Title: How do women living with HIV experience menopause? Menopausal symptoms, anxiety
and depression according to reproductive age in a multicenter cohort
Version: 1 Date: 25 Jan 2021
Reviewer:  Shema Tariq
Reviewer's report:
Thank you for the opportunity to review this interesting paper examining menopausal symptoms
amongst midlife women in Spain.  This is a valuable contribution to this emerging literature.  I
would advise publication with some revisions as outlined below:
1. Please modify language throughout - avoid use of abbreviations (PLHIV/WLHIV) as seen as
dehumanizing and please do not use HIV-infected which is viewed as stigmatising.  Use women
or people living with HIV throughout, as advocated by many in the community. (see https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3499898/)
2. Rephrase physical and mental situation to physical wellbeing
3. Unclear what is meant by ad-hoc questionnaire?  Do the authors mean convenience sampling?
4. Methods:
i. Overall the study design and measurement tools are very close to those used in the PRIME
Study.  Can the authors either justify use of these tools or acknowledge the PRIME Study in the
Methods section please? (https://bmjopen.bmj.com/content/9/6/e025497.abstract)
ii. Note PHQ-4 measures current symptoms of anxiety and depression i.e. it is not diagnostic
iii. Please state in methods section that biological confirmation of menopause was not used and
justify
iv. What about pregnant/lactating women, and those using hormonal contraception? Were they
included?
v. Use transgender instead of transexual - also state in intro that this study is on cis-gender
women only i.e. not trans men/non-binary people
vi. How were comorbidities ascertained (from self-report or from notes)? Why were these ones
selected?
vii. Avoid use of 'menopausal' - use wither peri or postmenopausal (or both)
viii. Suggest replace sexual relations with sexual intercourse - and clarify what type of
intercourse
ix. What was rationale to look at psychological component of MRS AND anxiety/depression
(in PHQ-4) - justify
5. Results: please mindful of cross-sectional design and discuss prevalence and/or likelihood
rather than risk
6. Not clear why data on social support/mental health are included - they are interesting but do
not seem to fit into the paper overall which is focusing on menopausal symptoms.
7. Do the authors have details on types on alternative medicines used as that may guide clinicians
in terms of DDIs?
8. Discussion:
i. Vasomotor symptoms are not the only ones associated clearly with menopause - urogenital
symptoms too (in literature)
ii. Be aware that some guidelines e.g. BHIVA in UK recommend that women living with HIV
receive HRT when indicated as per HIV-negative population.
iii. Symptoms starting premenopausally doesn't mean symptoms predate transition.  The
menopause transition starts from symptoms which can predate any menstrual irregularity.
iv. Another limitation is that MRS is not validated in HIV - how can the authors be confident that
these symptoms are menopausal (and not HIV-related).  Could they expand on this a bit more?
v. I would like to see some specific recommendations for practice (rather than recommendations
for further research).  Can the authors tell us how their findings inform care?
vi. Please clarify as could not understand this sentence: "On the other hand, excluded women
may represent greater vulnerability, which we have not been able to evaluate in this analyses."
9. Check use of peri/post/pre-menopausal vs peri/most/premenopausal throughout so there is
consistency