Reviewer's report
Title:Change of Menopausal Hormone Therapy Use among Women in Germany
between 1998 and 2003
Version: 3Date:20 July 2007
Reviewer: Bruce Ettinger
Reviewer's report:
SPECIFIC COMMENTS:
1. Progress has been made in the revision process, but further revisions are
necessary.
2. The authors state that they have “carefully reedited the text”. Unfortunately,
the paper suffers from lack of clarity, awkward syntax, and grammatical errors.
Expert editorial help is needed.
3. Do not repeat numbers in text that are shown in tables. Instead summarize.
4. Avoid active verbs when describing associations.
5. Round Odds Ratios to one decimal place.
6. Discussion might better focus on information and motivation. What evidence
from the literature can be brought to support the contention that lower social
class women are either a) more likely to start HT in recent years or 2) more likely
to continue HT therapy? How would either or both activities be related to
information and education? How would social class and access to health care
alter the relationships? Is that substantially different in East vs. West Germany?
Can anything be said about the role of healthcare provider in the differences
noted?
7. The hysterectomy explanation needs to be more clearly presented. The logic
can be described in 3 steps:
a) Based on German population data, hysterectomy prevalence can be estimated
at about __% for women in the study cohort.
b) In Germany, the hysterectomy prevalence is substantially higher among
women of low social class __ compared to those of higher social class___
c) Hysterectomized women are more likely to continue using HT
d) The previously described positive association between social class and HT
use may now be attenuated because lower social class women with
hysterectomy are the ones who have continued despite WHI findings (while
educated women have stopped or do not start).
e) Both in US and Europe, strong evidence supports the association between
hysterectomy and continuing use; use of estrogen with progestin has declined
twice as much as estrogen alone.
SPECIFIC COMMENTS:
Page 1: This report shows differences between HT use in 2 periods, but since
the same population of women is not being followed in the same way, the Title
should be changed to “Differences in ...”.
Page 2, line 1 and throughout the paper: “differences” not “changes”
Page 2, Results, line 2: Begin with “In the 1997-1999 survey, variables
associated with current MHT use...” and continue “In contrast, in the 2003-2004
survey, ...”
Page 2,, Results, line 5-10: The associations between social class and current
HT use can be better summarized. For example: Higher social class was
positively associated with HT use in the earlier survey but was this association
was not found in the later survey. Suggest deleting lines 8-10 altogether. Instead
report the age prevalence of current use (recent survey shows lower rates
among younger and no differences among older age categories).
Page 2, Conclusions: Delete second sentence. Not supported by data.
Page 6, para 2: Discontinuation is measured indirectly and is probably quite
imprecise. Therefore, delete mention of analyses based on this variable (page
10, middle) and Figure 2.
Page 8, line 18: Delete mention of Past Users since these data not available for
both cohorts.
Page 8, bottom: Provide OR for “new starters” (4.7;2.7-8.1))
Page 9, para 2: The prevalence of current use by age is not clearly presented.
There is now Figure 1 to show this. It indicates differences in current use
between surveys exist largely for women 45-59, to a lesser degree in those
60-64, but there are little or no difference in use prevalence among those 65 and
older. Instead of the arbitrary and overlapping age categories, provide in the text
the percentage difference between surveys by decade of age.
Page 14, bottom: The text is particularly unclear here. The German study (ref 38)
found that declines in prevalence of HT use were larger among well-educated
women compared to those less well-educated. The British study found the
reverse; the prevalence of HT use declined most among the least educated
women.
Page 18, Conclusions, last sentence: Instead of this vague statement, suggest
hypotheses that future studies could test. Otherwise, delete.
Page 26, Table 3: OR 1.74 for survey period 2003-4 is in error since current HT
use is much less likely in the more recent survey.
What next?: Unable to decide on acceptance or rejection until the authors have
responded to the major compulsory revisions
Level of interest: An article of limited interest
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I consult with a number of drug companies that market hormone therapy or
similar drugs.