A systematic review and meta-analysis of the effects of high-intensity, impact, and strength training on bone mineral density in premenopausal and postmenopausal women.

IMPORTANCE: Menopausal estrogen decline is the leading cause of osteoporosis, leaving bones vulnerable to fractures. Of the interventions available for preserving bone density, exercise is potentially the most accessible. However, the ideal type, intensity, and age of initiation of exercise interventions remain under debate. OBJECTIVE: This systematic review and meta-analysis set out to summarize recent evidence on the effects of high-intensity, impact, and strength training on bone mineral density in postmenopausal women, and to compare this evidence to equivalent data in premenopausal women. EVIDENCE REVIEW: PubMed and the Cochrane Central Register of Controlled Trials were searched on July 17, 2025, for randomized controlled trials published on or after March 1, 2018. Search terms were structured around menopause-related, exercise-related, and bone-related terms. Studies were eligible if they included either premenopausal or postmenopausal women, at least one intervention arm completing either high-intensity, impact or strength training, a control arm, and bone mineral density as an outcome. Following identification of eligible studies, participant and study characteristics were tabulated, and studies were assessed for quality using the Physiotherapy Evidence Database scale and risk of bias using the RoB 2 tool. Outcomes data were extracted, and a meta-analysis was performed. FINDINGS: Eight randomized controlled trials incorporating 379 participants met the inclusion criteria; six (n=267) in postmenopausal and two (n=112) in premenopausal women. Meta-analysis of pooled intervention types revealed small but significant effects of high-intensity, impact, and strength training at the femoral neck (0.47, t[3]=5.22, P=0.014; n=141) and lumbar spine (0.36, t[4]=4.36, P=0.012; n=182) in postmenopausal but not premenopausal women. CONCLUSIONS AND RELEVANCE: High-intensity, impact, and strength training (pooled analysis) appeared to be effective at increasing bone mineral density in postmenopausal women, though the small effect sizes and methodological limitations identified should be considered. Further studies are required to determine whether more robust protocols would have generated stronger effects in premenopausal women, or whether there are different osteogenic responses to exercise in the two populations.