Title: What can be done to improve Polycystic ovary syndrome (PCOS) healthcare? Insights
from semi-structured interviews with women in Canada
Version: 0 Date: 01 Jan 2022
Reviewer's report:
Overall Comments:
• Authors of this study investigated the medical care experiences of women with PCOS and
explored possible solutions to  improve the quality of care. The manuscript was well-written
and easy to read, as well as important to the field. While I agree with most of the manuscript
conclusions, I recommend that the authors revisit the manuscript to provide conclusions that
are from the view of the patient, rather than making structural judgement or recommendations.
An example includes stating that the training of physicians is inadequate. Since the authors
did not evaluate the training of physicians,  we cannot make these structural recommendations.
Comments below provide further explanation.
ABSTRACT
• Please spell out what “MI” stands for in methods. I assume it is the name of the first author
but the “the” in front can be confusing. Recommend replacing with “an investigator”.
• How many participants were interviewed for the study?
• More details are needed regarding the methods. Did a single investigator analyze the data?
• What is very important to note is that the results are from the perspectives of the patient, and
not the PCPs nor did the study investigators evaluate the current training that the PCPs have
received. Thus, we can only interpret the results from the perspective of the patient. We cannot
state that “greater training is needed for PCPs” since we did not analyze the actual structure
of training in the study. Recommend reframing the conclusions to avoid overextrapolation of
the data.
INTRODUCTION:
Major Comments:
• Recommend including citations after every sentence when possible, including the sentence
that begins with “With no known cause or conclusive treatments or cure”. While there are no
absolute known cause or conclusive treatments, we have a fairly firm idea of the component
causes that contribute to some PCOS phenotypes and treating the symptoms of PCOS.
• The insights that are gathered by the study are not necessarily transferrable to other countries,
primarily due to differences in medical training and reimbursement (among other factors).
Further, it is unclear whether the 25 interviews (or participants?) can truly be enough to
generalize for all women with PCOS. Recommend removing that sentence.
• Recommend including more about how this study contributes to the gap in the literature in
relation to other studies. Is this study confirming the Copp et al 2021 article? Or how is this
study addressing the knowledge gaps from previous literature?
• It seems the study had 2 objectives: exploring the experiences (similar to Copp) and identifying
potential strategies to improve their quality of care. Recommend identifying the primary and
secondary objectives in your introduction.
Minor Comments:
• Unclear what “confounding condition” means. Recommend revising the term.
• Do you have a citation regarding the evidence suggesting that women are not receiving the
quality of care that is needed?
METHODS:
Major Comments:
• Can the authors provide more information on the PCOS diagnosis and treatment for each
participant in Table 1 (e.g., how long since PCOS diagnosis, how many physicians they have
seen for PCOS for each participant)? It would provide more of a snapshot of the participants’
experiences.
• Did the authors meet saturation? How was thematic consistency determined? I see in the
supplementary table 2 that saturation was reached. Recommend including in methods.
• Great support and descriptions of the approach used for inductive analyses.
• How was the interview guide created? Was the content validity assessed? A limitation was
that the guide was not tested.
RESULTS:
Major Comments:
• While I understand the use of Melissa’s experience in the presentation of PCOS, there is
a common misconception among with women with PCOS that follicles are not cysts. Using
Melissa’s quotation regarding cysts to discuss the spectrum of presentation of PCOS is not
entirely correct as the presence of cysts (yes/no) are not a true PCOS criterion- rather, it is the
number of follicles per the Rotterdam diagnostic criteria. Essentially, the quotation is leveraging
a common misconception to demonstrate that GPs are not aware of PCOS presentation, while
in fact, cyst presence (in the dichotomy) is not a true presentation. Recommend using another
quotation (since it seems there are more quotations that identify under this theme).
• Recommend providing further details regarding the number of participants were theme. For
example “Many participants were diagnosed without receiving…” Could the authors provide
the number (%) of participants who identified with these themes?
• While I agree that clinicians may not have much experience with PCOS, many of these
quotations equated information provision with PCOS knowledge, which is not necessarily the
case. For example, the PCPs might not be knowledgeable about the resources that are out
there, but they might know about the condition. Another example could be that they don’t
know about the condition, and just refer patients to an online government website. Essentially,
would physicians giving a pamphlet truly demonstrate their knowledge base about PCOS? The
quotation by Patricia seems to represent this. My question is whether the main issue the fact
that physician training is negligible about PCOS or the fact that they are not providing that
information? Or maybe both? I think the manuscript could be further strengthened if there were
mutually exclusive quotations regarding these two arguments because I do find both to be the
case.
o Another reason why I highlight this perspective is because of the last sentence, “When
encountering unknowledgeable or uninvolved physicians…” What are they unknowledgeable
about (in the perspective of the patient? Again, I want to emphasize that we are investigating this
from the perspective of the patient so we have to ensure that is highlighted in the manuscript.
This is not to say that the patients’ concerns are not valid but we must remain an objective party.
The study did not evaluate whether these physicians were truly unknowledgeable (through a
PCOS knowledge exam, etc). Recommend going through the results section and modify some
sentences as from the patients’ lenses.
DISCUSSION AND CONCLUSION:
Major Comments:
• Limitations could include the sample size and how future research could use a mixed-method
approach. Further, while a single investigator identified the themes, I am curious whether there
was another person involved in thematic coding to increase reproducibility. For example, have
more than 1 investigator trained, both investigators identify themes from the transcriptions, and
then coming together to discuss. If there are disagreements, then a third-party comes in to review.
• Agreed with most of the policy and future research but I question about whether we have
enough data to support improving clinical training in PCOS. While personally, I agree with this
perspective – the data that is currently examined here do not allow for that conclusion. To be
able to make that recommendation, I would suggest evaluating curriculum in the hospitals to
determine how/whether PCOS is being taught and what the gaps are. Right now, we only have
the perspectives of patients about the training that the physicians receive. The recommendations
that we can provide should only address patients’ perceptions and what we can provide to them.