Title: Severity and factors of menopausal symptoms in middle-aged women in Gansu Province
of China: a cross-sectional study
Version: 3 Date: 19 Jul 2021
Reviewer:  Edward Mezones-holguin
Reviewer's report:
The article is interesting; however, it needs some clarifications. I think the manuscript could be
improved if an exposure variable is clearly defined. Thus we would have an ordinal response
variable and other control variables. I would also add the request for an exploratory analysis
with the response variable as discrete numeric (no categories).
1. The introduction needs improvement; there is no academic structure of the paragraphs. Three
elements are essential here: What is known, what is unknown about the research question, and
why the study was needed to carry out. The paragraphs must have an academic structure with
an opening sentence, support sentences, and closing statement.
2. Sample size calculation or, failing that, the estimation of statistical power is not explicit.
3. Neither has it been defined which is the response variable and which is the primary exposure
variable. Although the study of “associated factors” is proposed, I believe that a better way to
approach the analysis is to propose a primary exposure variable (exposure) and an outcome
controlled by other co-variables. This allows having a better theoretical and epidemiological
framework.
4. The exclusion criteria used to define “mental illness” should be better specified since
depression is part of the mental sphere, but there may also be depressive symptoms typical of
menopause. It should be specified whether only women who had psychiatric medication were
excluded. In addition, women with “communication disorders” should be more clearly defined.
5. The advantages of using the mKMI over the MRS as a scale to measure menopausal symptoms
should be specified
6. In which stage were categorized the women taking contraceptives and did not have
menstruation? (as premenopausal?)
7. Authors should put references in statistical methods for ordinal logistic regression models
and their assumptions. The authors do not present the criteria (statistical or epidemiological) to
include the control variables in the multiple regression model.
8. In methods, the association measure to be estimated and how its interpretation will be is not
described either. Nor is it mentioned if interaction terms will be used or if they will use any post
estimation methods to see the model’s validity.
9. The duration of menstruation and menstruation intervals could be collinear with the primary
exposure variable since STRAW considers irregularity as an essential factor. In addition, the
presence of regular menstruation defines the premenopausal stage.
10. I think the discussion is disorganized. It should present the main findings, the mechanisms
that explain the results, compare them with previous studies, see the implications of the findings,
present future studies, limitations and strengths, as well as a recommendation and conclusion.
11. The limitations should be mentioned. It should be presented how these would affect the
study’s validity (biases) and reliability (random error). In addition, the strategies that the authors
used to reduce the negative effects of the limitations.