Biomarkers of female reproductive aging in gerotherapeutic clinical trials

The United Nations World Population Statistics reported that 10 % of the global population, approximately 830 million people, were aged 65 years and older in 2024. This number is projected to double, reaching almost 20 % or 1.7 billion, by 2050. With a growing aging population world-wide, age-associated diseases are also expected to increase, which has prompted research into geroscience to optimize the healthspan of aging individuals. For women, menopause significantly increases the risks of ageassociated diseases, which highlights the importance of sex-specific approaches to precision geromedicine. At present, there is a limited understanding of biomarkers of female reproductive aging and its inclusion into gerotherapeutic clinical trials. Previous gerotherapeutic trials have not specifically evaluated reproductive aging, instead focusing primarily on cardiometabolic, neurocognitive, and musculoskeletal outcomes. In contrast, clinical studies targeting subfertility often assess biomarkers such as AMH, FSH, and LH, while trials addressing menopausal symptoms commonly apply the STRAW+ 10 criteria for reproductive staging. Only recently has ovarian aging been recognized as a critical determinant of women's overall health, extending beyond its role in fertility. Therefore, this article discusses the available (FSH, AMH, Inhibin, antral follicle count) as well as the emerging biomarkers (estradiol, progesterone, LH, Sirtuin- 1, microRNAs, menstrual blood markers, epigenetic markers, ovarian stiffness, vaginal microbiome markers, survey information) of female reproductive aging and a protocol for evaluating the impact of gerotherapeutics in clinical trials. Using an example of a Phase 2 Clinical Trial (1 year), short-term (every 3 months) and long-term (every 6 months) follow-ups can be performed. Importantly, female reproductive lifestage should be taken into consideration when prescribing gerotherapeutics to improve female reproductive aging, ultimately optimizing the health and healthspan of females.