Reviewer’s report
Title: 
Investigation of the relationship between hot flashes, sweating and sleep
quality in perimenopausal and postmenopausal women: the mediating effect of
anxiety and depression
Version: 
0 
Date: 
18 May 2020
Reviewer's report:
The present study was a cross sectional analysis of 467 perimenopausal and
postmenopausal women to examine associations among hot flashes, sleep
quality, anxiety, and depression. Given the high rates of sleep disturbance and
mental illness in peri and postmenopausal women, the submitted manuscript
covers an important topic. Indeed, identifying causal or at least temporal chains
across these symptoms is important to guide clinical intervention. However,
there are methodological limitations that diminish my enthusiasm for the report.
1. Several studies have shown that hot flashes, night sweats, mental health
symptoms, and sleep (self-reported and objective) are related in peri and
postmenopausal women. Yet, causal models and mediation models would be a
novel contribution to the field. However, as this study is cross sectional,
temporal precedence cannot be established and mediation analyses are
inappropriate. The authors propose that depression and anxiety mediate effects
of hot flashes on sleep quality. Yet, it's possible that poor sleep quality mediates
the effect of hot flashes on anxiety and depression. Or that hot flashes mediate
the effect of sleep quality on depression, or depression on sleep quality. But with
cross sectional data, it is literally impossible to test these prospective
associations. Interestingly, however, is that sleep quality is a more robust
predictor of future depression and anxiety, than the other direction, which
perhaps calls into question the theoretical framework of the mediation model. 
2. Peri and postmenopausal women can either have insomnia that preexisted
menopause or have insomnia directly related to menopause. The symptoms can
actually be quite different such that insomnia that onsets around menopause
tends to have sleep maintenance difficulties as cardinal symptoms (directly
related to awakenings related to hot flashes), whereas insomnia that onsets
before menopause tends to have a strong cognitive basis. The authors should
consider incorporating this information in to their Discussion. Seems possible
that causal chains could maybe differ based on whether insomnia etiology is
directly related to menopause or preexisted it.
Are the methods appropriate and well described?
If not, please specify what is
required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which
controls are required in your comments to the authors.
No
Are the conclusions drawn adequately supported by the data shown?
If not,
please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review
is recommended, 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 corrections before being published
Declaration of competing interests
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1
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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
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or in the future?
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Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
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organization that holds or has applied for patents relating to the content of
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paper?
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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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