Reviewer's report 
 Change of Menopausal Hormone Therapy Use among Women in Germany between 1998 and 2003 Title: 
 1  27 May 2007 Version: Date: 
 Randall S Stafford Reviewer: 
Reviewer's report: 
General 
This is a well-researched analysis of changing patterns of menopausal hormone therapy in Germany that 
makes use of two large national health surveys. The results are of significant interest. 
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Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 
1. The abstract highlights the use of a regression model applied to pooled data. While this technique is 
briefly discussed, the main results are presented using models that stratify the sample by survey year (Table 2) or social class (Table 3). 
2. The clarity of the data presentation is degraded by the use of the survey acronyms (GSTel04 and 
BGS98). The authors should refer to the data by the years of the surveys (1997-98 and 2003-04, 
respectively). The current use of these acronyms is particularly awakward in the Abstract. 
3. It is stated that proportions weighted to reflect the sampling design are reported. Several results where 
integer numbers of respondents are provided suggest that this may not be the case. 
4. The material presented within Table 3 is not sufficient to justify presentation in a table and should instead 
be presented within the text. 
5. Further discussion of the finding of no change in the population 60+ is needed. 
6. In comparing the present study to others, mention of the rates of MHT found in past German surveys 
would be particularly relevant. For example, even after accounting for the narrower age range (45-60 years) 
included by Heitmann, the overall prevalence of MHT use in July 2003 (35%) is likely higher than reported 
for 1997-98 for these same age groups (~30-32% from Figure 1) and clearly much higher than the 2003-04 
data (~16-18%). These results suggest that the results may not be fully reliable. The discrepancy with this 
past report should be acknowledged and discussed. 
7. Some English usage is awkward and re-editing for clarity is needed. Of several instances, take for 
example on p. 7 "weighted HT use differed by 40.2% from 16.9% to 10.1%," should be modified, as with: 
"weighted HT use decreased by 40.2% from 16.9% in 1997-98 to 10.1% in 2003-04." 
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Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
8. The Discussion section could be significantly condensed. In particular, some of the comparisons with 
past studies could be abbreviated. The contrast with Mishra, et al., but may be explainable by Mishra's examination of only early trends. 
9. Although the social status results are presented in a number of different ways, it seems most appropriate 
to describe the trends as a convergence of high social status MHT use with pre-existing patterns in lower 
social status women. 
10. The authors should clarify whether other national surveys were conducted in the years intervening the 
two cited surveys. 
11. A brief discussion of the possible effect of the differing definitions of MHT use in the two surveys is 
needed. 
12. The conclusion could be stronger. In particular, it weakens the paper to end with a sentence describing 
the need for further investigations. 
13. The authors should provide the sample sizes of respondents included in the analysis (i.e., women 40-79 
years) for both surveys in the manuscript text, as well as in Table 1 (where these numbers are currently 
presented). 
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Discretionary Revisions (which the author can choose to ignore) 
14. The authors should more clearly address the issue of having two points in time without information on 
the nature of intervening trends. 
 Unable to decide on acceptance or rejection until the authors have responded to the major What next?: 
compulsory revisions 
 An article of importance in its field Level of interest: 
 Needs some language corrections before being published Quality of written English: 
 Yes, and I have assessed the statistics in my report. Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests.