R Chattha, R Nagarathna, V Padmalatha, HR Nagendra

Objective To assess tbe efficacy of an integrated approach of yoga therapy (IAYT) on cognitive abilities in climacteric syndrome.

Design A randomised control study wherein the participants were divided into experimental and control groups.

Settings Fourteen centres of Swami Vivekananda Yoga Research Foundation, Bangalore, India,

Sample One hundred and eight perimenopausal women between 40 and 55 years with follicle-stimulating hormone level equal to or greater than 15 mitt/ml. One hundred and twenty perimenopausal women were randomly allotted into the yoga and the control groups.

Methods The yoga group practised a module comprising breathing practices, sun salutation and cyclic meditation, whereas the control group practiced a set of simple physical exercises, under supervision {1 hour/day, 5 days/week for 8 weeks).

Main outcome measures Assessments were made by vasomotor symptom checklist, six-letter cancellation test (SLCT) for attention and concentration and Punit Govil Intelligence Memory Scale (PGIMS) with ten subtests.

Results The Wflcoxon test showed significant IP < 0.001) reduction in hot flushes, night sweats and sleep disturbance in yoga group, with a trend of significant difference between groups at P = 0.06 on Mann-Whitney test in night sweats. There was no change within or between groups in the control group. The SLCT score and the PGIMS showed significant improvement in eight of ten subtests in the yoga group and six of ten subtexts in the control group. The yoga group performed significantly better (P < 0.001) with higher effect sizes in SLCT and seven tests of PGIMS compared with the control group.

Conclusions Integrated approach of yoga therapy can improve hot flushes and night sweats. It also can improve cognitive functions such as remote memory, mental balance, attention and concentration, delayed and immediate recall, verbal retention and recognition tests.

Keywords Climacteric, cognitive abilities, yoga.

Climacteric is a physiologic transition characterised by depletion of the ovarian follicles, decreasing estradiol and inhibin production, leading to an increase in follicle-stimulating hor­mone (FSH), loss of menstrual cycle, accompanied by menopausal symptoms.1 Because the average life span of women in India has touched 62 years, the problems of menopause have attained a greater attention.2 Altered levels of neurotrophic ovarian steroid (17beta-estradiol) have been recognised as one of the factors influencing degenerative processes that lead to ageing.3 Senescence is characterised neurologically by a decline in cognitive function.4 Cognitive decline during ageing is seen in memory abilities,5 focusing, attention6,7  and information processing.8 Numerous studies indicate that estrogen is essential for optimal brain function. Estrogens have been reported to influence verbal fluency, verbal memory tests and performance on spatial tasks and fine motor skills.9-12 This decline is the result of degenerative processes initiated by deregulation of the hyporthalamic—pituitary-gonadal (HPG) axis with menopause and andropause that leads to alterations in the concentration of all serum HPG hormones, Estrogen is known to enhance the activity at neuronal synapses, thus exerting its direct neuroprotective and neurotrophic effects on brain tissue, by maintaining the integrity of the nigral-dopamine system.'3 These dopamine-producing neurons that are involved in cognitive functions start dying when estrogen levels are low.14 The protective effect of estrogens on neuronal cells may also be due to their ability to alter free radical production and/or free radical action on ceils.13 It has been shown that estrogen deprivation is likely to initiate or enhance degenerative changes caused by oxidative stress and to reduce the brain's ability to maintain synaptic connectivity and cholinergic integrity leading to the cognitive decline seen in aged individuals.16
The hippocampus has long been presumed the primary site of action of estrogens on cognition; and explicit memory is considered the cognitive function most vulnerable to menopausal loss of estrogen. Keenan et al. hypothesised that the prefrontal cortex and its neural circuitry are prime mediators of estrogen's role in cognition. The prefrontal cortex is critical for intact working memory, and estrogen enhances perfor­mance on working memory tasks.17 Neuroimaging techniques like positron emission tomography and magnetic resonance imaging proved that estrogen-induced increase in cerebral blood flow were particularly noticed in the hippocampus, para hippocampus, gyrus and temporal regions, which are a part of memory circuit.18 Murphy et ailg reported that age-related loss of brain tissue in hippocampus and parietal lobes was significantly greater in women than in men. Thus, estrogen strongly influences mood and cognition, and the decline of this hormone at menopause can produce significant emotional and cognitive problems in women.9
No doubt hormone replacement therapy (HRT) reverts the cognitive, vasomotor and psychological impairments and is cardio-protective, but holds a risk of cancer of endometrium and breast, as well as three-fold risk of venous thromboembolism.28 Due to these serious adverse effects of HRT, there has been a gap in the management of menopausal symptoms emphasising the need to develop and explore the efficacy of alternative therapeutic avenues that have demonstrated promise in alleviating menopausal symptoms since 2006,21 Cognitive-behavioural intervention was shown to be effective in treating anxiety, depression, hot flushes and cardiac com­plaints, improving partnership relations and overall score of sexuality in a pilot study on 30 women with climacteric syndrome.22 There are very few studies on yoga treating used for climacteric syndrome. There are several studies (two pilot studies and one three-armed study) that shows that yoga improves the menopausal symptoms,23"25 but there are no studies on the effect of yoga on cognitive functions in climacteric.
Yoga is an ancient Indian science and way of life that includes the practice of specific postures, regulated breathing and meditation.26 Yogasanas and pranayamas are today rec­ognised as techniques that can improve muscle strength, flexibility, blood circulation and oxygen uptake as well as hormone functions27 at the gross level. Meditation (intrinsic yoga techniques called Dharana, Dhyana and Samadhi) has been described as training in awareness, produces definite changes in perception, attention and cognition.28 It has been shown that processing of sensory information at the thalamic level is facilitated during the practice of pranayama (breathing exercises)29 and meditation.30 Integrated approach of yoga that combines physical postures, pranayama and meditation together with the notional correction based on philosophy of yoga was found to improve both cognitive (visual perception) and motor functions (hand steadiness)31 in college students following 10 days of yoga practice. This improvement was believed to be due to improved eye hand coordination, attention, concentration and relaxation. With these promising benefits of yoga, we could hypothesise that yoga may decrease the cognitive dysfunction and the clinical symptoms of climacteric.
Thus, the aim of the study was to assess the efficacy of the integrated approach of yoga therapy (IAYT) on cognitive functions in perimenopausal women.