Title: Changes in menstrual symptoms and work productivity after checklist-based education
for premenstrual syndrome: an 8-month follow-up of a single-arm study in Japan
Version: 1 Date: 18 Jan 2024
Reviewer's report:
The authors conducted an online single-arm, pre- and post-intervention study that assessed
whether a checklist-based education tool for premenstrual syndrome (PMS) had an impact on
help-seeking behaviours, symptoms, or work productivity. For the most part, the study took
place during the COVID-19 pandemic. Over a nine-month follow-up, only a small number
of participants (5%) sought medical help for their PMS. Women who had more severe PMS
and higher incomes were more likely to seek help. Women with more severe PMS who
sought help showed a statistically significant improvement in intermenstrual Menstrual Distress
Questionnaire scores during follow-up.
I offer the following comments to the authors for their consideration:
Abstract:
Line 42: The authors note that the predominant reason women did not seek help was ‘slightness
of symptoms’. Could the authors clarify this statement further? Slightness implies that the
women did not have symptoms; however, could it be that the women are normalising their
symptoms i.e., they are not seeking help because they believe that their symptoms was a just
part of life and something they should deal with.
Line 46: Do the authors mean that the results were not statistically significant? This should be
clarified (both in the Abstract and throughout the manuscript).
Line 49: I am not clear what the final sentence of the Abstract means.
Introduction:
Line 62: The 80% cited in the opening sentence comes from a reference that is cited in the
first reference in the manuscript. The original reference is very old (1987). I think that it would
be more appropriate to cite a more recent reference such as this systematic review and meta-
analysis (Direkvand-Moghadam A et. al. Epidemiology of Premenstrual Syndrome (PMS)-A
Systematic Review and Meta-Analysis Study. J Clin Diagn Res. 2014 Feb;8(2):106-9. doi:
10.7860/JCDR/2014/8024.4021], and perhaps refer to a range of prevalences, given the variation
reported across different studies/countries. I would also recommend referring to the results from
the Japanese study separately to provide context for your paper.
Line 65: For completeness, I suggest that the authors provide a more complete list of the
emotional and physical symptoms of PMS (as on the ACOGS website) in either an appendix
or table in the main paper.
Lines 73-75: The authors make the statement that a reluctance to use the oral contraceptives
prescribed at clinics demonstrates a general reluctance among women to visit clinics for
reproductive health issues. After looking at the reference for this statement, I’m not sure that
this statement is correct. The reference is looking at the prevalence of oral contraceptive use
before and after legalisation in Japan and finds that the prevalence of use did not increase
significantly after legalisation, potentially indicating that women are not being provided with
sufficient information on OCP use and other contraceptive methods to make informed choices
about this aspect of their reproductive health.  This is a valid point and I suggest that the authors
reword their text to better reflect the findings of the referenced publication if this is the point
they intended to make.
Lines 75-76: Could the authors clarify whether it was the women’s perception whether or not
their primary care doctor could address gynaecological diseases or whether their doctor was not
permitted/able to address these diseases? NOTE: The link to the reference for this statement in
the paper is not working.
Methods:
Lines 110-111. Could the authors clarify whether it is easy for women to access an obstetrics/
gynaecology doctor in all regions of Japan, or is there a geographic maldistribution? In addition,
could the authors also provide some context for how these clinics are funded in Japan i.e., are
the costs to patients subsidised by the government, or are there out-of-pocket expenses for the
patient?
Lines 126-128: Could the authors clarify whether they used the complete premenstrual
symptoms screening tool and Menstrual Distress Questionnaire, or whether they used only parts
of these tools? The use of the wording ‘based on’ makes this unclear. If they only used parts of
these tools, could they please provide more information on this.
Lines 166: Could the authors please clarify whether they used the full or short-form version
of the WHO-HPQ? The longer version includes questions about health conditions, smoking,
alcohol consumption, pregnancy  etc.
Discussion
Lines 318-320: I am not clear what the authors mean by the statement: “9% during the 8-month
follow-up might not be low, considering previous studies showing natural courses”.  In addition,
the reference cited for the statement “only 5% of moderate-to-severe PMS patients are known
to receive medical treatment” did not report this result from their study. The 5% referred to in
this reference was mentioned in the Introduction of the paper and related to the proportion of
women with severe PMS who may require pharmacological management (referencing a paper
published in 2000). The results from the reported Korean study are also not comparable with
the current study as it reports the proportion of Korean women diagnosed with PMS at medical
facilities, not the proportion of Korean women with PMS who seek medical care.
Please see my comments above (Abstract) about ‘slightness of symptoms’.
The authors should note that a limitation in the work productivity analysis is that they cannot
assume that levels of differences in levels of absenteeism and presenteeism between women
with none/mild PMS and moderate/severe PMS are due to the presence of PMS. The differences
may be due to other health conditions that have not been measured. In addition, the impact of
the COVID-19 pandemic on this aspect of the analysis cannot be over-stated.