • Williams D.R.
      Cumulative psychological stress and cardiovascular disease risk in middle aged and older women: rationale, design, and baseline characteristics.
      ]. Physical activity and PE have been associated with lower PS in observational studies [
      • Salmon P.
      Effects of physical exercise on anxiety, depression, and sensitivity to stress.
      ,
      • Guérin E.
      • Biagé A.
      • Goldfield G.
      • Prud’homme D.
      Physical activity and perceptions of stress during the menopause transition: a longitudinal study.
      ]. In a 5-year longitudinal study of middle-aged women, vigorous exercise reduced PS in years 1 and 2 [
      • Guérin E.
      • Biagé A.
      • Goldfield G.
      • Prud’homme D.
      Physical activity and perceptions of stress during the menopause transition: a longitudinal study.
      ]. The present systematic review included old women as well as middle-aged ones and PE was not vigorous. Therefore, it can be speculated that the combination of intensity of PE with the age of the women in the available RCTs was not enough to provide the expected benefits of PE. In fact, a significant positive correlation has been reported between the amount of PE and life satisfaction [
      • Maher J.P.
      • Doerksen S.E.
      • Elavsky S.
      • Hyde A.L.
      • Pincus A.L.
      • Ram N.
      • et al.
      A daily analysis of physical activity and satisfaction with life in emerging adults.
      ]. Finally, PE intensity may influence PS, as occurs with other emotional or mental responses [
      • Paolucci E.M.
      • Loukov D.
      • Bowdish D.M.E.
      • Heisz J.J.
      Exercise reduces depression and inflammation but intensity matters.
      ].
      In the present meta-analysis, there were no significant changes after PE in both weight and BMI in two RCTs. In middle-aged women, regular PE may mitigate the tendency for weight gain and change in body composition [
      • Sternfeld B.
      • Bhat A.K.
      • Wang H.
      • Sharp T.
      • Quesenberry Jr., C.P.
      Menopause, physical activity, and body composition/fat distribution in midlife women.
      ].
      The present systematic review and meta-analysis had some limitations. First, the studied populations were heterogeneous by age, years of menopause and comorbidity. Second, the type and intensity of PE varied. Third, PS is a complicated process, including physical activity, mental and social factors, which would require individualized interventions, and cannot be solely neutralized by changes in physical activity and/or PE. Fourth, self-report questionnaires do not guarantee accurate reporting of personal views [
      • Dodd-McCue D.
      • Tartaglia A.
      Self-report response bias: learning how to live with its diagnosis in chaplaincy research.
      ]. Fifth, the estimation of heterogeneity of meta-analyses of a small number of studies (≤5) is challenging.
      On the other hand, the present meta-analysis had some strengths. First, the randomization procedure provided a balanced distribution of women regarding age, menopausal status and morbid conditions between PE intervention and control groups. Second, it has repeatedly been reported that PE tools, such as the PSS and DASS-21, are simple, validated instruments to detect changes in a variety of circumstances [
      • Cohen S.
      • Janicki-Deverts D.
      Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009.
      ,
      • Cohen S.
      • Kamarck T.
      • Mermelstein R.
      A global measure of perceived stress.
      ,
      • Henry J.D.
      • Crawford J.R.
      The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample.
      ].
      Future studies should have better designs to assess, objectively and quantitatively, basal physical activity, individual resilience, physical functioning, social support, self-efficacy, and PE, with concomitant assessment of endocrine and/or biochemical modifications.
      It can be concluded that there is no evidence that PE, applied over a period of 6–12 months, can modify PS in middle-aged and old women. Therefore, it cannot be recommended as a first-line approach for this purpose. Further studies are needed to elucidate if other types of PE (regarding frequency, intensity, duration and type) or other therapeutic modalities can alleviate PS in peri- and post-menopausal women.

      Contributors

      Meletios P. Nigdelis did the literature searches, designed the data extraction, and carried out the statistical analyses.
      Samuel J. Martínez-Domínguez designed the study, did the literature searches, designed the data extraction, and carried out the statistical analyses.
      Dimitrios G. Goulis supervised the statistical analyses and wrote the first draft of the paper.
      Faustino R. Pérez-López designed the study, did the literature searches and wrote the first draft of the paper.
      All authors contributed and approved the final manuscript.

      Conflict of interest

      The authors declare that they have no conflict of interest.

      Funding

      No funding was received for the preparation of this systematic review and meta-analysis.

      Provenance and peer review

      This article has undergone peer review.

      References

        • Cohen S.
        • Janicki-Deverts D.
        • Miller G.E.
        Psychological stress and disease.
        JAMA. 2007; 298: 1685-1687
        • Chrousos G.P.
        Stress and disorders of the stress system.
        Nat. Rev. Endocrinol. 2009; 5: 374-381
        • Siegrist J.
        Adverse health effects of high-effort/low-reward conditions.
        J. Occup. Health Psychol. 1996; 1: 27-41
        • Albert M.A.
        • Durazo E.M.
        • Slopen N.
        • Zaslavsky A.M.
        • Buring J.E.
        • Silva T.
        • Chasman D.
        • Williams D.R.
        Cumulative psychological stress and cardiovascular disease risk in middle aged and older women: rationale, design, and baseline characteristics.
        Am. Heart J. 2017; 192: 1-12
        • Suglia S.F.
        • Koenen K.C.
        • Boynton-Jarrett R.
        • Chan P.S.
        • Clark C.J.
        • Danese A.
        • Faith M.S.
        • Goldstein B.I.
        • Hayman L.L.
        • Isasi C.R.
        • Pratt C.A.
        • Slopen N.
        • Sumner J.A.
        • Turer A.
        • Turer C.B.
        • Zachariah J.P.
        • American Heart Association Council on Epidemiology and Prevention
        • Council on Cardiovascular Disease in the Young
        • Council on Functional Genomics and Translational Biology
        • Council on Cardiovascular and Stroke Nursing
        • Council on Quality of Care and Outcomes Research
        Childhood and adolescent adversity and cardiometabolic outcomes: a scientific statement from the American Heart Association.
        Circulation. 2018; 137: e15-e28
        • Wiernik E.
        • Lemogne C.
        • Thomas F.
        • Perier M.C.
        • Guibout C.
        • Nabi H.
        • Laurent S.
        • Pannier B.
        • Boutouyrie P.
        • Jouven X.
        • Empana J.P.
        Perceived stress, common carotid intima media thickness and occupational status: the Paris Prospective Study III.
        Int. J. Cardiol. 2016; 221: 1025-1030
        • Steptoe A.
        • Kivimäki M.
        • Lowe G.
        • Rumley A.
        • Hamer M.
        Blood pressure and fibrinogen responses to mental stress as predictors of incident hypertension over an 8-Year period.
        Ann. Behav. Med. 2016; 50: 898-906
        • Gerber M.
        • Börjesson M.
        • Ljung T.
        • Lindwall M.
        • Jonsdottir I.H.
        Fitness moderates the relationship between stress and cardiovascular risk factors.
        Med. Sci. Sports Exerc. 2016; 48: 2075-2081
        • Yıldırım N.K.
        • Özkan M.
        • İlgün A.S.
        • Sarsenov D.
        • Alço G.
        • Aktepe F.
        • Kalyoncu N.
        • İzci F.
        • Selamoğlu D.
        • Ordu Ç.
        • Pilancı K.N.
        • İyigün Z.E.
        • Eralp Y.
        • Özmen V.
        Possible role of stress, coping strategies, and life style in the development of breast cancer.
        Int. J. Psychiatry Med. 2018; (91217417749789)
        • Osmanovic-Thunström A.
        • Mossello E.
        • Åkerstedt T.
        • Fratiglioni L.
        • Wang H.X.
        Do levels of perceived stress increase with increasing age after age 65? A population-based study.
        Age Ageing. 2015; 44: 828-834
        • Cuadros J.L.
        • Fernández-Alonso A.M.
        • Cuadros-Celorrio A.M.
        • Fernández-Luzón N.
        • Guadix-Peinado M.J.
        • del Cid-Martín N.
        • Chedraui P.
        • Pérez-López F.R.
        • MenopAuse RIsk Assessment (MARIA) Research Group
        Perceived stress, insomnia and related factors in women around the menopause.
        Maturitas. 2012; 72: 367-372
        • Cohen S.
        • Janicki-Deverts D.
        Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009.
        J. Appl. Soc. Psychol. 2012; 42: 1320-1334
        • Hansen C.J.
        • Stevens L.C.
        • Richard C.J.
        Exercise duration and mood state: how much is enough to feel better.
        Health Psychol. 2001; 20: 267-275
        • Bond D.S.
        • Lyle R.M.
        • Tappe M.K.
        • Seehafer R.S.
        • D’Zurilla T.J.
        Moderate aerobic exercise, t’ai chi, and social problem-solving ability in relation to psychological stress.
        Int. J. Stress Manag. 2002; 9: 329-343
        • Elavsky S.
        • Gold C.H.
        Depressed mood but not fatigue mediate the relationship between physical activity and perceived stress in middle-aged women.
        Maturitas. 2009; 64: 235-240
        • Cuadros J.L.
        • Pérez-Roncero G.R.
        • López-Baena M.T.
        • Cuadros-Celorrio A.M.
        • Fernández-Alonso A.M.
        Life satisfaction and related socio-demographic factors during female midlife.
        Enferm. Clin. 2014; 24: 315-322
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Int. J. Surg. 2010; 8: 336-341
      1. US Clinical Trials, https://clinicaltrials.gov. (Accessed 30 January 2018).

      2. UK Clinical Trials Gateway, https://www.ukctg.nihr.ac.uk/. (Accessed 30 January).

      3. Australian Clinical Trials, https://www.australianclinicaltrials.gov.au. (Accessed 30 January 2018).

        • Cohen S.
        • Kamarck T.
        • Mermelstein R.
        A global measure of perceived stress.
        J. Health Soc. Behav. 1983; 24: 385-396
        • Lovibond P.F.
        • Lovibond S.H.
        The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories.
        Behav. Res. Ther. 1995; 33: 335-343
        • Henry J.D.
        • Crawford J.R.
        The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample.
        Br. J. Clin. Psychol. 2005; 44: 227-239
        • Ng F.
        • Trauer T.
        • Dodd S.
        • Callaly T.
        • Campbell S.
        • Berk M.
        The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure.
        Acta Neuropsychiatrica. 2007; 19: 304-310
        • Clara I.P.
        • Cox B.J.
        • Enns M.W.
        Confirmatory factor analysis of the Depression anxiety Stress Scales in depressed and anxious patients.
        J. Psychopathol. Behav. Assess. 2001; 23: 61-67
        • Soules M.R.
        • Sherman S.
        • Parrott E.
        • et al.
        Executive summary: stages of reproductive aging workshop (STRAW).
        Fertil. Steril. 2001; 76: 874-878
        • Higgins J.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Higgins J.P.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • Deeks J.J.
        • Higgins J.P.T.
        • on behalf of the Statistical Methods Group of The Cochrane Collaboration
        Statistical Algorithms in Review Manager 5.
        2010 (Available from)
        • Review Manager (RevMan)
        Computer Program]. Version 5.3.
        The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen2014
        • Imayama I.
        • Alfano C.M.
        • Kong A.
        • et al.
        Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial.
        Int. J. Behav. Nutr. Phys. Act. 2011; 8: 11840
        • Klem M.L.
        • Wing R.R.
        • Simkin-Silverman L.
        • Kuller L.H.
        The psychological consequences of weight gain prevention in healthy, premenopausal women.
        Int. J. Eat. Disord. 1997; 21: 167-174
        • Messier V.
        • Rabasa-Lhoret R.
        • Doucet E.
        • Brochu M.
        • Lavoie J.M.
        • Karelis A.
        • Prud'homme D.
        • Strychar I.
        Effects of the addition of a resistance training programme to a caloric restriction weight loss intervention on psychosocial factors in overweight and obese post-menopausal women: a Montreal Ottawa New Emerging Team study.
        J. Sports Sci. 2010; 28: 83-92
        • Simkin-Silverman L.
        • Wing R.R.
        • Hansen D.H.
        • Klem M.L.
        • Pasagian-Macaulay A.P.
        • Meilahn E.N.
        • Kuller L.H.
        Prevention of cardiovascular risk factor elevations in healthy premenopausal women.
        Prev. Med. 1995; 24: 509-517
        • Toobert D.J.
        • Glasgow R.E.
        • Strycker L.A.
        • Barrera Jr., M.
        • Ritzwoller D.P.
        • Weidner G.
        Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.
        Int. J. Behav. Nutr. Phys. Act. 2007; 17: 1
        • Williams P.
        • Lord S.R.
        Effects of group exercise on cognitive functioning and mood in older women.
        Aust. N. Z. J. Public Health. 1997; 21: 45-52
        • Lazarus R.S.
        Emotions and interpersonal relationships: toward a person-centered conceptualization of emotions and coping.
        J. Pers. 2006; 74: 9-46
        • Warttig S.L.
        • Forshaw M.J.
        • South J.
        • White A.K.
        New, normative, English-sample data for the short form perceived stress scale (PSS-4).
        J. Health Psychol. 2013; 18: 1617-1628
        • Hedgeman E.
        • Hasson R.E.
        • Karvonen-Gutierrez C.A.
        • Herman W.H.
        • Harlow S.D.
        Perceived stress across the midlife: longitudinal changes among a diverse sample of women, the Study of Women’s health Across the Nation (SWAN).
        Women’s Midlife Health. 2018; 4: 2
        • Darling C.A.
        • Coccia C.
        • Senatore N.
        Women in midlife: stress, health and life satisfaction.
        Stress Health. 2012; 28: 31-40
        • Stubbs B.
        • Vancampfort D.
        • Veronese N.
        • Schofield P.
        • Lin P.Y.
        • Tseng P.T.
        • Solmi M.
        • Thompson T.
        • Carvalho A.F.
        • Koyanagi A.
        Multimorbidity and perceived stress: a population-based cross-sectional study among older adults across six low- and middle-income countries.
        Maturitas. 2018; 107: 84-91
        • Barry V.W.
        • Baruth M.
        • Beets M.W.
        • Durstine J.L.
        • Liu J.
        • Blair S.N.
        Fitness vs. fatness on all-cause mortality: a meta-analysis.
        Prog. Cardiovasc. Dis. 2014; 56: 382-390
        • Arem H.
        • Moore S.C.
        • Patel A.
        • Hartge P.
        • Berrington de Gonzalez A.
        • Visvanathan K.
        • Campbell P.T.
        • Freedman M.
        • Weiderpass E.
        • Adami H.O.
        • Linet M.S.
        • Lee I.M.
        • Matthews C.E.
        Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship.
        JAMA Intern. Med. 2015; 175: 959-967
        • Warburton D.E.R.
        • Bredin S.S.D.
        Health benefits of physical activity: a systematic review of current systematic reviews.
        Curr. Opin. Cardiol. 2017; 32: 541-556
        • Yeh M.L.
        • Liao R.W.
        • Hsu C.C.
        • Chung Y.C.
        • Lin J.G.
        Exercises improve body composition, cardiovascular risk factors and bone mineral density for menopausal women: a systematic review and meta-analysis of randomized controlled trials.
        Appl. Nurs. Res. 2018; 40: 90-98
        • Bueno-Notivol J.
        • Calvo-Latorre J.
        • Alonso-Ventura V.
        • Pasupuleti V.
        • Hernandez A.V.
        • Pérez-López F.R.
        • Health Outcomes and Systematic Analyses (HOUSSAY) Project
        Effect of programmed exercise on insulin sensitivity in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials.
        Menopause. 2017; 24: 1404-1413
        • Rubio-Arias J.Á.
        • Marín-Cascales E.
        • Ramos-Campo D.J.
        • Hernandez A.V.
        • Pérez-López F.R.
        Effect of exercise on sleep quality and insomnia in middle-aged women: a systematic review and meta-analysis of randomized controlled trials.
        Maturitas. 2017; 100: 49-56
        • Pérez-López F.R.
        • Martínez-Domínguez S.J.
        • Lajusticia H.
        • Chedraui P.
        • Health Outcomes Systematic Analyses Project
        Effects of programmed exercise on depressive symptoms in midlife and older women: a meta-analysis of randomized controlled trials.
        Maturitas. 2017; 106: 38-47
        • Martínez-Domínguez S.J.
        • Lajusticia H.
        • Chedraui P.
        • Pérez-López F.R.
        • Health Outcomes
        • Systematic Analyses (HOUSSAY) Project
        The effect of programmed exercise over anxiety symptoms in midlife and older women: a meta-analysis of randomized controlled trials.
        Climacteric. 2018; 21: 123-131
        • Daley A.
        • Stokes-Lampard H.
        • Thomas A.
        • MacArthur C.
        Exercise for vasomotor menopausal symptoms.
        Cochrane Database Syst. Rev. 2014; 11: CD006108
        • Gerber M.
        • Pühse U.
        Review article: do exercise and fitness protect against stress-induced health complaints: a review of the literature.
        Scand. J. Public Health. 2009; 37: 801-819
        • Albert M.A.
        • Durazo E.M.
        • Slopen N.
        • Zaslavsky A.M.
        • Buring J.E.
        • Silva T.
        • Chasman D.
        • Williams D.R.
        Cumulative psychological stress and cardiovascular disease risk in middle aged and older women: rationale, design, and baseline characteristics.
        Am. Heart J. 2017; 192: 1-12
        • Salmon P.
        Effects of physical exercise on anxiety, depression, and sensitivity to stress.
        Clin. Psychol. Rev. 2001; 21: 33-61
        • Guérin E.
        • Biagé A.
        • Goldfield G.
        • Prud’homme D.
        Physical activity and perceptions of stress during the menopause transition: a longitudinal study.
        J. Health Psychol. 2017; (1359105316683787)
        • Maher J.P.
        • Doerksen S.E.
        • Elavsky S.
        • Hyde A.L.
        • Pincus A.L.
        • Ram N.
        • et al.
        A daily analysis of physical activity and satisfaction with life in emerging adults.
        Health Psychol. 2013; 32: 647-656
        • Paolucci E.M.
        • Loukov D.
        • Bowdish D.M.E.
        • Heisz J.J.
        Exercise reduces depression and inflammation but intensity matters.
        Biol. Psychol. 2018; 133: 79-84
        • Sternfeld B.
        • Bhat A.K.
        • Wang H.
        • Sharp T.
        • Quesenberry Jr., C.P.
        Menopause, physical activity, and body composition/fat distribution in midlife women.
        Med. Sci. Sports Exerc. 2005; 37: 1195-1202
        • Dodd-McCue D.
        • Tartaglia A.
        Self-report response bias: learning how to live with its diagnosis in chaplaincy research.
        Chaplaincy Today. 2010; 26: 2-8