Self-Reported Use and Effectiveness of Marijuana for Pelvic Pain Among Women with Endometriosis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

It has been a pleasure to review this manuscript, which addresses the use of marijuana for the management of chronic pelvic pain in women with endometriosis. The study provides valuable data on prevalence of use, consumption patterns, perceived effectiveness, adverse effects, and associated factors.

This work is of clear relevance to the scientific community, offering original insights—particularly regarding the influence of legal status and accessibility on usage patterns.

With the sole aim of strengthening the manuscript and maximizing its scientific impact, I offer the following recommendations:

1. Introduction

   • Explicitly articulate the study objectives (both general and specific) and clearly state the hypothesis being tested.

2. Discussion

   • More thoroughly acknowledge and discuss the low response rate and its potential implications for selection bias.

   • Explicitly note the absence of formal validation of the questionnaire as a key methodological limitation.

   • Emphasize that the diagnosis of endometriosis in the EA group is self-reported and not clinically confirmed, and highlight this as a significant limitation.

   • Broaden the discussion by integrating comparisons with recent publications and relevant international studies.

I believe that addressing these points will enhance the clarity, methodological rigor, and overall contribution of the study to the field.

Author Response

• Introduction
• Comments 1: Explicitly articulate the study objectives (both general and specific) and clearly state the hypothesis being tested.
• Response 1: More explicit objectives and hypothesis specified in abstract lines 15-18
• Discussion
• Comments 2: More thoroughly acknowledge and discuss the low response rate and its potential implications for selection bias.
• Response 2: Response bias associated with low response rate addressed in more detail, lines 321-323
• Comments 3: Explicitly note the absence of formal validation of the questionnaire as a key methodological limitation.
• Response 3: Discussion updated, 324 – additional information on validation process also added to methods line 92-95
• Comments 4: Emphasize that the diagnosis of endometriosis in the EA group is self-reported and not clinically confirmed, and highlight this as a significant limitation.
• Response 4: Discussion updated lines 325-331
• Comments 5: Broaden the discussion by integrating comparisons with recent publications and relevant international studies. 
• Response 5: Additional publications incorporated into the discussion/conclusion, lines 301-307 and 353-355

Reviewer 2 Report

Comments and Suggestions for Authors

The topic is relevant and original, addressing self-reported marijuana use for pelvic pain among women with endometriosis—a field with limited clinical data but growing interest.
The introduction provides a good background, but some references are slightly outdated and could be complemented with more recent studies on cannabinoid use in gynecology.
The methodology is generally clear, but the authors should better describe the validation of their survey instrument (currently described as “face validity” only) and provide more details on how missing data were handled in the statistical analysis.
The results are comprehensive, but a more concise presentation (especially for Tables 1–3) would improve readability. Some figures (e.g., Figures 2–4) could benefit from clearer legends and higher resolution.
The discussion appropriately interprets the results but could be expanded to compare findings with recent international surveys and meta-analyses (e.g., published in 2023–2024).
Language quality is generally good but could benefit from minor polishing for flow and clarity.

Comments on the Quality of English Language

The manuscript is generally well-written and understandable. However, there are several instances where sentence structure, punctuation, or word choice could be improved for better clarity and academic tone. A light professional editing or proofreading would enhance readability and flow.

Author Response

• Comments 1: The introduction provides a good background, but some references are slightly outdated and could be complemented with more recent studies on cannabinoid use in gynecology.
• Response 1: Additional publications incorporated into the discussion/conclusion, we’ve hesitated to put newer studies into the introduction as they were not existing at the time that this survey was conceived and performed, but have incorporated where we thought appropriate in the discussion – lines 301-307 and 353-355
• Comments 2: The methodology is generally clear, but the authors should better describe the validation of their survey instrument (currently described as “face validity” only) and provide more details on how missing data were handled in the statistical analysis.
• Response 2: Elaboration of validation process performed within methods section lines 92-95
• Comments 3: The results are comprehensive, but a more concise presentation (especially for Tables 1–3) would improve readability. Some figures (e.g., Figures 2–4) could benefit from clearer legends and higher resolution.
• Response 3: Tables 1-3 condensed into a single table, Tables 2 and 3 reformatted as well for clarity, All figures modified to improve resolution and use of space. 
• Comments 4: The discussion appropriately interprets the results but could be expanded to compare findings with recent international surveys and meta-analyses (e.g., published in 2023–2024).
• Response 4: Additional surveys added, one such reference was previously mentioned but not cited in the discussion and this has been fixed. There are many redundant meta-analyses so we have not added all of them but selected most relevant and cited recent clinical guidelines from ACOG and SOGC – added lines 301-307
• Comments 5: Language quality is generally good but could benefit from minor polishing for flow and clarity.
• Response 5: Revisions made throughout manuscript (highlighted in yellow on manuscript)

Reviewer 3 Report

Comments and Suggestions for Authors

The authors report on effectiveness of marijuana for pelvic pain among women with endometriosis.

Comments

1. Indeed, the treatment of endometriosis is, often, very disappointing and it is no surprising that the most frequent comorbidity found by the authors was depression.
2. The present manuscript is the result of a detailed and well conducted study! Good work!
3. I consider that the conclusions of the study are interesting for any clinician and, especially for those who are practicing in countries where marihuana is totally illegally.
4. The percent around 70% of the cases where marihuana proved to be very or moderate effective is promising and should be used as a strong argument for other national programs, regarding chronic pain treatment (not only that induced by endometriosis).

Author Response

Comments 1: Indeed, the treatment of endometriosis is, often, very disappointing and it is no surprising that the most frequent comorbidity found by the authors was depression.

2. The present manuscript is the result of a detailed and well conducted study! Good work!

3. I consider that the conclusions of the study are interesting for any clinician and, especially for those who are practicing in countries where marihuana is totally illegally.

4. The percent around 70% of the cases where marihuana proved to be very or moderate effective is promising and should be used as a strong argument for other national programs, regarding chronic pain treatment (not only that induced by endometriosis).

Response 1-4: Thank you for your support of our manuscript!  Comments interpreted as not requesting specific revisions. 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

It has been a pleasure to review this second version of the manuscript. The authors have made an effort to incorporate all the recommendations and suggestions to improve the quality of the manuscript, and I believe they have succeeded. In my opinion, the manuscript can be accepted in its current form.

Kind regards.