Title: The Relationship between Genetic Variants Associated with Primary Ovarian
Insufficiency and Lipid Profile in Women Recruited from MASHAD Cohort Study
Version: 1 Date: 22 Apr 2021
Reviewer's report:
I reviewed the manuscript “ The Relationship between Genetic Variants Associated with
Premature Menopause and Lipid Profile in Women Recruited from MASHAD Cohort Study“.
The authors aimed to explore the associations between premature menopause related genotypes
with lipid profile and susceptibility to cardiometabolic disease risk factors in Mashhad stroke
and heart atherosclerotic disorders (MASHAD) cohort study population.
The title reflects the content of the manuscript, the authors mentioned that the study was
approved by the Ethical Committee of the institution and all the subjects signed an informed
consent.
According to the text, they included 117 women with POI and 183 control women, all of them
recruited as part of the MASHAD study, a cohort study that included 0704 participants.
My comments are listed below:
1. The authors used Premature Menopause and the definition mentioned was “Menopause that
happens before the age of 40 years”. The authors have used PM, POI and POF. Guidelines
have expressed opposition to the use of “Premature menopause”. Please, change the term in the
manuscript. The better term is Premature Ovarian Insufficiency
2. Methods: Was it performed a karyotype for all POI-women? please, make clear that all POI-
women presented secondary amenorrhea, since only the history of genetic abnormalities in not
enough to exclude for example a 46XX gonadal dysgenesis.
3.  “If HDL cholesterol levels <40 mg/dl (<1.04 mmol/l) for men and <50 mg/dl (<1.3 mmol/l)
for women is considered low HDL cholesterol’. Please, remove the criterium for men.
4. How were selected the control women? Why the number of control women was different
of the study group? How old were the women in each group? The authors have only included
the mean age of the total group. Were the control-women matched by age or by duration of
hypoestrogenism? Considering the importance of the age in cardiovascular risk, please, include
details. Please, also include the mean age at the moment of the last period and the duration of
the hypoestrogenism for both groups.
5. Did the authors estimate the sample power?
6. Were the POI-women treated with hormone therapy? What HT? For how long? POI-
women using and not using HT probably could have differences in the lipid profile and in the
cardiovascular risk. Considering the first paragraph of the discussion, could the authors affirm
that age, HT, duration of hypoestrogenism did not have influence in the results? The model
used was adjusted for age and for physical activity in the moment of inclusion, but not for the
characteristics of POI.
7. Discussion: the author wrote: “……..secondary amenorrhea (cessation of menstruation for at
least 3 consecutive months) was one of the criteria for including POI cases; While, this period
was too short compared to our criteria (12 consecutive months). The explanation should be
revised. I suggest that the authors follow the ESRHE Guideline to POI criteria.
8.  Please, make clear the idea in paragraph:” Moreover it has been demonstrated that POI
cases had significant lower level of Free Androgen Index (FAI) than people with regular
menstrual cycles and there, it has been suggested that higher FAI was associated with high
serum triglyceride and LDL in POI cases 50. Overall, these results suggest that impairment in
sexual hormones level, as a result of decreased females' reproductive system activity, is related
to weaken lipid metabolism”.
9. The authors wrote: “In our analysis, we observed that genotypes of 2 different SNPs
including rs4806660 (TMEM150B) and rs10183486 (TLK1) are substantially associated with
abnormalities of lipid profile. Regarding the first one, low level of HDL was observed by 5.26
times higher in PM cases with TC genotype rather than CC participants. This association was
not found in the controls. It is possible that these results are due to hormonal disorders that occur
in postmenopausal individuals and consequently the lipid profile in individuals is impaired”.
The mean age of the total women was 55. The manuscript did not compare postmenopausal and
premenopausal women (control group) or POI with premenopausal control women.