PONE-D-23-15016Uterine fibroids and longitudinal profiles of the vaginal microbiota in a cohort presenting for transvaginal ultrasoundPLOS ONE

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Additional Editor Comments:

The three reviewers are quite positive over this manuscript with which I agree. I have no further comments.

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

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Reviewer #1: The interesting manuscript by Robbins et al. tries to shed light on the association between uterine fibroids and vaginal bacterial composition. Anyway, it seems that no particular association can be found between vaginal microbiome profiles and uterine fibroids cases.

I have just few questions for the authors:

-line119: the authors state that women with STIs were not included in the study. Was Mycoplasma genitalum positivity considered or not? I have not seen this pathogen included in their list. If not, authors should comment why they have not performed Mgen laboratory tests.

- line 121: I am wondering why women with symptomatic BV condition have been excluded. I Think that the authors should add comments in the methods.

- line 182 and table 1: for most European readers the difference between ethnicity and race can be confusing. Please expand this part.

- line 231: Black race and low income were significantly associated with low Lactobacillus profiles. I am wondering if Black race and low income are significantly associated or not. If these are associated the authors should revise the sentence.

- The discussion is quite long and could be shortened

Reviewer #2: Review:

This is study of the vaginal microbiome in patients with benign gynaecological conditions. Although it is limited in sample size, the hypothesis and urgency is clear. Especially the remarkable frequency of uterine fibroids in ethnically african women compared to white women raises the question whether the higher prevalence of BV in this group is associated with uterine fibroids.

One of the weaknesses of this study is the heterogeneity of the control group. These women may also have a condition that causes pelvic mass or pain in which vaginal microbiome also plays a role. Is there a way to put these data in the context of other longitudinal datasets of vaginal microbiome in patients or control group from past studies. How do these compare to the study group here, cases and controls taken together? Do women who get a referral for TVUS due to pelvic symptoms have a higher incidence of low-Lactobacillus microbiota? This could place the relatively small group of women with uterine fibroids in context.

Line 123

This line is not clear. Do I understand correctly that the exclusion criteria for the cases group were different than for the control group to increase the number of cases? If so, please clarify which exclusion/inclusion criteria were used for the cases and control groups? This may explain some of the observed demographic/ethnic differences.

Reviewer #3: Title: Uterine fibroids and longitudinal profiles of the vaginal microbiota in a cohort presenting for transvaginal ultrasound

Here a secondary analysis was performed on vaginal microbiota data collected from women participating in the GALE study with the aim to assess whether the vaginal microbiota composition associated with having uterine fibriods while controlling for important confounding factors such as oral contraceptive use. The authors use sound, previously well described, analytical methods to reduce the microbiota data into biologically and clinically relevant bacterial groups. They further collapse longitudinal microbiome datasets to allow for binomial statistical modelling. The authors do not detect any statistically significant relationship between having uterine fibroids and the vaginal microbiota composition. Their study has a number of limitations all of which are addressed in the manuscript and mainly arise from this being a secondary analaysis and only few women in the parent study had uterine fibroids. Nonetheless, this explorative study provides useful insights for future work.

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Reviewer #1: Yes: Antonella Marangoni

Reviewer #2: No

Reviewer #3: No

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Uterine fibroids and longitudinal profiles of the vaginal microbiota in a cohort presenting for transvaginal ultrasound

PONE-D-23-15016R1

Dear Dr. Brotman,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Sylvia Maria Bruisten, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

All comments were answered well. There is only one remark that was also raised by reviewer #1.

In the United States 'race' is used whereas this has a negative connotation in Europe (and maybe elsewhere).

For future studies the authors should be aware that 'ethinicity' is the preferred term instead of 'race'.

Reviewers' comments: