Title: Severity and factors of menopausal symptoms in middle-aged women in Gansu Province
of China: a cross-sectional study
Version: 3 Date: 15 Jun 2021
Reviewer:  Saionara Maria Aires Da Câmara
Reviewer's report:
Thank you for the opportunity to review this paper. Although it brings an interesting theme,
it needs more clarification of the study justification and a broader discussion of the results.
Moreover, some crucial information about the methods is missing, which makes it difficult to
understand some of the results. Below, I provide specific comments for each of the paper’s
topics.
Introduction
Although I like the short introduction, I believe some important information is missing. The
authors should explore the impact of menopausal symptoms in a woman’s life to let the reader
aware of the importance of this theme. Also, please, provide more details about why you think
that information from China, particularly the northwest, is more urgent, considering the global
audience of this journal. I am not from China and I do not know exactly what do you mean.
What do you think you will find in your sample that may be different from other samples? I did
not understand your hypothesis.
Methods
I suggest the authors use the STROBE checklist to make sure they describe all important
information in the text. For the methods, I missed some information as I describe below.
Describe the study design early in the methods.
Please, include the psychometric information about the mKMI if you have it. It would be
important to let the reader know about the validity and reliability of this questionnaire and
why you used that classification for the severity of symptoms. Also, please provide the same
information for the STRAW classification.
Also, please give more information about the sample calculations or the power of the study.
How was the sample recruited? The reader needs more information about the representativeness
of this sample.
The authors describe the categorization of the independent variables only in the statistics section.
I would suggest including it in the methods, when describing the study variables, and providing
more information to let the reader to understand why they were chosen for this study. Also, it is
important to understand why those categories were defined. For instance, why the authors chose
classify menarche as <15y or >=15y?
For each variable, the authors should give sources of data and details of methods of assessment.
Some questions I had when reading your paper: which chronic conditions were defined and how
were they collected? The variables duration of menstruation and interval of menstruation refer to
the woman’s lifetime or the last periods? Also, do you ask this question for all participants, even
the postmenopausal women? The same concern should be addressed for all variables. The reader
need to know how the variables were collected to have a better understanding of the results.
Please, define MHT in the first time it appears in the text.
Results:
Which unqualified questionnaires mean?
Why did you use BMI as categorical in tables 1, 2 and 3, but as a continuous variable in table 4?
Define the acronyms you used in the tables as footnotes.
If I understood correctly, table 4 presents the results for the variables associated with menopausal
symptom score but considering the categories of severity of the symptoms in the analysis. Is this
correct? If yes, please, let it clearer in the table which score you refer to as dependent variable.
Also, I would suggest putting the category less associated with the menopausal symptoms as
reference, so you keep the standard of presenting which categories are associated with increased
odds of severe symptoms.
I suggest you re-phrase the sentence “higher levels of family income, education, etc., were
negatively associated with the score” for something like “were associated with lower odds…”.
Regarding physical activity, the authors say that higher levels were negatively associated with
the menopausal symptom score. However, 4-6 days of physical activity was associated with
higher odds of severe symptoms compared to no physical activity. So, this sentence is not
accurate.
Discussion and conclusion
Although you describe the association of ethnicity on menopausal symptoms, the fact you did
not include this variable in the multivariate analysis limits the understanding on how ethnicity
and socioeconomic/cultural aspects interacts. This should be comment at least as a potential
limitation.
The authors say: In our study, we found that people who exercised less than 7 times per week
had more severe menopausal symptoms than those who never exercised, while those who
exercised more than 7 times had less severe menopausal symptoms. I missed more comments
or hypothesis to explain these contradictory results? Why 4-6 times per week is associated with
higher symptoms? Do you think that women searching for exercising is a consequence of the
menopausal symptoms? I mean, maybe they try to engage in physical activity because they
know this may help with the symptoms, presenting an inverse causal-relationship. This cannot
be clarified with a transversal study, and may justify the contradictory results. Do you think is
this possible? Are there other explanations?
Some of the significant results were not addressed in the discussion. Which are the authors
comments about the associations between menopausal symptoms and reproductive variables?
And chronic conditions? Also, which are the clinical implications of the results you found? The
authors say “a better understanding of these factors may help to reduce the effect of menopausal
symptoms on the quality of life of the middle-aged women”, but how? More information is
needed.
References
Only five from 38 references are from papers published in the last 5 years. The paper should
include more updated references.