Narrative Review of Clinical Indices and Imaging Tools, With a Proposal for an Integrative Grading Scale for Vulvovaginal Aging

Genitourinary syndrome of menopause (GSM) encompasses vulvar and vaginal symptoms and signs related to estrogen deficiency that affect quality of life, sexual function, and urogenital health. This narrative review synthesizes clinical signs, patient-reported outcomes, and commonly used clinician-reported indices to appraise vulvovaginal aging, highlighting strengths and gaps of available tools. Core clinician-reported measures include the Vaginal Health Index (VHI) and the Vulvar Health Index (VuHI), whereas patient-reported measures span global symptom ratings and validated questionnaires such as the Day-to-Day Impact of Vaginal Aging (DIVA). Objective markers (e.g., vaginal pH), cytological indices (vaginal maturation index), and emerging imaging or three-dimensional assessments complement clinical evaluation but remain variably standardized. Across tools, heterogeneity in construct definition, scoring anchors, and responsiveness may hinder comparability and clinical decision-making. We summarize practical, evidence-informed recommendations to improve assessment consistency in routine care and research, and we delineate priorities for future validation, cross-cultural adaptation, and minimal clinically important difference (MCID) determination.