Reviewer's report
Title:Primary Amenorrhea in the Physician's Office: Normal Coitus or Not?
Always Take a Look.
Version:4Date:8 November 2013
Reviewer: David Klein
Reviewer's report:
Dear Editor,
It was a pleasure to review the manuscript entitled “Primary amenorrhea in the
physician’s office: normal coitus or not? Always take a look. I believe that this
work will be well received and of great interest to the Journal’s readership.
Please see my comments below:
Major Compulsory Revisions:
1) Conclusion section: Be cautious about stating that “our cases highlight the
need for careful assessment of external genitalia in all girls” – external genitalia
examination can easily appear to be normal in patients with Mullerian agenesis
since the distal vagina can be preserved. Similar comment with the last sentence
in the conclusion regarding need for early identification of Mullerian agenesis.
Are the authors also recommending a first-line bimanual or speculum exam for all
adolescents with primary amenorrhea. This would be very controversial.
2) In the conclusion sections, it is difficult to tell if the authors are suggesting that
the microprolactinoma and MRKH syndrome are related (“associated” – i.e.
syndromic) or unrelated (e.g. the microprolactinoma was incidentally found in the
process of this work up, but unrelated to her presenting symptoms).
3) Although the authors correctly reference the AAP recommendation (reference
10), it is important to acknowledge some negative outcomes from universal GU
examination:
a. Potential loss of rapport – thus undermining the most revealing assessment of
the asymptomatic adolescent – the psychosocial history.
b. Decreased usefulness -- with less need for cervical cytology, alternative
methods for STI testing, etc.
c. Issues with test sensitivity - as stated above, Mullerian agenesis can easily be
missed on simple external GU examination
d. Time finding chaperone and conducting the exam -- universal GU exam takes
valuable time away from psychosocial screening
4) Similarly, clarify that the AAP recommendation is for “external exam”, not
pelvic/speculum exam (for which their table 1 gives specific indications). Stating
“gynecologic exam” in the second sentence of that paragraph” might be
confusing to some readers.
Minor Essential Revisions:
1) Under background, second sentence: please add a pregnancy test as a first
line test in primary (and secondary) amenorrhea.
2) Under case presentation, Case 1 (and conclusion): please change
Papanicolaou “smear” to Papanicolaou “test”
3) Under case presentation, Case 1: please characterize the microadenoma (at
least in size); and clarify the indications for treatment (size vs gonadal
dysfunction vs fertility issues) as opposed to simply monitoring it over time. Also
clarify “marked improvement” after treatment – is this only in size/prolactin level
or in patient oriented outcomes as well (patient feeling better, etc.). For
asymptomatic patients with small lesions, size/prolactin level improvement is less
important.
4) Under conclusion, both first and second paragraphs state “very rare sexual
phenomenon” – change the wording on one of the two.
5) For case 2: please clarify the vaginal dilator recommendation – clearly there
must have been some vaginal tissue present; the reported physical exam and
imaging results seem to indicate a complete absence of vaginal tissue. What did
bimanual exam show? Will dilators work for this patient?
Discretionary Revisions:
1) Abstract and throughout text: To be consistent with reference 1 (which is
commonly cited for articles on amenorrhea); the authors should consider using
“Mullerian Agenesis” instead of “MRKH syndrome,” although both terms are
commonly used.
2) Under background, first sentence: consider citing reference 1 (even though
cited after the following sentence), since this definition varies among experts and
references.
3) Under case presentation, case 2: please clarify “attempted sexual intercourse”
– did she report penetration? Also, specify that this finding, in addition to the
dilated urethra, helped to confirm urethral coitus.
4) If the length of the manuscript allows, please specify the lab results (hormone
panels) for case 2, even if “normal.”
Overall, an excellent manuscript that will be of interest to the readers.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests