Editor’s Note: Physical health is a key aspect of mental and emotional health for all people. During Mental Health Awareness Month, it is important to consider the impact of physical activity on every aspect of a woman’s health throughout her lifespan, including the reproductive years and beyond. While on the FACTS online elective on fertility awareness, Rajwinder Kaur summarized a 2016 article[i] published by Harrison et al titled, “The Role of Physical Activity in Preconception, Pregnancy and Postpartum Health.” The authors provide a review of the evidence supporting the benefits of physical activity in the various phases of a woman’s life; below is a brief summary of their findings.

Introduction

Women of reproductive age are a high risk group for weight gain, progression to obesity, and the associated comorbid conditions. Trends show that obesity is affecting the population at a younger age, with the most rapid weight gain occurring between the ages of 20 and 40 years. Several cross-sectional studies suggest women are at the highest risk, with higher rates of conversion to overweight and obesity than men. In women of reproductive age, weight gain is associated with higher rates of glucose intolerance, dyslipidemia, type 2 diabetes, cardiovascular disease, anovulation, polycystic ovarian syndrome (PCOS), infertility, and psychological health risks. Additionally, pregnancy increases the risk of obesity, and current data shows the majority of women exceed the recommendations for gestational weight gain (GWG). In turn, excessive GWG increases postpartum weight retention and drives long term obesity risk independent of pre-pregnancy body mass index (BMI).

Regular physical activity has many protective benefits for the reproductive, cardiovascular, and psychological health of women as well as their overall health and well-being. Preconception, pregnancy, and the early postpartum period represent opportunities to engage women in regular physical activity to optimize their health and prevent weight gain, with the added potential to transfer behavior change to children and families. Yet, research shows that 55% of women ages 18 to 45 in developed countries do not meet current physical activity recommendations, and there is a downward trend in physical activity with increasing age along with an upward trend in weight gain.

The 2016 article by Harrison et al summarized below reviews the current evidence for how regular physical activity can support women’s health in the preconception, pregnancy, and postpartum stages. Current physical activity guidelines recommend 150-300 minutes of moderate intensity physical activity each week, 75-150 minutes of vigorous physical activity or a combination of both each week, with at least two days of muscle strengthening activities weekly. Moderate physical activity consists of 55-70% of maximum heart rate and a noticeable heart rate change while still being able to maintain a conversation; examples include brisk walking, household chores, swimming, and low impact aerobics. Another important recommendation is to minimize prolonged sitting.

Preconception

For the preconception period, physical activity has been shown to be beneficial in the areas of infertility, assisted reproductive therapy (ART), PCOS, weight gain prevention, and psychological well-being. Since preconception activity level is a strong predictor of continued activity during pregnancy, establishing a regular routine prior to pregnancy should be an important component of pregnancy planning.

Weight management, including regular physical activity, is important to both prevent and treat infertility, as overweight and obesity can impair female fertility and reduce the likelihood of spontaneous and even assisted conception. Evidence shows that moderate regular physical activity positively influences fertility and ART outcomes.

PCOS is a leading cause of anovulatory infertility and affects 12-18% of reproductive-aged women. Regular exercise has been shown to reduce some of the insulin resistance present in PCOS. It was also shown to improve menstruation and ovulation frequency in 60% of women following a moderate intensity exercise intervention three times weekly for 45 minutes over 12 weeks. Continuity of exercise is important, as cessation reverses metabolic and weight benefits achieved. However, the evidence for the effect of exercise on fertility in PCOS patients is limited, and more research is needed to address frequency, duration, and intensity of exercise.

Regular physical activity has multiple benefits for psychological well-being, including mood, self-efficacy, anxiety, depression, and health-related quality of life. Lower levels of anxiety and depression are seen in women who maintain at least 60 minutes/week of self-reported moderate physical activity compared with sedentary women. A systematic review of 11 interventional studies showed significantly improved psychological and physical health and quality of life with 3-6 months of light to moderate intensity physical activity compared with no treatment. These effects are also seen among patients with infertility, where regular physical activity is associated with improvements in depression, body image distress, and quality of life.

Pregnancy

Throughout pregnancy, physical activity may prevent excess gestational weight gain, gestational diabetes, and preeclampsia, and may promote better labor and neonatal outcomes. The current physical activity recommendations by the ACOG for pregnant women include 20-30 minutes of moderate physical activity on most or all days, in the absence of contraindications such as incompetent cervix, placenta previa, 2nd or 3rd trimester bleeding, heart or lung disease, or multiple gestations. In normal pregnancies in which physical activity is at the recommended levels, the benefits of exercise outweigh any risks to mother or fetus.

On the other hand, pre-existing overweight and obesity are risk factors for maternal complications of miscarriage, hypertension, gestational diabetes mellitus (GDM), large for gestational age (LGA) infants, and caesarean delivery. Increased GWG is a risk factor for antenatal complications such as GDM, hypertension, and preeclampsia. Studies have found that increased physical activity was as effective as dietary interventions to reduce the risk of excessive GWG.

GDM increases neonatal and maternal risks including neonatal hypoglycemia and morbidity, LGA neonates, and increased rates of caesarean sections, along with increased risk of maternal and offspring progression to type 2 diabetes. A 2015 systematic review of 10 RCTs comparing physical activity as a stand-alone intervention with standard care showed a 28% lower risk of developing GDM; this is likely due to the role of physical activity on glucose uptake and utilization. However, the role of exercise in the treatment of GDM remains inconclusive, partly because of a Cochrane review of 4 trials reporting no statistically significant difference between combined exercise and diet therapy and minimal or dietary therapy alone on glucose control, insulin prescription, or neonatal/maternal outcomes.

While the protective role of physical activity on hypertension in the general population is clear, its role in preventing preeclampsia is not clear. Studies in this area have reported contradictory findings, potentially due to methodological differences. 

Postpartum

Physical activity helps prevent depression and postpartum weight retention. While physical activity may not induce sufficient weight loss as a solo therapy (without dietary changes) in the postpartum period, it supports weight maintenance and prevention of weight gain. Furthermore, moderate to vigorous physical activity has not been shown to negatively affect breast milk composition or volume as long as there is adequate fluid and food intake.

Although studies looking at physical activity and exercise interventions to prevent or treat postpartum depression (PPD) are limited, RCTs have shown 59-65% reduction in scores following a 12-week intervention of 2-3 walking sessions per week. Physical activity may act to elevate mood, improve self-efficacy and sleep patterns, alleviate stress, and increase coping strategies. Additionally, there is evidence to suggest that preconception and antenatal exercise is associated with reduced PPD risk following pregnancy.

Conclusion

The data reveals many benefits of regular physical activity across the different stages of a woman’s reproductive life—from preconception to pregnancy and the postpartum period. While some of the data is mixed or inconclusive, the benefits of regular physical activity are markedly noticeable in the preconception period when it comes to fertility, ovulation, achieving pregnancy, and overall health and mood. More studies are needed to address the optimal type, frequency, duration, and intensity of physical activity required to attain these beneficial health outcomes, and more studies are needed to assess its benefits throughout pregnancy and the postpartum period.

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References

[i] Harrison CL, Brown WJ, Hayman M, Moran LJ, Redman LM. The Role of Physical Activity in Preconception, Pregnancy and Postpartum Health. Semin Reprod Med. 2016;34(2):e28-e37. doi:10.1055/s-0036-1583530.