Title: Type of menopause, age of menopause and cardiovascular disease: a cross-sectional study
based on data from Rafsanjan cohort study
Version: 0 Date: 20 May 2024
Reviewer's report:
The article by Jamali and co-authors is interesting. Several authors have already tried to answer
if age at menopause and non-natural menopause were associated with cardiovascular disease.
However, the cross-sectional approach is not the best for this analysis. So appropriate evaluation
of the results and adequate acknowledgment of all limitations and their implications should be
done in this article. Overall the article needs a revision of the English and writing. There are
some questions raised and pointed out below. I would also like to point several aspects that need
improvement in each section of the article in order for the article to be improved:
Abstract:
• Improve methods description: it is confusing the way it is written. For instance, clarify:
Cardiovascular disease was self-reported. Not physician reported.
Introduction:
• Overall English and writing need improvement in this section.
• Did you test if category of “early” menopause or “abnormal” menopause would lead to “earlier”
onset of CVD? I understood this was not tested at this moment due to the nature of the cross-
sectional analysis, so please correct.
Methods:
• Overall English and writing need improvement in this section.
• Please clarify: Cardiovascular disease was self-reported. Not physician reported and not based
on charts. Actually all the conditions were self reported, is that correct? Improve methods
description: it is confusing the way it is written.
• In the Rafsanjan Cohort Study, was the use of medication (current or past) collected?
(antidiabetic, antihypertensive, lipid-lowering etc)
• Did you exclude current users of hormone replacement therapy or only past users? It is unclear
in the text. Why did you exclude these patients? Wouldn’t it be more interesting to evaluate if
there was a difference between postmenopausal HRT users and non-users in CVD?
• For diabetes and hypertension, diagnosis was considered only if self-reported? Usage of
medications was also not considered for diagnosis and this information was not collected?
• Were samples collected for the diagnosis of dyslipidemia? You mention a diagnosis based on
the levels of lipids, so it was the only condition not self-reported?
• Why do you report opium use and not other drugs used to treat comorbidities?
• Did you test if the variables had normal distribution to choose the best statistical approach?
• Did you test the association of CVD with age at menopause, as a continuous variable?
Results:
• Please review table 1, BMI variable is incorrect. Standardize the way you present the data in
the table. Correct English.
• Table 1: Why do you present opium consumption and not other medications?
• Differences in menopausal age are very small between groups – and actually not statistically
significant nor clinically relevant. Maybe < and > 49yrs is not the best approach (median 48.61
vs 49.14). You could try to evaluate tertiles or categorize the groups differently.
Discussion
• Overall English and writing need improvement in this section. Information should be presented
in a more engaging manner to keep the attention of the reader.
• Please review the discussion. Lipid comment is repeated and identical. Please correct.
• The authors should make sure the discussion is adequate. The findings of this study are not
definitive and confirmative but hypothesis-generating.
• The lack of data on medication usage is a significant limitation and needs to be pointed out.
• All limitations should be stated. If there is an intention to evaluate the cohort to see which
women develop CVD in the long-term, I would suggest to include in the discussion to increase
the interest in this article.