Global and Chinese epidemiologic study of polycystic ovary syndrome in women of childbearing age, 1990–2021, and projections to 2035: Based on the Global Burden of Disease 2021 study

Junping Liu; Yan Cai; Jiaying Li; Xiaodan Zhang

doi:10.1371/journal.pone.0329090

Peer Review History

Original SubmissionFebruary 17, 2025
Decision Letter - Wan-Xi Yang, Editor Dear Dr. xiaodan, 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. ============================== ACADEMIC EDITOR: ============================== Please submit your revised manuscript by May 09 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. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). 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Thank you for stating the following financial disclosure: “This work was supported by the National Natural Science Foundation of China, "Construction and validation of different cardiovascular risk stratification early warning models for patients with essential hypertension based on Chinese medicine pulse detection" (NO.81973749);Construction of Ye Yumei Pudong Famous Chinese Medicine Workshop (PDZY-2021-1005);Shanghai Municipal Healthcare Commission Healthcare Program (202340155); Shanghai Pudong New District Clinical TCM Characteristic Discipline Construction Grant (YC-2023-0611); Shanghai Pudong New District Health System Leading Talent Training Program (PWRl2023-10).” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. 4. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: I Don't Know Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The articles is focused on PCOS problem in Chinese popul;ation and the progression during the time. I recomended authors to discuss the problem of PCOS with exposition to EDCs and other environmental pollution and include some figures to sumarrize data. Reviewer #2: Dear author, Thank you for the great effort in summarising such an important data, indicating appropriately limitations and possible directions regarding findings, though with caution as it is a condition with very high heterogenicity, and thus with data not comparable many times. About the review, I would address important issues to take into account, such as: - Review "Results" in abstract, regarding punctuation, structure and use of incidence and prevalence. - Line 72 - I would better define as "hyperandrogenism, oligoanovulation and polycystic ovarian morphology" (based on the latest PCOS guideline in 2023 (https://www.monash.edu/__data/assets/pdf_file/0003/3379521/Evidence-Based-Guidelines-2023.pdf)), and I would suggest to complete the information about impact and risks with the initial content of the guideline (dermatological burden, cardiometabolic, and so on) - Line 185 and other titles: PCOS with capital letters - Lines 189 and 190 review grammar please - From line 200 (215, 238, ...) onwards I identify many "prevalence" words when they should indicate "incidence". I would suggest to review it carefully as it doesn't match with tables and figures. Thank you for submitting the manuscript and I hope you find the review useful. And thank you again for this study and conclusions. Efforts in PCOS with the most recent guidelines aim at pursue common criteria used worldwide so the data become comparable. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No ******** [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. https://doi.org/10.1371/journal.pone.0329090.r001
Revision 1
11 May 2025 Author Response Dear Reviewer: Greetings! Thank you very much for your valuable comments on our paper. We have carefully revised the relevant questions, and the following are the responses to your comments: For the first question: We have explored in detail the relationship between PCOS and environmental endocrine disruptors (EDCs) and other environmental pollution. Specifically, we added that although the incidence of PCOS in China has decreased, its prevalence and disease burden have increased significantly by 86.95% and 86.56%, respectively. We propose that this increase may be related to the rise in EDCs. EDCs are widely present in various products and pollutants, such as plastics, pesticides, cosmetics, and industrial pollutants, and can adversely affect the endocrine system. For instance: Exposure to bisphenol A (BPA) can cause hyperandrogenemia and ovarian polycystic changes. The underlying mechanism involves the abnormal activation of estrogen receptor β and the dysregulation of the insulin signaling pathway. The concentration of phthalate metabolites in the urine of PCOS patients is significantly higher than that in healthy individuals and is positively correlated with insulin resistance and oxidative stress. In a group of women with long-term exposure to industrial pollutants, such as polychlorinated biphenyls (PCBs), the occurrence of ovarian cysts may be associated with an increase in EDCs. Additionally, in a female cohort exposed to industrial pollutants like PCBs, the risk of ovarian cysts and the levels of inflammatory factors were significantly higher. It should also be noted that during China's rapid industrialization, the continuous increase in EDCs may partially account for the rising trend in PCOS prevalence. For the second question: As you suggested, we have defined PCOS as "hyperandrogenism, oligoovulation, and polycystic ovarian morphology" and supplemented this definition with the 2023 international evidence-based guidelines. Furthermore, we have refined the information on the impacts and risks of PCOS. PCOS is the leading cause of anovulatory infertility and is associated with an increased risk of cardiovascular disease, endometrial cancer, and significant psychosocial impairment. It is also accompanied by skin manifestations such as hirsutism, acne, and alopecia. Regarding the similarity check: We have checked the similarity rate of the manuscript. The result of the thesis check is 13%, and the file name of the check report is "similarity rate.pdf". We have uploaded the similarity check result. Thank you again for your interest and support of our paper, and please feel free to advise us of any further comments and suggestions. XiaoDan ZHANG Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0329090.r002
Decision Letter - Wan-Xi Yang, Editor Dear Dr. xiaodan, 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. ============================== ACADEMIC EDITORA minor revision is needed. Please revise the manuscript accordingly. ============================== Please submit your revised manuscript by Aug 13 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. 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 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, Wan-Xi Yang, Ph.D. 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: Editorial comments: As you could see, one of the reviewers had minor concerns on your revision. Please revised it accordingly. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #2: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The manuscript entitled: Global and Chinese epidemiologic study of polycystic ovary syndrome in women of childbearing age, 1990-2021, and projections to 2035: based on the Global Burden of Disease 2021 study. Authors revision meet all my acceptation regarding the paper. Reviewer #2: Than you very much for the corrections and the text added. However, in my previous comments I suggested a review of the use of prevalence and incidence, since both were interchanged at some points (for example, line 200, were prevalence was used twice for different purposes). Once this is corrected, I consider the article recommended for publication. Thank you very much again for the effort and very interesting study and analysis. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No ******** [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 https://doi.org/10.1371/journal.pone.0329090.r003
Revision 2
9 Jul 2025 Author Response Dear Editors� Thank you for reviewing our manuscript. We have addressed all reviewers' comments in the revised manuscript. Response to Journal Requirements Regarding References: As requested by the journal, we have thoroughly reviewed the reference list in our manuscript to verify its completeness and correctness. We specifically checked for any potential retracted papers cited within our references and can confirm that no retracted articles are cited in our manuscript. Therefore, no changes were required to the reference list in accordance with this specific point. All cited references remain appropriate and support the claims made in the text.” Dear Reviewer 2, Thank you very much for your additional feedback and for highlighting the confusion in the usage of prevalence and incidence in the manuscript. We sincerely appreciate your meticulous review and apologize for the oversight in addressing this point in our previous response. Your comment is highly valuable for improving the clarity and accuracy of our work. We have carefully reviewed the entire manuscript to identify all instances where prevalence and incidence were interchanged. As you correctly pointed out (e.g., in line 200 of the original version), prevalence was used incorrectly in place of incidence. To address this: ①We have systematically replaced "prevalence" with "incidence" in the relevant sections, including line 200, to ensure consistency and proper terminology usage. ②This correction has been highlighted in the Revised Manuscript with Track Changes, marked in red text for easy reference (specifically, in the tracked changes version). We have ensured that the distinction between prevalence (as a measure of existing cases) and incidence (as a measure of new cases) is now clear throughout the text. With these revisions, we believe the concern you raised has been fully resolved. Your suggestion has significantly enhanced the quality of our article, and we are grateful for your expertise. Thank you once again for your time, constructive criticism, and for considering our study as "very interesting." We hope that the manuscript now meets the standards for publication and look forward to your final evaluation. Sincerely XiaoDan ZHANG Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0329090.r004
Decision Letter - Wan-Xi Yang, Editor Global and Chinese epidemiologic study of polycystic ovary syndrome in women of childbearing age, 1990-2021, and projections to 2035: based on the Global Burden of Disease 2021 study PONE-D-25-06617R2 Dear Dr. xiaodan, 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. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Wan-Xi Yang, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): The author had revised the manuscript accordingly. No further revision is needed. Reviewers' comments: https://doi.org/10.1371/journal.pone.0329090.r005
Formally Accepted
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