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: 25 Dec 2023
Reviewer:  Motoyuki Nakao
Reviewer's report:
The authors examined the effects of an educational tool about PMS on menstrual symptoms and
labor productivity through medical help-seeking behavior among working women in Japan.
It is a crucial issue that menstruation, despite being a healthy physiological function in women,
produces significant physical and psychological suffering. Recently, there has been a worldwide
attention on the great impact of PMS and other menstruation-related symptoms on various social
activities of women, including labor productivity. The topic of this study is interesting and
socially relevant. The findings obtained from this study will assist in the understanding of these
issues.
Therefore, I would recommend that this manuscript be accepted. However, some revisions are
necessary for publication.
These points are discussed below.
Methods section
1. L106-L123:"Participants and the study procedures"
Although the manuscript states that working women aged 25-44 were included in the sample, it is
not clear what process was used to filter the sample down to 7,752 women. The only description
given is that they are those who have a paying job and are not currently consulting an obstetrician/
gynecologist. Please describe the screening questions and eligibility criteria in more detail.
For example, I don't think people with early menopause, pregnant, or those who have lost their
uterus in the past are included. Please describe what the process was and how many people were
excluded and for what reasons.
2. L115: "…accepted prescreening responses until reaching 20,000 respondents (Figure 1)."
I think this "Figure 1" refers to "Figure 2".
3. L131: "…tool for PMS at the end of the T1 survey (Figure 2)."
I think this "Figure 2" refers to "Figure 1".
4. L185-L186: "…the PSST (Figure 2a), and it advised the user to consult doctors if she checked
two or more signs on the list (Figure 2b)."
I think "Figure 2a" and "Figure 2b" refer to "Figure 1a" and "Figure 1b," respectively.
5. L207-L226: "Statistical analyses"
Statistical analysis, especially logistic regression analysis and generalized estimating equations,
are not well described.
In generalized estimating equations, there should be more detailed descriptions of, for example,
the distribution of variables, the link function, the treatment of missing measures (whether
they are random missing measures or non-negligible missing measures and whether they are
included), and the significance of the regression equation itself.
These would have been specified by yourselves when calculating with the statistical software.
Or the software may have displayed them in the results.
Also, was the variable used for adjustment a forced entry method? Or did you use some variable
selection method? Either way, please describe the method.
You do not have to answer all of the above, but I think the current description is insufficient.
Results section
6. L253-254: "Only 4.9% (121/2487) of the T2 participants sought medical help during the 8-
month follow-up period (Table 2)."
Is it correct to say that the participants had a "new" visit to a medical facility "for PMS" between
T1 and T2?
How is this classified, for example, for people who were not visiting the clinic at the time of
T1, but had visited the clinic for PMS before T1, or for people who visited the clinic for other
gynecological problems between T1 and T2?
Also, I would think that the psychological barrier to seeing a doctor would be lower for those
who have seen a doctor in the past. Do you collect such information?
Discussion section
7. L318-L319: "…seeking, 9% during the 8-month follow-up might not be low, considering
previous studies showing natural courses."
Please provide references for this "previous study".
8. L327-L328: "Among moderate-to-severe PMS participants, those who sought medical help
showed significantly lower intermenstrual MDQ scores at T2 (Figure 4a)."
Since there is a difference in the change in MDQ scores between T1 and T2 between help-seekers
and non-help-seekers, it is clear that help-seeking behavior has some effect on MDQ scores.
By the way, the survey was conducted at the winter for T1 and the end of summer for T2. Is it
possible that in addition to help-seeking behavior, climate (temperature, humidity, barometric
pressure, hours of sunlight, etc.) may have some effect on PMS symptoms? If so, please describe
it.
Also, the authors refer to "Figure 4a" here, but Figure 4a refers to the premenstrual score, so it
would be correct to refer to Figure 4c if the results are to be taken as the text implies.
9. L333-L335: "The insignificant results (Figure 4a & 4b) might be partly attributable to various
treatments at each clinic; we could not collect detailed information on a specific treatment in
this study."
I do not understand the rationale that led to the consideration that the non-significant results in
Figures 4a and b could be attributed to the various treatments at each clinic.
Is the assumption that if LEPs are administered, they may be effective, but not so effective for
other treatments, and since we do not know what treatments the subjects in this study received,
does this mean that a significant number of them may have received such ineffective treatments?
Or is it that at this stage we don't know which treatments are effective for PMS? Then why was
the personalized treatment only effective for intermenstrual MDQ scores and not significantly
effective for premenstrual and intermenstrual scores?
10. L371-L372: "However, as another finding, we should note that 33% of the T2 participants
were unemployed (Figure 5a)…"
There was no significant difference in unemployment rates by severity by rough classification,
but even within the "moderate to severe" group, was there no difference in severity between
employed and non-employed individuals?
11. L394-L395: "Finally, this study was conducted in Japan using a social research panel, which
could have caused selection bias."
What are the possible differences in characteristics between the online social research panel and
the general population? In other words, if you describe what kind of selection bias you think
will occur, it would clarify the issue.