**2. Materials and Methods**

This prospective cohort study consisted of women evaluated between January 2021 and June 2021 in an outpatient gynecologic clinic at Hadassah University Medical Center, Jerusalem, Israel. The study consisted of two groups: (1) menopausal women with complaints characteristic of GSM, including dryness, and (2) premenopausal women without vulvovaginal symptoms, who denied dryness.

An additional inclusion criterion included age > 18 years. Exclusion criteria included urinary incontinence, vaginal prolapse, vulvovaginal infection, vulvar skin disease, diagnosed Sjogren Syndrome, pregnancy, and vaginal bleeding.

The study was approved by the Institutional Review Board (Number 0923-20-HMO) and all participants signed informed consent.

Measurement of vaginal moisture was performed by placing a calibrated filter paper test strip, in a standard manner (see below) for 5 min. In all cases, to keep uniformity, the tip of the paper was located adjacent to the hymenal tissue (or its remnants) on the right side of the vaginal opening (at the "7 o'clock" location) (Figure 1).

**Figure 1.** Modified Schirmer test—paper strip location**.** Measurement of vaginal moisture is performed by placing the tip of a calibrated filter paper test strip adjacent to the remnants of the hymenal tissue on the right side of the vaginal opening, at the "7 o'clock" location. **Figure 1.** Modified Schirmer test—paper strip location. Measurement of vaginal moisture is performed by placing the tip of a calibrated filter paper test strip adjacent to the remnants of the hymenal tissue on the right side of the vaginal opening, at the "7 o'clock" location. **Figure 1.** Modified Schirmer test—paper strip location**.** Measurement of vaginal moisture is performed by placing the tip of a calibrated filter paper test strip adjacent to the remnants of the hymenal tissue on the right side of the vaginal opening, at the "7 o'clock" location.

The paper was placed using a Q-tip while the patient was lying on a gynecological bed, and it was left in place for 5 min. After 5 min, the paper strip was gently removed. Fluid amount was measured by the length of the moistened area of the strip in millimeters (Figure 2). The paper was placed using a Q-tip while the patient was lying on a gynecological bed, and it was left in place for 5 min. After 5 min, the paper strip was gently removed. Fluid amount was measured by the length of the moistened area of the strip in millimeters (Figure 2). The paper was placed using a Q-tip while the patient was lying on a gynecological bed, and it was left in place for 5 min. After 5 min, the paper strip was gently removed. Fluid amount was measured by the length of the moistened area of the strip in millimeters (Figure 2).

**Figure 2.** Modified Schirmer test paper strip measurement modality. Fluid amount is measured by the length of the moistened area of the strip in millimeters, i.e., 20 mm. **Figure 2.** Modified Schirmer test paper strip measurement modality. Fluid amount is measured by the length of the moistened area of the strip in millimeters, i.e., 20 mm. **Figure 2.** Modified Schirmer test paper strip measurement modality. Fluid amount is measured by the length of the moistened area of the strip in millimeters, i.e., 20 mm.

The test is based on the principle of capillary action, which allows the fluid from the vagina to be absorbed along the length of a paper test strip in an identical fashion as a horizontal capillary tube. The hypothesis is that the rate of travel along the test strip for 5 min time represents the amount of fluid in the vagina. The test is based on the principle of capillary action, which allows the fluid from the vagina to be absorbed along the length of a paper test strip in an identical fashion as a horizontal capillary tube. The hypothesis is that the rate of travel along the test strip for 5 min time represents the amount of fluid in the vagina. The test is based on the principle of capillary action, which allows the fluid from the vagina to be absorbed along the length of a paper test strip in an identical fashion as a horizontal capillary tube. The hypothesis is that the rate of travel along the test strip for 5 min time represents the amount of fluid in the vagina.

To evaluate the association between the "modified Schirmer test" and other measures, the following data were collected for each patient: vaginal pH was measured using a pH-indicator strip (pH range 3–8, Merck, Germany), VHI score was calculated (Table 1) and documented, and patients were requested to score the degree of daily vaginal dryness as well as dryness during intercourse, using a 0–10 visual analogue scale (VAS), with 0 representing no dryness, and 10 being the worst possible dryness. To evaluate the association between the "modified Schirmer test" and other measures, the following data were collected for each patient: vaginal pH was measured using a pH-indicator strip (pH range 3–8, Merck, Germany), VHI score was calculated (Table 1) and documented, and patients were requested to score the degree of daily vaginal dryness as well as dryness during intercourse, using a 0–10 visual analogue scale (VAS), with 0 representing no dryness, and 10 being the worst possible dryness. To evaluate the association between the "modified Schirmer test" and other measures,the following data were collected for each patient: vaginal pH was measured using a pH-indicator strip (pH range 3–8, Merck, Germany), VHI score was calculated (Table 1) and documented, and patients were requested to score the degree of daily vaginal dryness as well as dryness during intercourse, using a 0–10 visual analogue scale (VAS), with 0 representing no dryness, and 10 being the worst possible dryness.


**Table 1.** The vaginal health index (VHI) (adapted from Bachmann et al. [20]).

Estimation of sample size was based on the expected difference in "modified Schirmer test" measurements between symptomatic menopausal women and asymptomatic nonmenopausal women, calculated using available preliminary data collected for another study (NCT03063684). Given standard deviation measurements of 8.8 mm in the control group compared to 0.79 mm in the GSM group, to prove any difference of 4 mm or higher between the two groups statistically significant, with a significance of 5% (unilateral) and a power of 80%, the calculated number of women needed in each group was 30.

Data were analyzed using the SSPS software (SSPS Science, Chicago, IL, USA). Comparison of "modified Schirmer test" results between the two groups was performed using a *t*-test. Correlation analysis was performed using Pearson's rank correlation. Statistical significance was set at *p* < 0.05.
