Title: Chronic cough in postmenopausal women and its associations to climacteric symptoms
Version: 2 Date: 07 May 2022
Reviewer's report:
An interesting and novel piece of work, exploring the frequently-observed association of chronic
cough with post-menopausal status in women. Some comments follow, specifically in regards
to the way the Leicester Cough Questionnaire has been used.
ABSTRACT
"...chronic cough is likely caused by hormonal changes affecting lung function" is too strong a
statement and needs to be changed. This is only a hypothesis, with only circumstantial evidence
(as far as I am aware).
In methods section here best not to say "women with cough of known origin", rather something
like "women with cough explained by a pre-existing diagnosis”. The ‘origin’ of chronic cough
is usually complex and multi-factorial.
METHODS
LCQ
The way in which the Questionnaire responses have been scored in this study does not follow
the method described by developers of the LCQ in their original 2003 paper in Thorax. The
maximal total score should range from 3-21, as a measure of cough-related quality of life. The
maximum score for each domain (physical, social, and psychological) should total 7, by dividing
each subtotal by the corresponding number of items (8, 4, and 7, respectively). This will give
each domain an equal weighting in the final LCQ score.
The way in which the current authors have assigned total scores to the LCQ results in this study,
not only gives values much larger than those normally used, but erroneously gives unequal
weighting to each of the three domains. This method of scoring the LCQ has not been validated
and should not be used.
The authors therefore need to correct this substantial anomaly and report LCQ scores in the
method intended by Birring et al. This may then of course affect the results, and possibly the
conclusions of the paper.
Definition of chronic cough
This section should probably be placed before the LCQ section. Please state exactly what
question was used to establish if participants had a cough – this is not currently clear.
RESULTS
“66 patients had mild to severe symptoms” is a little confusing. How are mild and severe
defined? Is it not better to say “66 patients reported a chronic cough” or something similar?
This then goes back to my previous comment on how (abnormal) “cough” was defined from a
patient’s perspective.
In how many patients did the onset of cough precede menopause symptoms?
Figure 1 should include error bars.
LCQ total results need correcting as above to use the appropriate scoring method, same for
correlation with MRS scores.
DISCUSSION
“Some of these changes might also affect the respiratory system, a fact that was not yet the focus
of either pulmonologists or gynaecologists.”
The authors need to please put their work in the context of any existing literature. This study
is novel as far as I am aware, but the authors should state whether there are any other similar
published studies, following an appropriate search on Pubmed. (This review is relevant: Front.
Physiol., 07 May 2021 | https://doi.org/10.3389/fphys.2021.654797).
The term “chronic refractory cough” is probably better used now rather that “chronic idiopathic
cough”, in line with the 2020 ERS Guideline on Chronic Cough.
Some English terms are incorrect here: “globus” is correct rather than “globe” symptoms, and
hot “flushes” is correct rather than “flashes”.
“In postmenopausal women, the chronic cough stimulus MAY BE due to the cough receptors’
increased sensitivity” is a safer thing to say than “is due to” as this is theoretical and still
speculative.