Title: A survey assessing the impact of symptoms related to the menstrual cycle and perceptions
of workplace productivity: considerations for employer-sponsored menstrual health programs
Version: 2 Date: 22 Mar 2025
Reviewer's report:
[1] Overall comments:
This manuscript addresses a timely and underexplored issue in occupational and women’s
health: the relationship between hormone-related menstrual symptoms and perceived work-
related productivity, with implications for employer-sponsored menstrual health programming.
The study leverages a validated tool (MDQ) and offers a large dataset with appropriate statistical
methods to explore phase-specific patterns in symptom prevalence and productivity perception.
[2] Essential Revisions:
1. Clarify Sampling and Generalizability:
Given that 40.1% of participants were employed by the funding organization (Exos), this may
introduce response bias. Please discuss the implications for external validity, and consider
performing sensitivity analyses excluding Exos employees if possible.
2. Improve Clarity Around Hormonal Phase Definitions:
The categorization of menstrual phases (e.g., “intermenstrual” combining late follicular and
early luteal) is non-standard and inconsistently applied across MDQ and productivity measures.
Also, there are concerns with the hormonal phase classification used (bleed-phase, pre-bleed,
late follicular, early luteal), which deviates from standard endocrinological definitions. The
“intermenstrual” label is inconsistently applied (e.g., combining late follicular and early luteal),
which could confuse readers.
Please provide a clear justification for this approach and include a figure mapping phase
definitions across instruments.
3. Tone Down Causal Language:
The manuscript often uses causal language (e.g., “predictors of productivity”), which is not
appropriate for a cross-sectional design. Please revise throughout to use associative language
(e.g., “associated with,” “may influence”).
4. Address Extreme Effect Sizes in Logistic Models:
Odds ratios above 90 are likely indicative of overfitting or categorization issues. My concern is
the magnitude of effect sizes (e.g., OR > 90 for some phases), which appears implausible and
suggests overfitting or model misspecification.
You should report model diagnostics (e.g., proportional odds assumption tests, AIC
comparisons) and justify extremely large odds ratios. If distributions are skewed, consider
transformation or categorization of productivity scores.
Please provide diagnostics (AIC, assumption testing) and consider categorizing or transforming
predictor variables to improve interpretability and model stability.
5. Validate Productivity Instrument Modifications:
The productivity questions adapted from Ponzo et al. are important, but validation of
the modified, phase-specific tool is not provided. Please include pilot validation data or
acknowledge this limitation. Some are concerned that the productivity questionnaire was
modified by Ponzo et al., yet no validation or pilot data are provided to confirm its reliability
or phase-specific utility.
6. Acknowledge Limited Racial/Ethnic Diversity:
The study sample is predominantly White (79.3%). Please acknowledge this limitation in
the discussion and its implications for generalizability, especially given known disparities in
menstrual care access.
7. Streamline Tables and Supplement Integration:
Tables 1 and 2 are overly detailed for the main text. Consider moving some of this to the
supplementary materials. Additionally, findings from Supplementary Tables 3–5 should be
better integrated into the Results section.
8. Enhance Conclusions and Recommendations:
The conclusions are well-supported but could be sharpened with more specific programmatic
recommendations for employers. Consider elaborating on how menstrual health programs might
be delivered (e.g., digital apps, workplace accommodations, peer education).
[3] Recommendation:
Major Revision
With attention to the points above, this manuscript has strong potential to significantly contribute
to the literature on women’s health in the workplace.