Reviewer's report 
 Change of Menopausal Hormone Therapy Use among Women in Germany between 1998 and 2003 Title: 
 1  12 May 2007 Version: Date: 
 Bruce Ettinger Reviewer: 
Reviewer's report: 
General 
This report compares observations from 2 German health surveys conducted 5 years apart (1997/8 and 
2002/3). The authors are careful to understand, adjust for, and discuss differences between the in-person questionnaires completed in the earlier one from the CATI telephone interview in the later one. The major findings regarding associations between use and social class are quite interesting and make sense—better 
educated/wealthier women have more access to medical care and to information—hence they would have 
been more likely to receive hormone therapy prior to WHI and would be more likely to discontinue afterwards. 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be 
reached) 
There are serious limitations of both surveys; these include lack of subjects' menopause status, 
hysterectomy status, and type of hormone therapy (estrogen alone versus combination with progestin). 
Additionally, self-reports may be biased, especially the recall of the time when therapy was stopped. 
The arbitrary use of age 40 as the lower limit is unusual. Most other surveys and prevalence studies have 
used 45 or 50 years, in addition to asking menopause status. Consider dropping this 40-45 year old group 
(and possibly the 45-50 year old group) unless menopause status is known. Otherwise, the prevalences reported will be considerably diluted by women who are not menopausal. 
In the US, there a strong association between low social class and hysterectomy. Is that also true in 
Germany? If so, the associations found between social class and hormoen therapy continuation found in 2003 could be mediated by hysterectomy. It is well recognized that hysterectomized women were much more likely to take up and continue hormone therapy both before and after WHI results were published. 
Long term use of hormone therapy is also recognized to have strong association with continuing use after 
WHI. Nowhere in the paper are data on duration of use. This variable must be analyzed and its associations 
tested. 
New starts of hormone therapy in the US were 50-75% lower after WHI. Was there any attempt to measure 
new start rate? 
The conclusion that WHI resulted in high rate of discontinuation is not really supported by the study’s 
discontinuation analyses. Discontinuation of hormone therapy is common in the first 1-2 after starting- nearly 50% stop with in the first year. Thus, whenever a survey is done, a high proportion of recent starters 
will report discontinuing within the previous few years. This kind of analysis would be useful only among 
women who were long-term users (e.g. >5 years) at the time of WHI. 
Table 3 should be removed and data shown in text. 
Figure 2 should be deleted, unless it is restricted to long term users. 
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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) 
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Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the major What next?: 
compulsory revisions 
 An article of limited interest Level of interest: 
 Acceptable Quality of written English: 
 Yes, but I do not feel adequately qualified to assess the statistics. Statistical review: 
Declaration of competing interests: 
I have received consulting fees and honoraria from several companies that market postmenopausal 
hormone therapy. These include: Eli Lilly, Berlex, Duramed, Novo Nordisk, Organon, and Schering.