Exercise helps women's hearts, but science barely asks about menopause

Oestrogen appears to offer premenopausal women some protection against cardiovascular disease, and that protection fades once menopause arrives. Cardiorespiratory fitness and cardiovascular risk factors are closely tied to how physically active a person is, which makes exercise the obvious candidate for filling the gap oestrogen leaves behind. The question this review set out to answer is whether the trial evidence actually shows physical activity programmes improving fitness and risk factors in women, and crucially whether anyone has checked if the effects differ before and after menopause. Given how much health advice is aimed at midlife women, it is worth knowing how solid the foundations are.

The researchers ran a computerised search of five databases, PubMed, Cochrane, Scopus, SportDiscus and Web of Science, covering articles published up until December 2021. They looked specifically for randomised controlled trials of physical activity interventions in women of any age that reported effects on cardiorespiratory fitness or cardiovascular risk factors. Each included study was assessed for risk of bias using the PEDro scale and graded against Oxford's levels of evidence. Fourteen scientific articles met the inclusion criteria, and the reviewers examined whether any of them accounted for menopausal state when reporting their results.

Every one of the 14 included studies reported an improvement in at least one fitness or cardiovascular risk variable following a physical activity programme, which is encouraging on its face. However, the reviewers found great variability in the physical activity approaches used across trials, making them hard to compare directly. The bigger problem was quality: risk of bias was high, and all but two articles were judged to be of low methodological quality. Only a single article considered differences by menopausal state, and it highlighted the importance of physical activity in both premenopausal and postmenopausal women.

The review confirms the broad expectation that being active improves fitness and cardiovascular risk markers in women, so it does not overturn anything. What it exposes is how thin and uneven the underlying evidence is, particularly on the question of whether menopause changes how women respond to training. The reviewers conclude that more rigorous randomised trials are needed, with appropriate length and dose and individualised exercise intensity, before firm menopause-specific guidance can be drawn. Until then, most exercise advice for postmenopausal women is extrapolated rather than directly tested.

If you are a woman weighing up whether exercise is worth it for your heart and fitness, this review is a reason for confidence in the general direction: every trial found something improved. What it cannot yet tell you is whether your menopausal status should change the type, intensity or amount of activity you choose, because almost no trial has asked that question properly. It is also a useful reminder that headline claims about exercise and menopause often rest on studies that were not designed to separate the two. The sensible reading is that activity helps at any stage, while the fine-tuning remains an open question.