Title: Possible significance of degeneration and decreased expression of progesterone receptor
in postmenopausal uterine leiomyoma
Version: 1 Date: 03 Jun 2022
Reviewer's report:
To authors,
The data is interesting. The viewpoint is new.  Have some advices.
1. Abstract: Study group: readers cannot understand the reason why some postmenopausal
women had surgery for myoma. For example, 1) in some, malignancy cannot be completely ruled
out based on “images”, 2) in others, acute/rapid “growth” prompted physicians to recommend
surgery, 3) in some, degeneration occurrence prompted surgery, and 4) in still others, patients
may become “tired” to visit regularly to check the size/feature of myoma, and others. You wrote
something around line 128. Please very shortly summarize this in abstract. I will touch this later,
which is a critical point of this study.
2. Abstract: “aim” unclear. You state, “we focused on hormone receptor expression and
pathological findings in postmenopausal uterine leiomyomas”. Then, you conclude “sex steroid
hormones are unlikely to be associated with the growth of leiomyomas after menopause”. The
latter suggests that the clinical question here is “whether sex steroid hormones are associated
with the growth of leiomyomas after menopause”. As you may know, aim = clinical question that
should be solved here = hypothesis; this should be definitely written. The answer (conclusion)
should be a direct answer to this question. Once again, what is the present study “aim”. Please
write it definitely. Is X is right? Yes, it is right; No, it is not right but Y,Z, like manner.
3. You state the situation (regarding number 2) better in Introduction. Here, the point is
“progesterone in postmenopausal myoma”; abstract does not well illustrate this. Then, please
touch (emphasize) “progesterone” in the abstract. It is very simple, “Although estrogen has been
hitherto related with myoma-growth, recent data suggests that progesterone may play pivotal
role in progression/decrement of postmenopausal myoma and thus we attempted to test this in
a hysterectomized specimen”, (example).
4. Need not state “12 patient”. Group A consisted of 9; this is sufficient. (3 rejected to participate,
right? then need not to write; complicated!).
5. Conclusion: “Since degenerative leiomyomas tend to be difficult to differentiate from
sarcoma, surgery may be recommended for the leiomyomas that grow after menopause.”: In my
opinion, in this manuscript, you did not focus this point. Your statement is “common sense”
and “you acutely jumped to treatment strategy”: thus, I advise you that this statement should be
deleted. Generally, if one touches “treatment strategy”, one must be very cautious.
6. The most important point is: “hysterectomy-required postmenopausal myoma”. This
is very heterogenous. “The doctors” judge/consider “hysterectomy had be better done”.
Please reconsider whether this “classification” and then deduce “conclusion” (based on this
classification) is right. For extreme example, some women may say “I am tired to visit this
institute every 6 months and thus I wish to have hysterectomy”; this is also “surgery needed”.
You state something regarding “need surgery”; growing tendency, not-becoming small as
expected, degeneration occurrence-concern. “All these” reflect the same physiology, right?
Your data may be OK but since “surgery needed/not-needed completely depends doctors’ and
(sometimes patients’) preference/judgement, then, please state your rationale that “group A (a)
consisting of all together (heterogenous population) and then analysis is OK!”.
7. One usually performs endometrial smear (sounding longer than 7 cm in such myoma+ case)
and ultrasound before prolapse surgery. Considering the very high resolution of the ultrasound
in Japan, I am wondering why “myoma ‘happened to’ detected” in prolapse-surgery women
AFTER surgery. Please shortly touch this issue (this is not critical but touching this issue might
be better).