Reviewer ’s report  
 
Title: Contemporary treatment utilization among women diagnosed with symptomatic uterine  
fibroids in the United States  
 
Version: 0 Date: 23 Aug 2019  
 
Reviewer: Jeremy Jonathan Owen Herod  
 
Reviewer's report:  
 
Please include all comments for the authors in this box rather than uploading your report as an 
attachment. Please only upload as att achments annotated versions of manuscripts, graphs, 
supporting materials or other aspects of your report which cannot be included in a text format.  
 
Thank you for the opportunity to review this paper.  
 
The manuscript is a descriptive observational piece th at describes the treatment of women for 
symptomatic uterine fibroids. The women concerned were selected and observed over a five year 
period. They were identified from two large medical insurance companies and information was 
retrieved form patient databas es. 
The strength of the paper is that it is a very large cohort of women and there is detailed 
information provided in the results section. It therefore describes what actually happened to the 
women concerned and is therefore useful as a benchmark and for understanding  current practice 
in North America  
 
The weakness is that much of the paper effectively states what is already known and indeed I 
could have written many of the passages in this paper without ever conducting the study. If 
anything there is an opportunity missed to explore the data that is provided further and to 
consider some of the interesting questions that arise from the results but which seem to be 
ignored by the authors. Copious data is provided in the paper filling many pages of tables. I  do 
wonder if it is realistic to publish such extensive results in a medical journal and whether this 
section should be extensively edited. I have listed some points below.  
 
1) There is no discussion whatsoever about the very significant differences betw een the two 
populations of women included in the study. There are large differences in the approach to 
management which cannot arise by chance. I would assume it is likely that they reflect either 
differences in the two study populations of women studied ( there is a comment about the number 
of black women in one group which many indicate population differences or alternatively 
differences in clinical decision making which may reflect differences between clinicians or 
differences between the way in which the  medical insurance companies function  
 
2) I was curious about the high rates of secondary treatment that occurred AFTER hysterectomy. 
WHy should this be occurring since one would expect that hysterectomy would effectively 
manage the vast majority of patien ts 
 
3) Although there is a comment that COCP does not seem to be an effective treatment I am 
surprised that no mention is made of the apparent superiority of the Levonorgetstol releasing IUS 
when the results appear to be much better than COCP  
 
4) Why was n o comment made about surgical morbidity. A mortality rate of of 0.3% for benign 
disease looks a little high but a rate of &gt;1% is frankly shocking. With these large numbers that 
looks like more than just a statistical aberration due to small numbers. If I saw this result I would 
feel duty bound to raise my concerns with the organisation involved for further investigation. 
Astonishingly this does not warrant any mention by the authors  
 
5) Please do not use undescribed abbreviations . I am from the UK and t he meaning of HMOs 
and PPOs (line 163) are a mystery to me  
 
 
So my view is that this is a piece of work that should merit publication but at present I feel there 
is something of an opportunity lost and the current manuscript leaves me with lots of questions 
and few answers.  
 
I don't have any confidential comments f or the editors. However I would again raise the pint that 
I think the mortality rate in this study for the Medicaid cohort looks to be of concern and should 
merit further action  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is  required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, p lease explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require furth er 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is y es to any, please give details below.  
 
I declare that I have no competing interestsJ Herod  
 
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