Exercise in midlife

June 21, 2025

During the menopause transition, there are numerous changes that occur in our bodies that increase our risk developing cardiovascular disease.  Cardiovascular disease a blanket term for a combination of conditions effecting our blood vessels including heart attacks, strokes, and peripheral artery disease.  Since heart disease is the leading cause of death for women in the United States, it’s important to investigate ways to lower our risk of developing it. 

Unfortunately, in our current insurance-based, corporate healthcare system, preventive care often takes a back seat. With limited time for face-to-face visits, healthcare practitioners are forced to focus more on treating disease than preventing it. This is one of the many reasons I believe so strongly in direct primary care (DPC), which allows space for truly personalized, proactive care.

Okay—stepping off my “DPC is the best way to practice medicine” soapbox (after posting a link below, of course) and back to the point: why exercise matters so much for women in midlife.

What Changes in Midlife That Raise CVD Risk?

1. Visceral Fat Gain & Muscle Loss
Decrease in lean muscle mass and an increase in “visceral fat” – this is the fat that lives deep in our abdomen and surrounds our internal organs.  Even in women with a normal body mass index, these are both independent risk factors for cardiovascular disease and death.

2. Decreased Insulin Sensitivity
As estrogen levels decline, women may become more insulin resistant, raising the risk for type 2 diabetes and metabolic syndrome.

3. Weight Gain
Weight gain is a common—and frustrating—part of the menopause transition. Hormonal changes, shifts in metabolism, sleep disturbances, stress and changes lifestyle demands all contribute. I hear it from women every day: “I haven’t changed a thing with my diet or exercise, but I’m still gaining weight!” Others tell me that the strategies that once helped them shed pounds in their 20s or 30s no longer work at all.

4. Sleep Disturbances
Short sleep duration and poor sleep quality are common and independently linked with markers of subclinical cardiovascular disease like greater carotid intima-media thickness and plaque buildup—even after controlling for estradiol levels and traditional risk factors.

5. Increased Psychological Stress
Midlife is also a time when psychological stress, anxiety, and depression become more common—all of which are associated with greater cardiovascular risk.

6. Adverse Shifts in Lipid Profiles
Total cholesterol, LDL (“bad cholesterol”), apoB (a strong predictor of CVD risk) and triglycerides all increase as estrogen levels decline during the menopause transition

Good News About Menopausal Hormone Therapy (MHT):
MHT has been shown to positively influence many of the above changes—helping maintain lean muscle, improve insulin sensitivity, reduce visceral fat, and favorably shift cholesterol levels - decreasing total cholesterol, LDL and apoB. The only exception is how MHT can impact triglycerides - oral estrogen can actually lead to an increase in serum triglycerides. “Transdermal” hormone therapy (meaning delivered through the skin) does not impact triglyceride levels.

How Exercise Can Counteract These Changes

Exercise is one of the most powerful interventions for heart health—especially during and after menopause. It can:

• Improve insulin sensitivity

• Decrease visceral fat

• Enhance sleep

• Lower stress

• Improve lipid profiles

• Preserve lean muscle and bone

But which type of exercise is best?

Cardio vs Resistance Training: Which Is Better?

Trick question! - Cleary, the answer is both.

Regular cardiovascular exercise—like brisk walking, cycling, swimming, or dancing—can help protect the heart and blood vessels during and after menopause. Exercise helps lower blood pressure, improve cholesterol, control weight, and keep blood sugar in a healthy range. It also helps blood vessels stay flexible and healthy, which is especially important after menopause in light of the CVD risk discussed above.  In her book, Next Level, Stacy Sims specifically recommends “sprint interval training,” (SIT) as a key type of cardio for midlife women.  Fortunately for me, you don’t have to literally sprint on a treadmill to achieve the SIT goals – the key is high intensity.

Next Level is one of several books available for patients to borrow at my clinic. Fair warning: most copies come with underlined sections and added comments in the margins—consider it a bonus layer of enthusiasm by yours truly.

Key Guidelines about Cardio

1. Move Away from Steady-State Cardio
   Moderate cardio ("zone 2/3") may actually raise cortisol and promote fat storage. Use it strategically—for active recovery or relaxation—not as your primary workout.

2. Prioritize High-Intensity Interval Training (HIIT)

• Keep it short: ~30 minutes including warm-up and cool-down

• Max 2x per week

• Benefits: lowers cortisol, boosts testosterone and growth hormone, supports fat loss and sleep

  • Add Sprint Bursts to Lifting Days

    • Example: 5x30 second sprints post-lift, with 1 min rest

    • Fast, effective, and metabolism-boosting

  • Short and Strategic Workouts Work

    • You don’t need an hour at the gym

    • 20-40 minutes of smart, targeted work is enough

  • Respect Recovery

    • Don’t overdo intense sessions

    • Balance HIIT with rest, strength, and mobility work

Why Strength Training is Non-Negotiable

DO NOT BE AFRAID TO LIFT HEAVY!!

Loss of estrogen accelerates the decline in muscle strength and bone density. But lifting heavy can slow or even reverse this.

Key Benefits:

• Preserves bone and muscle mass

• Increased metabolic rate and maintenance of body composition

• Improves posture, balance, and fall resistance

• Supports brain health and nervous system resilience

Sims Recommends:

• Low reps, high weight (e.g., 3–6 reps of deadlifts or squats)

• 2–3 strength sessions per week

• Don’t forget to warm up: important for injury prevention, but also enhances performance

  • Sims uses a 10-15 minute mobility session designed by Erin Carson as an example in chapter 6 in her book

• Simple structure: compound lifts + short metabolic finisher

• Rest between sets: Minimum of 2 minutes to ensure a full recovery between sets

• Strength sessions can be 30–40 minutes and still very effective

Don’t Skip the Jumps: Plyometrics in Midlife

Jumping and power movements aren’t just for athletes—they’re for menopausal women too.

Why Jump?

• Builds bone density (3–5% annual gains shown in studies)

• Improves insulin sensitivity and muscle power

• Protects joints when done correctly

Sample Routine:

• 3–5 minutes of squat jumps, hops, or box jumps

• Add after strength sessions 2–3×/week

• Can be scaled for all levels—even “pretend jumps” can be effective

How Much Exercise Do I Need?

The American Heart Association recommends:

• 150 minutes of moderate activity per week

• Or 75 minutes of vigorous activity

For weight loss, aim for 250–300 minutes weekly.
But even if weight doesn’t change, the health benefits of movement are profound—please don’t quit if the scale doesn’t budge.

🩺 “If I could prescribe exercise as easily as an estradiol patch, I would do so for every single woman I see at my practice! The benefits are just that powerful.”

📚 Resources & References

Books & Podcasts

• Next Level by Stacy Sims, PhD

• Unbreakable by Vonda Wright, MD (I’ve preordered my copy - have you??)

• Hit Play Not Pause, Episode 229: “Hormones and Heavy Lifts” with Holly Rilinger

Instagram Coaches
I’ll be honest—I'm more of a books, podcasts, and original research (🧠🤓) kind of person than a social media scroller. But when I’m not trying to crack the Instagram algorithm to spread the word about Elevated Menopause Care, I do take note of who’s recommended by experts I trust.

The following coaches are featured in menopause books I keep stocked at the clinic for patients to borrow:

• Holly Rilinger and Cara Metz – featured in The New Menopause by Dr. Mary Claire Haver

• Erin Carson – featured in Next Level by Dr. Stacy Sims

Patient Handouts

Research Sources

• El Khoudary SR, et al. Menopause Transition and Cardiovascular Disease Risk: AHA Statement. Circulation. 2020.

• Thurston RC, et al. Sleep Characteristics and Carotid Atherosclerosis. Sleep. 2017.

• Marlatt KL, et al. Body Composition Across Menopause. Obesity. 2022.

• Uddenberg ER, et al. Menopause Transition and Cardiovascular Disease Risk. Maturitas. 2024.

• *Apolipoprotein B and Cardiovascular Disease. Various authors, 2024.

• Next Level, Stacy Sims PhD

Additional support and literature summaries gathered using OpenEvidence, an AI-powered clinical search tool.