Title: The impact of physical activity and exercise interventions on symptoms for women
experiencing menopause: overview of reviews
Version: 1 Date: 20 May 2024
Reviewer's report:
I heartily commend the authors to taking on the challenge of writing this overview of reviews.
This is a thorough and well-written review that was pre-registered on PROSPERO, appropriately
followed PRIOR guidelines, incorporated a variety of search engines, and used a review
software management program to ensure tight organization and control. The methodology and
conclusions are sound. I anticipate this review will be highly cited and useful to both researchers
and clinicians.
The comments below are intended to improve the clarity of the report.
Throughout - the author initials used in text are AMM and AM but on the title page the first
two authors do not have middle initials to distinguish which one is AMM and which is AM.
Please clarify.
Throughout –please spell out acronyms and provide some additional details  about the “what
and why” of each of the following. These are important for readers, particularly clinicians, to
understand as they contribute to the rigor of this review. This list of acronyms and explanations
could be a table.
• PROSPERO – why pre-registration is important
• PRIOR guidelines – why following such guidelines is important
• Search engines – why these were chosen and why this combination is considered
comprehensive/representative of published health-related research
• Rayyan – fact that this is a comprehensive review organization platform and why using this
helped reduce errors at each stage of the review
• PROGRESSplus – what this is and why it was selected over other lists (e.g., WHO).
• AMSTAR-2 – describe tool and reason for selection or why best one applicable to this review
• CCA – what does this mean, how is it calculated, why using this is important in ensuring rigor,
what was corrected/adjusted in the summary of results to manage the Fig 1 overlap.
• SWiM – what were the steps/stages in SWiM that were used
• GRADE domains – what are these and why these were selected for use
• TIDieR – why using TIDieR in reporting would help ensure rigor
Rationale – why was an overview of reviews selected rather than a systematic review with or
without meta-analysis of the individual studies? What was gained/lost with this decision?
Methods – box 1, last line, based on the citation please change the scale name to the “Hot Flash
Related Daily Interference scale”.
Methods – please clarify whether and how you confirmed that studies / reviews were
published in reputable journals. This is particularly important given Wiley’s retraction of
over 11,000 studies and closure of 19 journals (see article in Wall Street Journal by Nikki
Subbaraman, 5/14/2024, https://www.wsj.com/science/academic-studies-research-paper-mills-
journals-publishing-f5a3d4bc ).
Further research – please clarify if the evidence is sufficiently similar to enable the network
meta-analysis that is mentioned. Given the variety of interventions (types, lengths, etc.) and
outcomes it makes me question whether this would even be possible or if possible whether it
would yield any useful results.
Further research – it  might be helpful to emphasize a bit more strongly the point that this
review really suggests more rigorous and appropriately powered trials are needed before the
field concludes that exercise interventions are not beneficial. I think it is also important to state
very clearly whether the authors are concluding that there is insufficient evidence to recommend
exercise for menopausal symptoms in clinical practice (e.g., not a recommended intervention
at this time, but is recommended to be investigated in high powered trials). A statement of this
type would be helpful to researchers to justify additional studies and for clinicians/researchers
who author guidelines and consensus statements.
Tables and Figures:
• Legends are needed for all figures.
• Figure 1 – what is the “other” category in the first box? An explanation as a footnote or in
the legend would be helpful.
• Figure 2 – how was the number of total nodes derived? Adding a percentage to each number in
the small explanation of overlap box inside this figure would be helpful – e.g., 70 slight overlap is
70/136=51%. Perhaps then could emphasize in text that 49% has  moderate to very high overlap.
I am not clear how this was corrected for in the summary of results.
• Table 2 – it would be helpful to insert the reference numbers next to each green and black bar.
This could more clearly convey how the individual reviews are mapped within this table 2 and
would also convey very concisely some of the detailed information in Table 1
• Table 3 – rather than stating “total” in the first box, perhaps clarify this is total number (or
severity?) of menopause symptoms. It would be easier to read and perhaps more concise to
use two columns under risk of bias – one for high and one for unclear – this would eliminate
those words being repeated in at twice for each citation in each row. Similarly it would be more
concise to add columns under the intervention column labeled SMD, 95% CI, I squared, # RCTs,
# participants. Multiple rows would only be needed for differing outcomes such as in Liu 2022.
Putting words in table headings will significantly reduce the length of this table and I think might
make it easier to visually scan and compare the reviews.