PONE-D-24-57399Climacteric Women’s Perspectives on Menopause and Hormone Therapy: Knowledge Gaps, Fears, and the Role of Healthcare Advice.PLOS ONE

Dear Dr. Rodrigues,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR:  Congratulations on the study. The work has the potential to advance knowledge about the epidemiology of climacteric syndrome among Brazilian women. Overall, the reviewers' comments were positive, with suggestions for minor revisions throughout the text.

As an academic editor, I believe it would be very interesting if the authors could stratify the analyses not only by menopausal status, but also by the type of health system use, i.e., public vs. private. Approximately 50% of the sample is composed of users of the public system and 50% of users of the private system. It would be important, for example, to know the prevalence of MHT use among users of the Brazilian public system and compare it with the private system. In addition, to know the opinions about MHT comparing these two groups of women. It was not clear to this reader the difference between “Private w/ Healthcare” and “Private w/o Healthcare”.

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Please submit your revised manuscript by Feb 24 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Luiz F. Baccaro

Academic Editor

PLOS ONE

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G.A.R.M. - is currently receiving funding from Theramex

J.M.S.J. - is currently receiving funding from Theramex and Pfizer

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

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: No

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Congratulations to the authors for the excellent research. Women's experience of menopause varies hugely and there is no one-size-fits-all approach to management. Many women transition this stage of life uneventfully, whereas some experience prolonged or severe symptoms and need information, support, or medical treatment. Historically, women have been poorly served by both the research community and by society. It is time for a sensible conversation about menopause to enable informed, individualised decision making on optimal management of this transition, and several medical specialties should be part of this conversation. Understanding our population is the first step to combating misinformation, fear, and deficits in comprehending overall health and comorbidities.

Reviewer #2: Abstract

- Objective: Menopause Hormone Therapy- define the acronym MHT on first use of the abstract

Introduction:

The introduction is quite confusing, both the language and the content.

It is not clear how important it is for menopausal/premenopausal women to know their symptoms and what attitudes are recommended and how they are carried out around the world. I suggest rewriting a few paragraphs with this information that is relevant and supports your work.

We two clear objectives in our study: (1) to evaluate women’s during the menopausal transition and (2) to examine how these changes influence their decision-making regarding MHT. This second objective was included in your analysis?

“Unlike two earlier studies conducted in Brazil [18,19], before the pandemic period, our survey included premenopausal and postmenopausal patients aged between 40 and 65 years” – Did these Brazilian studies have the same objective as this study? Or did the findings of these previous studies support the decision to carry out this study?

Methods

- I suggest removing the period: “This tool was used in this study” and using the reference in the previous period.

- it is not clear that the answers to the questions are arranged on a Likert scale, nor how the authors used to assess the correlation between the answers (Reading the Results section, in Knowledge, there was a categorization to assess the degree of women’s satisfaction and the level of concerns related to menopausal period)

- the healthcare providers are only gynecologists or general practitioners?

Results

Table 1:

- organize the table, making it uniform. For example, how to put “n/N (%)” in the columns and not in the rows [Total (n (%))]

- approximate the percentages so that the total is 100%. In “Occupation” for “Premenopausal Women” the sum is 100.01%

- please, describe the statistical test used

- In the results section, it is necessary to present the findings in your research. Therefore, I suggest reviewing and removing the adverbs of intensity (surprisingly, notably).

Reviewer #3: This was a well designed study, with a expressive number of women assessed, highlighting an important theme, which will affect even more women around the world. I have only minor comments to do:

- Introduction: at the second paragraph fourth line - the utilization of this treatment use (sounds confusing as a sentence)

- Methods - also present at the abstract, the dates are not in international Standard. The year is written first, then the month, then the day. This is also known as the YYYY/MM/DD format

- At the sample size calculation there is a sentence where "864 women will be required" suggestion - 864 would be required to conduct

- Ethical considerations - Considering there are two centers, where are the approval of the second one?

Results:

At the table 1 it is written: Total %), lacking a parenthesis, and there are spaces between the parenthesis and some of the numbers - only suggestions of details

As it was done in table 2 - suggest in table 1 to put the statistical tests used

No further considerations

The discussion was brilliant, separating and organizing the writing like the way you did, only makes the reading better

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Reviewer #1: Yes:  Jan Pawel Andrade Pachnicki, Ph.D.

Reviewer #2: No

Reviewer #3: Yes:  Renan Massao Nakamura

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PONE-D-24-57399R1Climacteric Women’s Perspectives on Menopause and Hormone Therapy: Knowledge Gaps, Fears, and the Role of Healthcare Advice.PLOS ONE

Dear Dr. Rodrigues,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Dear Authors,

Congratulations on the corrections made to the article. The reviewers' questions were adequately answered and the changes to the manuscript are appropriate. However, I suggest correcting the following points before possible publication.

In the section “We analyzed the relationship between public and private health systems and the use of hormone therapy (HT) for menopause treatment. Our findings indicate that women using the public health system are less likely to use HT (62.59% out of 270) compared to those using the private system (49.78% out of 233), representing a difference of 12.81%. To assess the statistical significance of this observation, we performed a Chi-Square test, which yielded a p- value of 0.0168. Given a significance level of 0.05 (95% confidence), we can reject the null hypothesis and conclude that these results are unlikely to be due to chance. Further research will explore the broader impact of public and private health systems on treatment choices.” I believe there was a typing error, since, from what can be understood from what was written, women in the public system used more HT. I suggest reviewing it.

In Table 1, I suggest making it clear that there is missing data for some women, since the sum of the absolute numbers in the rows does not always correspond to the total number evaluated.

==============================

Please submit your revised manuscript by Apr 05 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Luiz F. Baccaro

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Authors,

Congratulations on the corrections made to the article. The reviewers' questions were adequately answered and the changes to the manuscript are appropriate. However, I suggest correcting the following points before possible publication.

In the section “We analyzed the relationship between public and private health systems and the use of hormone therapy (HT) for menopause treatment. Our findings indicate that women using the public health system are less likely to use HT (62.59% out of 270) compared to those using the private system (49.78% out of 233), representing a difference of 12.81%. To assess the statistical significance of this observation, we performed a Chi-Square test, which yielded a p-value of 0.0168. Given a significance level of 0.05 (95% confidence), we can reject the null hypothesis and conclude that these results are unlikely to be due to chance. Further research will explore the broader impact of public and private health systems on treatment choices.” I believe there was a typing error, since, from what can be understood from what was written, women in the public system used more HT. I suggest reviewing it.

In Table 1, I suggest making it clear that there is missing data for some women, since the sum of the absolute numbers in the rows does not always correspond to the total number evaluated.

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Climacteric Women’s Perspectives on Menopause and Hormone Therapy: Knowledge Gaps, Fears, and the Role of Healthcare Advice.

PONE-D-24-57399R2

Dear Dr. Rodrigues,

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,

Luiz F. Baccaro

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: