Vaginal atrophy, now more commonly called genitourinary syndrome of menopause (GSM), is diagnosed primarily through a combination of your reported symptoms and a pelvic exam. There is no single definitive test. Instead, your provider pieces together what you’re experiencing, what they observe during examination, and sometimes a pH test or cell sample to confirm the diagnosis. About half of all postmenopausal women develop this condition, though many never bring it up with a provider.
It Starts With Your Symptoms
The diagnostic process begins with you describing what you’re feeling. The key symptoms providers ask about include vaginal dryness, burning, irritation, pain during sex, and bleeding during or after intercourse. Urinary symptoms also count: increased urgency, frequent urinary tract infections, or discomfort while urinating. According to 2025 guidelines from the American Urological Association, a GSM diagnosis requires that you find these symptoms bothersome and that they can’t be explained by another condition. In other words, your experience of the problem matters as much as any lab finding.
Many women assume dryness or discomfort is just a normal part of aging and don’t mention it. Providers are increasingly encouraged to ask about these symptoms directly during routine visits, because the condition is treatable and left unaddressed, it typically worsens over time rather than resolving on its own.
What the Pelvic Exam Reveals
During a pelvic exam, your provider visually inspects the vulva, vagina, and cervix, then inserts two gloved fingers into the vagina while pressing gently on your lower abdomen to assess the uterus and ovaries. For vaginal atrophy specifically, they’re looking at the tissue itself for a set of characteristic changes.
Healthy vaginal tissue has visible folds (called rugae), a pink color, and a moist surface. With atrophy, the tissue looks noticeably different. Classic signs include pale, dry, smooth, and shiny tissue that has lost its folds. The walls may appear thin and fragile. Your provider may also see tiny red dots (petechiae), patchy redness, small tears or fissures, and blood vessels that are more visible than usual because the tissue has thinned. In more advanced cases, the vaginal canal itself may have become shorter, narrower, or less flexible.
These visual findings are often enough to confirm the diagnosis when combined with your symptom history, especially if you’re postmenopausal or have another reason for low estrogen levels such as breastfeeding, certain medications, or surgical removal of the ovaries.
pH Testing
Your provider may check your vaginal pH by touching a small strip of pH paper to the vaginal wall. This is quick and painless. Normal vaginal pH in reproductive years sits between 3.5 and 4.5, kept acidic by beneficial bacteria that thrive in the presence of estrogen. When estrogen drops, those bacteria decline and the pH rises. A pH of 5.0 or higher supports a diagnosis of vaginal atrophy, though it doesn’t confirm it alone since infections like bacterial vaginosis also raise pH.
Cell Sampling and Maturation Index
In some cases, your provider may collect a small sample of cells from the vaginal wall, similar to how a Pap smear works. These cells are examined under a microscope to determine what types are present. The vaginal lining is made of three cell types: deep (parabasal), middle (intermediate), and surface (superficial) cells. When estrogen is adequate, the lining is thick and dominated by surface cells. With atrophy, the lining thins dramatically, and the proportion shifts toward the deeper, immature parabasal cells.
A finding of 0% to 5% superficial cells on the sample is consistent with atrophy. Providers can also calculate a maturation value, which weights each cell type into a single score on a 0 to 100 scale. A lower number means fewer mature surface cells and greater atrophy. This test isn’t performed routinely for every patient because the diagnosis is usually clear from symptoms and exam findings alone, but it’s useful in research settings or when the clinical picture is ambiguous.
Vaginal Health Index Scoring
Some providers use a standardized scoring tool called the Vaginal Health Index (VHI), which rates five aspects of vaginal health: elasticity, fluid secretion, pH, moisture of the tissue, and the condition of the lining. Each factor is scored on a scale of 1 to 5, with lower scores indicating more atrophy. A total score of 15 or below (out of 25) indicates atrophy. One study of postmenopausal women in India found that 79% scored below this threshold, illustrating how common the condition is even among women who may not have sought treatment for it.
Ruling Out Other Conditions
Because symptoms like itching, burning, discharge, and pain overlap with several other conditions, your provider needs to rule out alternative explanations before settling on a GSM diagnosis. The most common conditions that mimic vaginal atrophy include yeast infections, bacterial vaginosis, and trichomoniasis, all of which can be identified through simple swab tests. Bacterial vaginosis can actually develop as a consequence of atrophic changes, so both conditions sometimes coexist.
Skin conditions affecting the vulva and vagina also cause similar symptoms. Lichen sclerosus, lichen planus, and lichen simplex chronicus all produce chronic itching, irritation, or pain that can look and feel like atrophy. These require different treatment, so distinguishing them matters. If your provider sees a localized area of redness, thickening, or ulceration that doesn’t fit the usual pattern, they may recommend a small tissue biopsy to rule out precancerous changes or other dermatologic conditions.
Contact irritation from soaps, perfumes, lubricants, or moisturizers can also cause chronic vulvovaginal symptoms. Your provider will likely ask about products you use in the area to help sort out whether irritation is contributing to or causing your discomfort.
What You Can Expect at the Appointment
For most women, the diagnostic process is straightforward and happens in a single visit. You’ll describe your symptoms, have a pelvic exam, and potentially have your pH checked. There’s no imaging, no blood draw, and typically no need for follow-up testing unless your provider suspects something else is going on. The entire assessment usually takes less time than you’d expect, and most providers can discuss treatment options in the same visit once the diagnosis is clear.
If you’re experiencing symptoms but haven’t been through menopause, your provider may investigate other causes of low estrogen, such as hormonal contraceptives, breastfeeding, or medications that suppress estrogen. The diagnostic approach is the same regardless of the underlying cause of estrogen loss.