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Gabes et al. [1] aimed to assess the structural validity of the Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire, in order to eventually refine the current available version. Postmenopausal women reporting vaginal symptoms related to menopause participated in the study in Germany. Item characteristic curves were analyzed to observe whether the response categories were functioning optimally. The assumptions of the Rasch model were tested for the whole DIVA as well as for each domain separately. Exploratory factor analyses were carried out and correlations of the single items with the DIVA domains were analyzed to identify the most-fitting items. Finally, validation analyses were carried out on the refined version. The study was conducted in 185 eligible postmenopausal women.

Revising the response categories of each of the four domains led to adequate looking item characteristic curves. The whole DIVA represented a multidimensional construct, including activities of daily living, emotional well-being, sexual functioning and self-concept/body image.  Statistical analysis allowed to create a validated refined version of the DIVA, having now three response categories instead of five and maintaining the four dimensions with less items (17 items rather than 21 items for women with recent sexual activity). The authors concluded that the refined DIVA is more feasible and showed several excellent measurement properties.


Estrogen depletion with menopause, androgen decline with age and the effects of aging per se result in a series of signs and symptoms now called the Genitourinary Syndrome of Menopause (GSM) [2,3]. In 2014, the International Society for the Study of Women’s Sexual Health (ISSWSH) and the North American Menopause Society (NAMS) proposed this new term with the aim to describe a variety of bothersome genital, sexual and urinary symptoms that can present either isolated or coexisting, and not related to other medical conditions. GSM is a clinical entity without the negative connotation of the term vulvovaginal atrophy (VVA), encompassing both the anatomical changes and the functional consequences of menopause [4]. Unlike vasomotor symptoms that usually improve with increasing time since menopause, VVA is a chronic and progressive condition unless adequately treated, and it is an essential part of the GSM [5].  Early recognition of signs and symptoms at midlife and appropriate management through a long-term strategy are mandatory to preserve urogenital health at older age [6]. Despite available effective and safe treatments, findings from international surveys consistently showed that VVA/GSM is underreported, underdiagnosed and undertreated [7].

The use of appropriate psychometric instruments is crucial to understand the impact of VVA/GSM on quality of life and sexual health [8], but the individual experience is as well very important [9]. The European Vulvovaginal Epidemiological Survey (EVES) assessed prevalence, symptoms and impact of VVA of menopause in the clinical setting and indicated that the DIVA may be a powerful tool to investigate the subjective experience of VVA/GSM [10]. That being so, DIVA is useful in the clinical setting and can be used to better understand the burden related to the VVA/GSM condition.

Rossella E. Nappi
Reproductive Medicine, GyneEndo & Menopause,
IRCCS San Matteo, University of Pavia, Pavia, Italy


  1. Gabes M, Stute P, Apfelbacher CJ. Refinement of the German Day-to-Day Impact of Vaginal Aging questionnaire in perimenopausal and postmenopausal women using item response theory and classical test theory. Menopause. 2020;28(3):292-299.
  2. Lachowsky M, Nappi RE. The effects of oestrogen on urogenital health. Maturitas. 2009;63(2):149-151
  3. Simon JA, Goldstein I, Kim NN, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women’s Sexual Health (ISSWSH) expert consensus panel review. Menopause. 2018;25(7):837-847.
  4. Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause 2014;79(3):349-354.
  5. Palacios S, Castelo-Branco C, Currie H, et al. Update on management of genitourinary syndrome of menopause: A practical guide. Maturitas. 2015;82(3):308-313.
  6. Nappi RE, Martini E, Cucinella L, et al. Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Front Endocrinol (Lausanne). 2019;10:561.
  7. Parish SJ, Nappi RE, Krychman ML, et al. Impact of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy. Int J Womens Health. 2013;5:437-447.
  8. Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric. 2014;17(1):3-9.
  9. Shifren JL, Zincavage R, Cho EL, et al. Women’s experience of vulvovaginal symptoms associated with menopause. Menopause. 2019;26(4):341-349.
  10. Palacios S, Nappi RE, Bruyniks N, et al; EVES Study Investigators. The European Vulvovaginal Epidemiological Survey (EVES): prevalence, symptoms and impact of vulvovaginal atrophy of menopause. Climacteric. 2018;21(3):286-291.

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