Reviewer ’s report  
 
Title: Menstrual pattern among adolescent girls of Pokhara Valley: A cross sectional study  
 
Version: 1 Date: 24 May 2016 
 
Reviewer: Harmon  Quaker  
 
Reviewer's report:  
 
BMWH -D-15-00175_R1:  Menstrual pattern among adolescent girls of Pokhara Valley: A cross 
sectional study  
Thank you for the opportunity to review this manuscript. It  adds useful information about the 
events following menarche for this group of adolescents. It highlights the health needs of this 
particular group overall and raises intriguing questions about differences that may exist in 
subsets of this population. As a  descriptive study I believe it is an important contribution to the 
field.  
I have a couple of comments which are mostly minor. (Page and Line Numbers refer to version 
BMWH -D-15-00175 -R1. Table comments however are based on BMWH -D-15-00175 as the 
tables wer e not included in the -R1 revision)  
 
Major Comments:  
1. I believe the column headings in Table 4 are flipped and should be corrected.  
2. The role of chance in these findings should be addressed. In particular there are very few 
Dalit girls and they seem to be driving the "difference" seen with cycle regularity and 
ethnicity. This may be a chance finding.  
3. Page 6, lines 7 -9: Ethnicity i s defined here, but further on caste (Hill) and religion (Muslim) 
and Dalit (unspecified if caste, ethnicity or religion) are used. For readers outside of Nepal, 
would it be possible to provide some context or distinction for these groupings? The finding 
that there are differences by ethnicity would be more meaningful if readers understood the 
differences between these groupings.  
4. If possible I think it would be helpful to examine time since menarche with some of these 
cycle characteristics. My understand ing is that it takes about a year for a cycle to become 
regular after menarche. In particular if there is a difference in the average age of the girls by 
ethnicity (for instance if the Dalit girls tend to be older and further from menarche) that 
might expl ain the difference seen in cycle regularity. Also the differences seen with other 
studies may be due to the age of the study populations and the average time since menarche. 
Older populations (university aged adolescents) may have had menarche many years 
previous and already transitioned to more regular cycles.  
 
Minor Comments  
5. The manuscript requires language editing. There are many small errors. The final sentence 
of the abstract in particular needs to be improved.  
6. Please provide consistent use of dec imal places or significant digits.  
7. Page 4 line 39: Please define dysmenorrhea for non -clinical readers.  
8. Page 5 lines 22 -32: The sampling method was not clear. Can you provide the number of 
girls in grade 5 -10, the number eligible and the number who a greed to participate? Was 260 
chosen a priori or was this all of the girls who agreed to participate among all of the 
eligible? Was the sampling equal across grades 5 -10? 
9. Page 6, lines 12 -21: Can you clarify if these characteristics are specific to the most recent 
menstrual cycle or to a girl's average cycle?  
10. Page 6, line 26: Were girls only asked the grade at which they started having periods? If so 
the estimates of age at menarche are only very approximate since students in a given grade 
can differ  by more than a year of age (at least in the United States).  
11. Page 7, Results paragraph: The break -down of age group and grade are not necessary.  In 
general it is better to refer the reader to the table for this type of information.  
12. Page 7, Line 2 4: The percent from the Hill caste are less than the Hill ethnic group. The 
order of presentation of these should be switched to match "majority".  
13. Page 9, Line 31: From the titles of the references it appears that the studies from India, 
Ghana and Turk ey may have been in older (university age) girls, which might explain the 
difference. Again time since menarche may be a useful variable to consider when comparing 
studies.  
14. Discussion in general: many of these comparisons to other studies are difficult  due to 
possible age differences in the study populations. For instance on page 10 line 19 -21, the 
disparities could also be due to the fact that studies in older girls will have most girls with 
regular 'adult' cycles, studies with younger girls will have girls who have just started 
menstruating and are more likely to have irregular, long, short etc cycles. Before pointing to 
environment, race or nutrition, study design questions should be addressed.  
15. Page 10, line 26: Not required for revision, but an a nalysis adjusting for age, time since 
menarche and BMI might help clarify if the apparent association with ethnicity is in fact true 
or if it is related to other factors.  
16. Page 10, line 53 and Page 11, Line 4, and Table 5: for small p -values please use p<0.0001 
(or whatever the cut point is in your software).  
17. Table 1: Is there a reason the Ethnic groups are sorted in non -descending order? Looks like 
it should be Hill Ethnic, Hill caste, Muslim (others), Dalit  
18. Table 2: Please be consistent in the number of decimal places.  
19. Table 3: >35 days row missing a parentheses  
20. Table 4: It looks like the column headings are flipped? Table 3 suggests N=167 with 
Irregular cycles, yet Irregular in Table 4 sums to 83.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequa tely supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommende d, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language correctio ns before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this  manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied f or patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
'I declare that I have no competing interests'  
 
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