Exercise dose and modality for blood pressure reduction in predominantly postmenopausal women: a dose-response network meta-analysis

Background: Blood pressure rises during the menopausal transition and postmenopause, yet exercise guidance seldom specifies the type and dose most effective for lowering it. We examined the dose-response relationship between exercise and blood pressure in trials enrolling peri- or postmenopausal women, while recognizing that the available evidence was predominantly derived from postmenopausal populations. Methods: We searched PubMed, Web of Science, Embase, and the Cochrane CENTRAL register from inception to March 2026 for randomized controlled trials of exercise interventions lasting at least 4 weeks in peri- or postmenopausal women. To limit dose misclassification, weekly dose was derived only from trials that reported exercise frequency, intensity, and session duration, expressed as METs-min/week and adjusted for attendance where this was reported. A Bayesian model-based dose-response network meta-analysis was fitted, with risk of bias assessed using RoB 2 and certainty of evidence using CINeMA. Results: Seventy-four trials involving 3,573 women (mean age, 59.5 years) were included; 70 exclusively enrolled postmenopausal women and four included perimenopausal women. Among eight candidate dose-response functions, the quadratic model yielded the lowest DIC and was retained as the primary model. Under this model, the largest predicted reductions occurred at 1,400 METs-min/week for SBP (-6.70 mmHg, 95% credible interval -9.18 to -4.29) and 1,500 METs-min/week for DBP (-4.20 mmHg, -6.52 to -1.74). The apparent attenuation at higher doses was model-dependent. At the highest observed AQE dose of 800 METs-min/week, aquatic exercise produced the largest model-estimated point reductions for both outcomes (systolic -11.63 mmHg; diastolic -7.73 mmHg); however, these estimates were based on only three AQE intervention arms and the ranking should be considered exploratory. Meta-regression found no significant moderation by age, baseline blood pressure, or intervention length. Certainty of evidence ranged from very low to low. Conclusion: Among trial populations composed predominantly of postmenopausal women, exercise was associated with a non-linear, dose-related reduction in blood pressure. The largest model-estimated reductions occurred near 1,400-1,500 METs-min/week. Aquatic exercise appeared promising, but the small number of contributing trials and the generally low certainty of evidence preclude definitive modality ranking. Evidence remains insufficient to draw stage-specific conclusions for perimenopausal women. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier [CRD420261354599].