Title: The association between reproductive history and menopausal symptoms: an evidence
from the cross-sectional survey
Version: 1 Date: 27 Nov 2021
Reviewer's report:
This study examines associations between symptoms being attributed to menopause and
reproductive history as risk factors in a small sample of pre-, peri- and postmenopausal Iranian
women attending a gynecologic clinic.  I have several questions and concerns about this
manuscript.
INTRODUCTION
The introduction is not focused on menopausal symptoms and risk factors for menopausal
symptoms.
Discussions of risk factors for cardiovascular disease and of risk factors for age at menopause in
the introduction are extraneous to the point of this paper (risk factors for menopausal symptoms)
and should be omitted.
A clearer statement regarding what constitutes symptoms of menopause versus symptoms of
aging is needed. A more thorough review of the literature on risk factors for symptoms, and
specifically what we know about associations with reproductive history is needed. Also, some
discussion of why risk factors may differ in the Iranian population, and why it is important to
have data on Iranian women is needed.
METHODS
Please provide more information about how women were identified for this study and how
the random selection was implemented.  As the study took place over an 11-month period, it
seems many women were not likely approached.  Please provide more information about the
total number of women attending the clinics during the 11 month period, the number that were
approached, the number that agreed to participate, and the number that were ineligible (and
whether eligibility was determined before or after approaching women to participate). What
present of women approached agreed to participate (response rate).
How did you ascertain women’s menopausal status?  Was this part of the questionnaire, and if
so what questions were used, or was this determined by a medical chart?
Please provide more information about how you selected variables for inclusion in your
regression models and how you built your models (i.e. the order of including/excluding highly
related variables).  For example, parity and number of children are very similar variables.  Was
abortion modeled as a continuous or dicotomous variable?
RESULTS
Given your exclusion criteria, it is important to clarify in results (and discussion) that you are
reporting information for women not using hormones and who if postmenopausal, are naturally
postmenopausal. women
Line 133-134 “Women were interviewed and questionnaires were given out.” This sentence
belongs in Methods section.
The paragraph for Table 3, does not mention age at first pregnancy, however this variable was
included in the Table for psychological symptoms.  Also, Number of Alive children and number
of children are both included in the Total symptom regression, these two variables are highlty
correlated and it is not clear they can be in the same model.
DISCUSSION
The first paragraph should not include beta’s and p-values, those belong in results. Also
paragraph 2 of the discussion is presenting data that were not in results (eg Gravidity is not
mentioned in results and is not in the tables).
You do not have data to attribute the symptoms to estrogen, although that may be one hypothesis
for the relationship between elevated symptoms and being perimenopausal. How are you
distinguishing effects of aging from effects of menopause?
The discussion is also suggesting associations found only in the bivariate analyses, but not
included in the multivariable models (eg BMI).
Table 1: It is not necessary to include both the category’s and the mean for each variable.  I
recommend providing only the categories. When means’ are important they could be provided
in the text.
Table 2:  Is also too busy.  Column with N’s are not needed as Table 1 provided the n’s.  An
asterisk by the p-values can indicate which tests are Mann-Whitney with the others being Kruskal
Wallis stated in a footnote.
Table 3: There is no model provided for urogenital symptoms. Should the label for abortion be
number of abortions (as you have number of children)
Grammar
Line 57 “… reproductive factors during their life that is associated with a variety of hormonal
and…”  “is”  should be “are”
Line 63 “…They reported a higher parity was associated with higher”  replace “a” with “that”