Menopause: The Journal of The North American Menopause Society

Vol. 18, No. 9, pp. 980/984

DOI: 10.1097/gme.0b013e3182135442
* 2011 by The North American Menopause Society

Combined resistance and endurance exercise training improves

arterial stiffness, blood pressure, and muscle strength
in postmenopausal women
Arturo Figueroa, MD, PhD,1 Song Y. Park, MS,1,2 Dae Y. Seo, MS,2 Marcos A. Sanchez-Gonzalez, MD,1
and Yeong H. Baek, PhD2

Abstract
Objective: Menopause is associated with increased arterial stiffness and reduced muscle strength. Combined
resistance (RE) and endurance (EE) exercise training can decrease brachial-ankle pulse wave velocity (baPWV), an
index of arterial stiffness, in young men. We tested the hypothesis that combined circuit RE and EE training would
improve baPWV, blood pressure (BP), and muscle strength in postmenopausal women.
Methods: Twenty-four postmenopausal women (age 47-68 y) were randomly assigned to a Bno exercise[ control
(n = 12) or to combined exercise training (EX; n = 12) group. The EX group performed concurrent circuit RE training
followed by EE training at 60% of the predicted maximal heart rate (HR) 3 days per week. Brachial systolic BP,
diastolic BP, mean arterial pressure, baPWV, HR, and dynamic and isometric muscle strength were measured before
and after the 12-week study.
Results: Mean T SE baPWV (j0.8 T 0.2 meters/s), systolic BP (j6.0 T 1.9 mm Hg), diastolic BP (j4.8 T
1.7 mm Hg), HR (j4.0 T 1.0 beats/min), and mean arterial pressure (j5.1 T 1.6 mm Hg) decreased (P G 0.05),
whereas dynamic leg strength (5.1 T 1.0 vs 0.6 T 1.0 kg for the EX and control groups, respectively) and isometric
handgrip strength (2.8 T 0.7 vs j0.6 T 1.2 kg) increased (P G 0.05) in the EX group but not in the control group.
Conclusions: Our findings indicate that a 12-week moderate-intensity combined circuit RE and EE training
improves arterial stiffness, hemodynamics, and muscle strength in previously sedentary postmenopausal women.
This study provides evidence that combined training may have important health implications for the prevention of
hypertension and frailty in postmenopausal women.
Key Words: Arterial stiffness Y Hemodynamics Y Menopause Y Muscle strength Y Resistance exercise training Y
Endurance exercise training.

women.1,2 However, hormone therapy has failed to increase

M
enopause influences an age-related increase in arte-
rial stiffness1 and a decrease in muscle strength.2 In
postmenopausal women, brachial-ankle pulse wave
velocity (baPWV), an index of systemic arterial stiffness, has
been associated with high blood pressure (BP)1,3 and sarcope-
nia,4 the age-related loss of muscle strength and mass. Recent
studies have indicated that increased isometric and dynamic
muscle strength may have a protective effect against arterial
stiffness,5 hypertension,6 and cardiovascular diseases.7 The
deleterious changes in arterial and muscular function seem to
be associated with estrogen deficiency in early postmenopausal
Received November 30, 2010; revised and accepted January 31, 2011.
From the 1Department of Nutrition, Food and Exercise Sciences, College
of Human Sciences, Florida State University, Tallahassee, FL; and
2
Department of Physical Education, Pusan National University, Busan,
Korea.
Funding/support: None reported.
Financial disclosure/conflicts of interest: None reported.
Address correspondence to: Yeong H. Baek, PhD, Department of Phys-
ical Education, Pusan National University, Busan 609-753, South Korea.
E-mail: ds-cook@hanmail.net
muscle strength in postmenopausal women.2 In contrast, exer-
cise training has been shown to be an effective means of im-
proving reduced muscle strength,8 elevated BP,9,10 and arterial
stiffness11 associated with sedentary aging.
Conventional resistance exercise training is characterized by
long resting intervals (2-3 min) between sets and exercises.
Resistance exercise training at moderate- to high-intensity is
recommended to increase muscle strength and mass in older
adults.8,12 However, it has been shown that high-intensity
resistance training may increase arterial stiffness in young13<15
and middle-aged adults.16 Although low-intensity conventional
and circuit resistance training with short (15-30 s) interset rest
periods has shown to decrease baPWV, low-intensity exercise
has not improved muscle strength in middle-aged17 and post-
menopausal women.11 In contrast, moderate-intensity circuit
resistance training can produce muscle strength gains com-
parable with those of high-intensity resistance training in
postmenopausal women.18 Moreover, there is evidence that
conventional high-intensity resistance training combined with
endurance training can improve both baPWV and muscle
strength in young men.19 These studies support the hypothesis

980 Menopause, Vol. 18, No. 9, 2011

Copyright © 2011 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 COMBINED TRAINING AND ARTERIAL STIFFNESS
that combined moderate-intensity circuit resistance and en-
durance training may improve arterial function and muscle
strength in postmenopausal women. Therefore, the purpose
of this study was to evaluate the effects of combined circuit
resistance and endurance training on baPWV, hemodynamics,
and muscle strength in postmenopausal women.
METHODS
Participants
Twenty-four women (age, 47-68 y) participated in the
present study. Menopause was defined as the absence of
menstruation for at least 1 year. None of the women was obese
(body mass index, Q30 kg/m2) or smoked. Exclusion criteria
included having cardiovascular disease, diabetes, and musculo-
skeletal problems that would limit exercise performance and
using medication or hormone therapy during the 6 months
before the study. All women were sedentary, defined as having
less than 1 hour of regular exercise per week in the previous
year. All participants gave a written informed consent form
approved by the institutional human research committee.
Study design
Participants were tested in the morning at the same time
of day to avoid potential diurnal variations. Women reported
to the laboratory after an overnight fast and abstained from
caffeine, tea, and alcohol for at least 12 hours and from exercise
for 48 hours before the tests. Cardiovascular measurements
were performed after at least 10 minutes of rest in the supine
position in a quiet, temperature-controlled room (approximately
24-C). BP was measured on two separate days. After baseline
measurements, women were randomized to an exercise group
(n = 12) or to a Bno exercise[ control group (n = 12) for
12 weeks. Participants were advised to make no changes to
their diet and exercise habits during the study.
Muscle strength
Dynamic muscle strength was assessed by the one repeti-
tion maximum (1RM) test using a leg extension machine
(Cybex 6000; Lumex, Albertson, NY). Women were famil-
iarized with the exercise and lifting technique before 1RM
measurement, which was achieved within five attempts. The
1RM was considered the highest weight lifted using the proper
form. Static muscle strength was measured as the highest of
three maximal voluntary contractions using a handgrip dyna-
mometer (Jamar, Bolingbrook, IL).
Exercise training
Women in the exercise group trained three times per week
on nonconsecutive days for 12 weeks. All training sessions
started with approximately 20 minutes of circuit resistance
training consisting of one set of 12 repetitions for nine exer-
cises (chest press, leg press, shoulder press, abdominal crunch,
leg curl, leg extension, low back extension, bicep curls, and
triceps extension) on weight machines (Jae il International,
Seoul, Korea). Short (G15 s) resting periods between sets
were allowed to maintain a heart rate (HR) at 60% of the pre-
dicted HR maximum, which corresponds to 60% of 1RM.20
Copyright © 2011 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
The resistance exercise session was immediately followed by
20 minutes of treadmill walking at 60% of the predicted HR
maximum. Exercise HR was monitored using a polar device
(Electro; Oy, Kempele, Finland). Exercise training was super-
vised by experienced trainers. The training load for circuit
resistance (weight) and endurance training (speed and/or incli-
nation) was adjusted to keep the HR at 60% of the predicted
HR maximum throughout the study.
PWV and hemodynamics
baPWV and BP were measured using a volume-
plethysmographic device (VP-1000; Colin Co., Komaki, Aichi,
Japan). Electrocardiogram (ECG) electrodes were placed on
the forearms, whereas a heart sound microphone was placed
on the left parasternal border of the fourth intercostal space.
HR was determined from the ECG. BP cuffs were wrapped
around both arms (brachial artery) and ankles (posterior tibial
artery). BP, ECG, and pulse waveforms were simultaneously
recorded for 10 seconds. The feet of the pulse waveforms
were related to the R wave of the ECG to calculate transit
time between the brachium and ankle ($Tba). The path dis-
tances from the suprasternal notch to the brachial (Db) and
to the ankle (Da) sensor were calculated using the following
equations: Db = 0.220  height (cm) j 2.07 and Da = 0.813 
height (cm) + 2.33. baPWV was calculated as Da j Db/$Tba.
The mean of the left and right baPWV was used in the analy-
sis. The validity and reproducibility of noninvasive baPWV
have been previously shown.21 The interclass correlation co-
efficient for baPWV calculated on two separate days was 0.95.
Body composition
Height was measured to the nearest 1.0 cm without shoes.
Body weight was measured to the nearest 0.1 kg, with the
participant wearing her undergarments and light clothes.
Fat-free mass and fat mass were measured using a bioelectrical
impedance meter (InBody 230; Biospace, Seoul, Korea).
Statistical analysis
Data are presented as mean T SE. An unpaired t test was
used for group comparisons at baseline. A two-way analysis
of variance with repeated measures (group [control and
exercise]  time [before and after the 12-wk study]) was used
to determine the effects of combined training and time on
dependent variables. If a significant interaction or main effect
was noted, a paired t test was used for post hoc comparisons.
Analyses were performed using SPSS 18.0 for Windows
(SPSS Inc., Chicago, IL). Statistical significance was set at
P G 0.05. Based on a previous study,19 we estimated that
12 women would enable 90% power to detect a 6% decrease
in baPWV after a combined training.
RESULTS
Participant characteristics
Participant characteristics at baseline and after 12 weeks for
the control and exercise groups are presented in Table 1. There
were no significant differences in baseline parameters between
the groups. Participant adherence to the supervised training
Menopause, Vol. 18, No. 9, 2011 981
 FIGUEROA ET AL

TABLE 1. Participant characteristics before and after 12 weeks of control or exercise training
Control (n = 12) Exercise (n = 12)

Before After Before After

Age, y 54 T 1 54 T 2
Height, m 1.58 T 0.02 1.60 T 0.01
Weight, kg 56.8 T 1.6 55.2 T 1.6b 62.1 T 2.2 60.6 T 2.0b
BMI, kg/m2 23.1 T 0.7 22.5 T 0.8b 24.2 T 0.7 23.6 T 0.7b
Fat mass, kg 19.8 T 1.3 18.5 T 1.3b 23.3 T 1.3 22.0 T 1.1b
Fat-free mass, kg 37.0 T 0.8 36.7 T 0.8 38.8 T 1.0 38.5 T 1.0
Dynamic strength, kg 38.3 T 1.5 38.8 T 1.5 38.3 T 1.1 43.3 T 1.7b,d
Isometric strength, kg 26.1 T 0.7 25.7 T 0.8 24.7 T 1.0 27.6 T 1.2a,c
Heart rate, beats/min 68 T 2 67 T 2 66 T 2 62 T 1b,c
MAP, mm Hg 89 T 3 89 T 3 89 T 3 84 T 2a,c
Values are presented as mean T SE.
BMI, body mass index; MAP, mean arterial pressure.
a
P G 0.05 vs before.
b
P G 0.01 vs before.
c
P G 0.05 vs control.
d
P G 0.01 vs control.

program was greater than 98%. There were significant reduc- healthy adults.24 Moreover, Okamoto et al19 reported that
tions (P G 0.01) in weight (j1.5 T 0.3 and j1.7 T 0.4 kg, 20 minutes of moderate-intensity endurance exercise combined
respectively, for the exercise and control groups), body mass with high-intensity resistance exercise decreased baPWV in
index (j0.7 T 0.1 and j0.7 T 0.2 kg/m2), and fat mass (j1.3 T young men. In addition to the previous reports, our findings
0.2 and j1.3 T 0.3 kg) in the exercise and control groups. Fat-
free mass did not change (P 9 0.05) in either group. Dynamic
leg strength (5.1 T 1.0 kg; P G 0.01) and isometric handgrip
strength (2.8 T 0.7 kg; P G 0.05) increased in the exercise group,
but no significant changes were observed in the control group.
Arterial stiffness and hemodynamics
There were no significant differences between the groups
in cardiovascular parameters at baseline (Table 1; Fig. 1).
There were significant group  time interactions (P G 0.05)
for baPWV (Fig. 1A), systolic BP (Fig. 1B), HR (Table 1),
and mean arterial pressure (Table 1). baPWV (j0.8 T 0.2 vs
0.1 T 0.2 meters/s), systolic BP (j6.0 T 1.9 vs 0.2 T 2.1 mm Hg),
diastolic BP (j4.8 T 1.7 vs 0.5 T 1.5 mm Hg; Fig. 1C), HR
(j4.0 T 1 vs 0.8 T 0.4 beats/min), and mean arterial pressure
(j5.1 T 1.6 vs 0.1 T 0.5 mm Hg) decreased (P G 0.05) in the
exercise group.

DISCUSSION
The main finding of the present study was that moderate-
intensity combined circuit resistance and endurance exercise
training resulted in beneficial effects on arterial stiffness, BP,
HR, and muscle strength in postmenopausal women.
Previous studies have reported improvements in baPWV
or arterial compliance after separate low-intensity conven-
tional resistance training,17 circuit resistance training,11 and
endurance training22 in premenopausal and postmenopausal
women. A recent study demonstrated that when performed
in separate groups, moderate-intensity endurance training
decreases but resistance training increases aortic PWV and
leg PWV,16 the main components of baPWV.23 However,
when endurance and resistance training are concurrently per- FIG. 1. baPWV (A), SBP (B), and DBP (C) before and after 12 weeks of
formed, 30 minutes of moderate-intensity exercise followed control (n = 12) and exercise training (n = 12) in postmenopausal women.
*P G 0.05, time effect; **P G 0.01, time effect; †P G 0.05, group effect.
by resistance exercise can counteract the increase in arterial Values are presented as mean T SE. baPWV, brachial-ankle pulse wave
stiffness observed after separate resistance training in young velocity; SBP, systolic blood pressure; DBP, diastolic blood pressure.

982 Menopause, Vol. 18, No. 9, 2011 * 2011 The North American Menopause Society

Copyright © 2011 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 COMBINED TRAINING AND ARTERIAL STIFFNESS
have shown that short-term combined circuit resistance exer-
cise followed by 20 minutes of endurance exercise decreases
baPWV by 6.2% in postmenopausal women, a population
with increased arterial stiffness and a high prevalence of pre-
hypertension (39%).1,25,26
Although the results of previous studies have shown
decreases in arterial stiffness after separate resistance training
and combined resistance and endurance training, they did not
report concomitant decreases in BP. In the present study, we
found reductions in systolic and diastolic BP of 6 and 5 mm Hg,
respectively, after combined training. Our findings are con-
sistent with those of Collier et al,16 who reported decreases
in systolic and diastolic BP of 5 and 3 mm Hg, respectively,
with concurrent reductions in aortic and leg PWV after 4 weeks
of endurance training in middle-aged adults with high BP.
Moreover, previous studies using separate exercise training have
reported isolated decreases in systolic BP of 6 mm Hg after
endurance training10 or decreases in diastolic BP of 3 mm Hg
after resistance training9 in postmenopausal women and older
adults with prehypertension to stage 1 hypertension. The ap-
parent discrepancy between previous studies and our study
regarding the effects of resistance training on BP could be
partially caused by the menopause status of our participants.
It has been suggested that the decreases in systolic and dia-
stolic BP after exercise training are more pronounced in
middle-aged women with high BP.27 Therefore, the mean sys-
tolic BP in our training group, which was in the prehyper-
tension category, may have influenced the decreases in BP.
The training-induced improvements in baPWV and BP are
probably caused by functional, rather than structural, adapta-
tions in the arterial wall.9,28 Combined exercise training19 and
low-intensity resistance training with short resting periods29
may decrease baPWV via improved endothelium-dependent
vasodilation. Consequently, reduced vasomotor tone in pe-
ripheral arteries19,29 may influence the decrease in systolic
and diastolic BP observed after resistance training in older
adults.9 Furthermore, impaired baroreflex control of BP and
HR has been associated with increased arterial stiffness in older
adults.30 Recent work suggests that regular combined training
in middle-aged adults increases cardiovagal baroreflex sensi-
tivity via reduced arterial stiffness.31 Although separate en-
durance32 and resistance training33 can improve cardiovagal
outflow in middle-aged and older adults, a reduction in resting
HR of 4 beats/minute has been noted only after endurance
training.32 We found a similar reduction in HR after combined
training, suggesting that 40 minutes of endurance stimulus
provided by circuit resistance and endurance training may
reduce HR in postmenopausal women through an improved
cardiovagal regulation.
Moderate-intensity resistance training has been shown to
increase muscle strength without any beneficial effect on arte-
rial function in middle-aged34 and postmenopausal women.26
In contrast, low-intensity conventional17 and circuit resistance
training11 have improved baPWV but not muscle strength in
middle-aged and older women. These results suggest that
low-intensity conventional and circuit resistance training may
Copyright © 2011 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
not provide sufficient stimulus to induce strength gains or to
promote the adverse effects on arterial stiffness showed after
moderate- and high-intensity resistance training.13,16,24 Inter-
estingly, our findings showed that moderate-intensity combined
training increased upper- and lower-body muscle strength with
a concomitant reduction in baPWV and BP in postmenopausal
women. Because our training program did not increase fat-free
mass, the increases in both dynamic and static strength may be
caused by neuromuscular adaptations.18 Indeed, increased mus-
cle strength, but not muscle mass, is associated with cardio-
vascular protection in older adults.7 Moreover, increased
muscle strength is inversely related with aortic PWV5 and the
risk of hypertension6 in men. Our findings support the use
of combined training to improve muscle strength and arterial
stiffness in postmenopausal women following the minimal ex-
ercise recommendations from the American College of Sports
Medicine for health promotion in older adults.12 The beneficial
effects observed after combined training in the present study
may have important health implications for postmenopausal
women because these improvements may reduce the risk of
adverse cardiovascular events (eg, myocardial infarction and
stroke)25 and frailty.12
There are some limitations to the present study. Because
our participants were apparently healthy early postmeno-
pausal women, our results may not be generalized to other
populations. However, because similar improvements in sys-
tolic BP and cardiac autonomic regulation of HR have been
reported after endurance training in obese women with and
without type 2 diabetes,35 the results of the present study
may be generalized to other postmenopausal women. Al-
though there were similar small reductions in body weight
(approximately 1.5 kg) and fat mass in both groups, the lack
of vascular effects in the control group may indicate that
the magnitude of the change was not sufficient to influence
arterial function. Moreau et al10 reported that small reductions
(approximately 1.3 kg) in body mass after endurance training
are not related to the decrease in systolic BP in postmeno-
pausal women. Moreover, a weight loss of approximately 7 kg
is needed to reduce aortic PWV.36 Further research is needed
to determine the mechanisms for the reduction in arterial
stiffness, BP, and HR after combined training in a larger group
of postmenopausal women.
CONCLUSIONS
Our findings indicate that combined circuit resistance and
endurance exercise training is effective in improving systemic
arterial stiffness, hemodynamics, and muscle strength in post-
menopausal women. Our results support the use of moderate-
intensity combined training for the prevention of hypertension
and frailty in postmenopausal women.
Acknowledgments: We thank the participants.
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* 2011 The North American Menopause Society