Rate of Squamous Cell Turnover: The vaginal epithelium is in a constant state of turn-over or shedding. The full layer turns over in about 30 days from the basal layer to the top layer. The fully maturated cells on top are being exfoliated into the vagina where they provide nutrition for the microflora. This is how the vaginal ecosystem works. The cells and fluids in the vagina provide the nutrients for the lactobacilli. Then lactobacilli secrete substances that suppress the 30+ bad bacteria in the vagina to a degree where they cause no harm. With the lack of sufficient nutrients, the concentration of fully maturated squamous cells will be too low. Also, certain inflammatory conditions in the vagina will cause the epithelium to turn over faster resulting in a higher proportion of Basal, Parabasal and Intermediate Cells. Once this process has been going on for some time, then there are fewer cells that are fully maturated and being exfoliated into vaginal secretions. These are patterns of vaginal constituents that are detected as part of the Vaginal Fluid Analysis (VFA Test).

Tissue Response to AVMF: In women who have developed AVMF patterns, the vaginal secretions can be irritative rather than neutral to surrounding tissues. These secretions do not tend to bother the upper two-thirds of the vagina on account of the relative low innervation or concentration of nerve endings found there. It’s the lower third of the vagina and particularly the vestibule where the epithelium often gets sensitized resulting in variable degrees of burning and itching depending on the woman’s innate tissue propensities. In other women, the AVMF also can cause discharge and or odor without genitalia symptoms.

The Vestibule: Is an area approximately 1-1.5cm wide encircling the opening of the vagina beginning just inside the labia minora or inner lips and extending up to to the level of the hymenal ring. The vestibule is made of endodermal embryologic origin which is wedged in between ectodermal epithelium. It is the vestibule that has the propensity of getting adversely stimulated by aberrant vaginal secretions. On the inside of the labia minora or small lip there is an invisible line to the human eye, known as the vestibular line of Hart, which demarcates the beginning of the vestibule being derived of endodermal or urogenital sinus origin.  (Kurman RJ, Ronnett BM, Sherman ME, Wilkinson EJ. Anatomy of the lower genital tract. Vol 4 Silver Springs: Armed Forces Institute of Pathology; 2010. This line can be demarcated by applying an iodine based Monsel’s solution. It stains the endoderm but not the ectoderm. Symptoms of burning and itching arise from the endoderm. Odor and discharge arise from the direct effect of the AVMF itself.

Hart’s line is visible over a portion of lower left vestibule.

Register to become a client online at fowlergyninternational.com and click “start here.”

By the time you arrive at FGI you have browsed the internet for solutions to fix your vaginal problem, you have likely exhausted your provider network. Meaning you have seen your primary care provider,  several gynecologists and perhaps even a “specialist.” No provider has impressed you, nothing has worked, you may have been told that you may just have to live with it or that it’s in your head. At a minimum you are perplexed and frustrated, but more likely, you are angry and distraught because the symptoms can severely compromising your lifestyle. I know you may feel like, “this is destroying my life.” Because it is.

When you have one of these conditions you need the perspective of an expert who has been in the field of treating these conditions for decades. But the solution transcends the years of experience. The problem is that not all experts are alike. An expert could have decades of experience and still be clueless as to the underlying etiology let alone know how to successfully treat your condition. It takes decades of experience coupled by objective testing that can monitor the effectiveness of treatment independent of symptomatic response. This means the underlying etiology for the condition must be understood. It takes cutting edge diagnostic methods to surmount the problem of monitoring changes of the underlying etiology. If that’s what you hoped to hear, you have arrived. Information in this book took me twenty years to figure out and now you get to read it inside of several days.

I had the good fortune of doing my advanced medical training in Gynecology at Mayo Clinic in Rochester, Minnesota. What a great institution, which I believe was divinely inspired. Thereafter, I was invited to join Mayo Clinic Arizona as a Consultant in Gynecology. I never did any obstetrics after passing my board certification, so 100% of my time was devoted to gynecologic problems. I’m probably the only one in our nation with this trajectory. I probably retired from obstetrics at the youngest age of any ob/gyn in the history of our country. At Mayo Clinic, I had hundreds of women referred to me in the Department of Gynecology for vulvovaginal problems. A routine obstetrician-gynecologist may see a women with vulvovaginal symptoms, like you, once every 6-8 months. That’s not enough to develop any expertise, let alone have the incentive to buy expensive laboratory equipment to properly evaluate a few patients per year. At Mayo Clinic I was seeing many women with vulvovaginal symptoms on a daily basis and began conducting clinical observations and research. Over two decades, I discovered the underlying etiology. The big surprise: many vulvar skin symptoms come from irritative secretions, not intrinsic to the skin itself but occur because of what’s going on inside the vagina. The standard of care in the US for a women who presents to a gynecologist with symptoms of vulvovaginitis is to preform a KOH & Saline Wet Prep. This technique is antiquated and has not changed in scope in over a 100 years!! This is still the diagnosis method of choice used by US gynecologists today. This technique evaluates for just four types of vaginitis. They are bacterial vaginosis (BV), yeast vaginitis, trichomonas and atrophic vaginitis. Things are different here at FGI. During 22 years of clinical observation and research at the Mayo Clinic, I discovered a spectrum of Altered Vaginal Microflora Patterns (AVMF) that proves the classification of only 4 types of vaginitis is a major mis-representation. I introduced to the medical literature an expanded spectrum of vaginitis. [ Fowler, R. Stuart.  J Reproductive Med 2007;52:93-99]. Undergoing the VFA test is sine qua non for a successful treatment. FGI offers this advanced diagnostic testing known as Vaginal Fluid Analysis (VFA) testing which is used to diagnose and monitor response to therapy with the test results dictating most adjustments that need to be made to the therapy.

The vaginal mucosa is the lining of the vagina which is in direct contact with the vaginal secretions. It composes part of the vaginal wall. Beneath the mucosa lies muscle, nerves, blood vessels and adipose tissue. Together they make up the vaginal wall. It extends form the inner labia minora of the vulva to the cervix. The average length of the front wall of the vagina is a 7.5cm and the back wall is 9cm. The difference in length occurs due to the projection of the cervix into the vagina at approximately a 45 degree angle. The vaginal caliber at the opening is approximately 3.5cm. When lack of estrogen occurs, the vagina shrinks in length and in caliber. The mucosa gets thinner, less elastic, pale and dry. Problems that arise from these changes include central pelvic pain during intercourse from the penis hitting the cervix and  pain and tearing with intercourse to symptoms of atrophic vaginitis. These symptoms can include vulvar burning, rawness and stinging, chronic bacterial and/or yeast infections and urinary frequency and urgency.  In most women virtually any type of estrogen applied to the vagina fixes these problems. However, there is a group of women who have high estrogen demand vagina (HEDV). This means their vaginal mucosa will only respond to higher levels of estrogen and in the correct proportion of bio-identical estrogens. These women are often frustrated because they travel from provider to provider looking for answers but receive the same old therapy. This group of women are uncommon but their symptoms are usually most extreme. If you are one of these women, your vaginal mucosa is likely not healthy, meaning the squamous cells are likely mostly Intermediate cells or parabasal and basal cells. This can be corrected but must be done by a provider who is aware how to treat HEDV’s. This is a particular expertise at FGI. So take it to heart that there is a provider out there who can get your condition fixed.

There are three constituents in a healthy vagina. Lactobacillus bacteria, maturated squamous cells and plasma from the blood stream. This BLOG will discuss where Maturated Squamous Cells come from.

Squamous Cells: Most people think these are cancer cells. They can be but most the time the term refers to the normal cells composing the surface of  skin and the vaginal lining. Your vagina is composed of thick rugated stratified squamous mucosa. Rugated means they are folded on top of each other and stratified means they are bunched up in layers. That means the vagina lining looks like the waves in the surf approaching the beach. Specifically, the lining is not smooth but is a series of ridges produced by folding of the wall of the vaginal lining known as the mucosa. The folding in and out enables it to greatly expand for intercourse and especially for childbirth. The older a woman gets and the more sexual intercourse she has had, the rugations tend to flatten out and become less pronounced. In a healthy marital relationships, women are likely to have had intercourse 6000 times by the age of 50. Even then, most women maintain good vaginal rugations with muscle snugness and moisture given the woman has paid some attention to exercise and perhaps hormone use. The word squamous sounds like cancer because so many cancers are of squamous cell derivation. But in fact it’s the same cell line as the skin covering the human body and vagina except the vagina is non-keratinizing stratified squamous epithelium meaning it does not develop the tough outer layer composed of keratin. This means it has no potential for callus formation; a distinct advantage for the vagina.

Squamous Cell Maturation: The vaginal mucosa is the wall of the vagina. It consists of multiple layers but only four cell types each representing different stage of development. The deepest layer is composed of Basal Cells. These cell have just developed into squamous cells derived from the basement membrane. Basal Cells are the newest cells that are forming to eventually develop into the more maturated cells located further towards the vaginal surface. The next layer towards the surface is composed of layers of Parabasal Cells. Both these cell types are small with little cytoplasm, large nuclei and no nutritional content to help sustain the healthy bacteria in the vagina. If the vagina receives some estrogen stimulation then the Parabasal Cells maturate into Intermediate Cells, which have some nutritional content for healthy vaginal bacteria. If there is full estrogen loads available, then Intermediate Cells maturate into Maturated Squamous cells with tiny nuclei and large amount of cytoplasm with abundant glycogen and other nutrients for the lactobacilli species of bacterial that dominate the vagina micro-flora in reproductive age women under healthy conditions.The Superficial Maturated Squamous Cells are the cells on the top layers of the mucosal lining, meaning directly in contact with the vaginal secretions in healthy conditions. These cells are exfoliated into the vagina and are part of normal vaginal secretions. Their presence in adequate numbers are key to supplying the nutrients for lactobacilli to thrive. This layer of superficial maturating squamous cells make up the lining or mucosa of the vagina.

The Clinical Problem: I have found that women with vulvovaginal burning, stinging, or rawness AND women with recurrent vaginal bacterial or yeast infections ANS chronic odor, have something different about their vaginal mucosa. While most women respond to any type of estrogen to get their vaginal mucosa to fully maturate. Women with these conditions do not respond to any of the estrogen products made by US pharmaceuticals. This is where FGI expertise comes in. I has developed unique topical agents that stimulate the vaginal mucosa causing it to maturate. The trick is that each woman requires a little bit different formula in order to respond depending on their hormone profiling (HP) and VFA test results.

You may be tempted to order one of the many types of vaginal microbiome test kits available on the internet to determine if you have vaginal dysbiosis. These tests range between $60-200.00. While they sound impressive because they use next-gen sequencing and/or metaqgenomic sequencing.  they are stuck on making one of 4 types of vaginitis; bacterial vaginosis (BV), trichomonas, yeast or atropic vaginitis. Not one of these has been the underlying etiology of chronic vaginal disorders diagnosed and treated by FGI. Many of the tests also look for the STD’s chlamydia and Neisseria gonorrhoeae. Neither of these is an underlying etiology of the chronic vaginal conditions  either. What women need for the chronic vaginal symptoms addressed by FGI is a Vaginal Fluid Analysis (VFA ) test.

The VFA test was developed and published by Dr. Fowler while he practiced gynecology at Mayo Clinic. (In 2011, at the ISSVD World Congress XXI in Paris France, Dr. Fowler presented “Quantification of Normal Vaginal Constituents by New Wet Prep Technique,” subsequently published in: J Low Genit Tract Dis. 2012 Oct;16(4):437-41. The VFA test is  preformed exclusively at the CLIA certified Fowler Gyn International Laboratories (FGIL). It’s located at FGI headquarters and results are available in 7 minutes. This means you get your results and protocol at your appointment. FGI has the only laboratory in the country that I know of dedicated to the evaluation for the vaginal constituents. It’s a one of a kind.

It gives the relative quantitative measurement of constituents in the vagina that reflect vaginal health. These include the maturation index of squamous cells, the relative concentration of squamous cells and the pattern of bacteria on the cells; the presence, concentration and type of wbc’s; the relative concentration and quality of lactobacilli; the relative concentration of non-lactobacilli, anaerobic and aerobic bacteria; and the presence and relative concentration of blastospores and/or pheudohyphae yeast elements.

Thousands of women have been treated with success at Fowler Gyn International (FGI) with this breakthrough approach. It has been over a century that some of these conditions had no known etiology let alone any consistent successful treatment.  Now you can get your life back.

If you find yourself always conscious of about your vagina, there is something wrong. Even if your gynecologist tells you everything looks normal. You are likely suffering from one of the conditions tat arise form altered vaginal microflora (AVMF).  All of the following vaginal symptoms, despite how varied they my seem, have the same underlying etiology meaning they all occur secondary to AVMF. The normal vaginal secretions change from constituents that provide a lactobacilli dominant to a non-lactobacilli dominant environment that contains numerous bad bacteria which cause problems such as discharge, odor, recurrent UTI or provide a culture media that supports recurrent bacteria or yeast infections. Also the secretions may change from its normal neutral, soothing effect to eliciting an irritative effect on the vestibule at the vaginal opening. This causes burning, rawness, stinging, pain, chafing, dryness, itching and or urinary frequency and urgency. The secondary effects are pain with intercourse, tight vaginal caliber, tearing of vaginal opening with intercourse, and shortening of vagina with the cervix or top of vagina being hit during deep thrusting with intercourse.  It seems odd that similar treatment would be effective in women with such varied vulvovaginal symptoms. The reason for this is that each woman responds differently to the same stimulus depending on the innate propensity of her individual vulvovaginal tissues. Also, to say the “same treatment approach” is not to say it’s the same treatment. To get you fixed you need a protocol that is individualized based on your particular hormone profile (HP) and the results of the VFA Test which determines the type and relative quantity of vaginal constituents present. FGI uses 36 different protocols. The hormone profiling is based on factors that affect the vaginal estrogen effect.

What are the Variables of Hormone Profiling (HP)?

This includes your age, proximity to menopause, factors that influence your endogenous estrogen production such as lifestyle stress, exercise and body weight, whether there is sexual arousal wetness and a q-tip assay for vaginal moisture on physical exam. These factors are used to individualize your treatment. The mainstay of your treatment is a unique blend of hormones. The vaginal mucosa does not respond if it senses too much or too little of the hormones. It took the experts at FGI over 10 years to figure out how to get the dosing just right. Of all the commercially available hormone preparations, none of them are suitable for treatment of these conditions. Using HP indicators, FGI experts have been able to consistently achieve  excellent results.

FGI deals with with vulvodynia characterized by burning, rawness and/or stinging and pain with insertion of tampons, pain with insertional intercourse, as well as the problem of the vaginal caliber being too tight and tearing or the vagina too short with penis hitting the top of vagina.  Also, FGI treats recurrent bacterial and/or chronic yeast infections, recurrent bladder infection without urologic cause, chronic vagina discharge and/or odor and urinary frequency and urgency without a UTI. All of these vulvar skin symptoms come from the same etiology: vaginal dysbiosis. Vaginal secretions which had been neutral, now are caustic. The secretions do not hurt the vagina much because it is made of tough ectoderm but just up inside the opening of the vagina is a 1/2” wide area of endoderm; this is the tissue that gets sensitized by the secretions. So these conditions are not intrinsic to the skin itself but occur because of what’s going on inside the vagina. FGI offers advanced diagnostic testing known as Vaginal Fluid Analysis (VFA) testing to diagnose and monitor response of these conditions.

How Much Hope is There?

I think this testimony from a client in Michigan spells it out pretty well:

“Dr. Fowler literally saved my life. After battling a chronic vaginal infection for 3 years, I developed unprovoked vulvodynia. I saw nine specialists in my region and no one knew how to treat me except to numb my pain. I spent over $20,000 on both traditional and alternative medical treatment plans. I was unable to have intercourse for nearly 5 years. I was unable to wear pants or panties for 3 years. I needed to resign from my job because I was unable to function as the pain was a 10/10. I was hopeless and my vulva/vaginal pain was ruining my life. I found Dr. Fowler through an internet search, it was a miracle provided by the Lord that I found him. The first time I spoke with Dr. Fowler on the phone, he was patient, kind and encouraging. He even allowed me to pray with him. I scheduled my visit to Arizona and started treatment immediately. My recovery was slow, and at times discouraging. Dr. Fowler kept encouraging me and said that for some women recovery is slow, to be patient, and to stay the course. After nearly 2 years of following his treatment plan, I am 95% better. I am so grateful to God for Dr. Fowler and the FGI staff! I got married and I'm now in a loving relationship able to have intercourse and reach orgasm without any pain. I never knew that sexual intimacy could be so pleasurable. We had sex every day for a year. Life has been wonderful. Have had so much sex I got pregnant. Dr. Fowler has given me my life back and then some, in a manner that I never thought was possible. God bless you, Dr. Fowler! You are changing the lives of women worldwide! Ladies, call Dr. Fowler NOW, he will change your life too! L. Holland, MI.”

FGI (Fowler Gyn International) Office Manager, Alice Yeates, recently reflected on the practice saying, “Isn’t it interesting, Dr. Fowler, how most of the new patients act a little suspicious about the practice on their first visit, but by the end of the visit they are totally at ease.” Then she added a very kind remark, “Dr. Fowler your are a master at enabling women to feel comfortable and secure with you and what a blessing it is. Look how many women have got their life back because of you.”

I wish there was a way to better connect with new prospective clients this but there are so many factors involved. First and foremost, FGI deals with issues in women’s health that are of the most inanimate in nature. Where else does a woman talk about the sensitivity and quality of her vagina? There is no way to create instant trust when dealing with questions like: Where exactly is the vaginal pain located? What factors trigger or exacerbate the pain? What happens during intercourse and sexual response including sexual wetness, vaginal caliber and length? Describe the vaginal secretions, discharge and odors? AND all this with a new provider, someone they have never met and often just found online.

Then there is the emotional sensitivity that the “V” problem evokes. Women’s lives are often in shambles over the detrimental lifestyle changes that the condition causes. Most of FGI clients have already seen multiple providers who have not been able to help them and they have began to feel despair. Some providers have even told them that their is nothing that can be done and they will just have to learn how to live with it.  This is the purpose that from the onset of opening FGI, I made it a testimony driven practice.  With the hundreds of testimonies posted, women cannot deny something different is happening at FGI. Asking patients to write testimonies would seem like a simple thing, but people are busy. Getting them to do so after this difficult problem is behind  them is challenging. They often have no need to return to FGI when they are fully cured. See the problem. However, if I approach them just before they have no reason to return, they are universally so grateful they are more than happy to write their testimony. It triggers their memory of how important is was for them to have read the testimonies and how it gave them hope to proceed with an FGI appointment. Now you can understand why so many women state in their testimonies that they are 80-90% better. This would be the last appointment before they are cured.

Moreover, the FGI website (fowlergyninternational.com) provides an Echat function where a prospective clients can contact one of FGI’s clients by email or phone and talk with her about her experience. There is no other practice that I am aware of that provides prospective patients with this degree of assurance and hope.

Some have reluctance to spend the money on a cross country trip for an out-of-pocket expense medical visit. The good news is that just the initial appointment requires in person visit, and subsequent visit at one year if needed. The 4th month and 8 month follow-up visits can be done virtually by collecting the specimens in the comfort of the clients own home and mailing it to FGI. This definitely reduces the financial sting. Additionally, for the in-office visits, many people have “out of network” insurance coverage which can cover 60-80% of the in-office visit charge. For this purpose, a Superbill is provided to every client who requests one. However, Medicare does not accept Superbills for “out-of-network” coverage.

FGI is the only practice in the country to my knowledge which has an associated CLIA approved laboratory dedicated to the analysis of the vaginal constituents at a complex level. This provides most of the critical information FGI needs to establish the individualized treatment protocol. Fixing vulvovaginal problems secondary to altered vaginal flora problems is not like treating something like high blood pressure where there are a number of medications to try. There are now over 50 FGI protocols. Selecting the correct one requires specific information on a number of factors.   Also, women find that the objective follow-up regarding the response to treatment seen in the Vaginal Fluid Analysis to be very gratifying.

Don’t be one of those women who consider it for several years before registering for an appointment at FGI. Once you have had symptoms for over 4 months, rarely do these conditions resolve on their own. Women who get these chronic vulvovaginal problem are believed to have an abnormality of their vaginal mucosal that makes it impossible for the vagina to self-correct aberrations in the microflora as it dose in most women. It’s a very infrequent situation; that’s why women with these conditions don’t know anybody else with the same problem. Be assured that you are no alone and we have helped thousands of women overcome these dreadful symptoms.

Bacterial Vaginosis and Desquamative Inflammatory Vaginitis

by Jorma Paavonen, M.D., Ph.D., and Robert C. Brunham, M.D.

N Engl J Med. 2018 Dec 6;379(23):2246-2254

In an opening paragraph the article says, “This review focuses on bacterial vaginosis and desquamative inflammatory vaginitis... Not discussed in this review are trichomoniasis and vulvovaginal candidiasis, two other common causes of vaginal symptoms.” If they were to add Atrophic Vaginitis, that’s FIVE types of vaginitis. So they did better than most articles that suggest there are only four types of vaginitis. They added desquamative inflammatory vaginitis (DIV) but they still fail to recognize two other types, that are much more common than DIV. And the authors equate DIV with the European term aerobic vaginitis which is incorrect. That’s an obvious sign the authors lack experience in actually evaluating patients with vaginitis. Aerobic vaginitis is the european term for what I coined in the literature published in the United States as Inflammatory Vaginitis (IV). Also, using quantitative wet preparations, there is a spectrum of severity; mild inflammatory vaginitis, moderate inflammatory vaginitis, severe inflammatory vaginitis and at the extreme worst end being DIV where white blood cells (wbc’s) are present in clusters and sheets, often toxic appearing. The wbc pattern in mild to moderate IV tend to be agranulocyte dominate. Moderated to severe IV tend to be granulocyte dominate. Severe IV and DIV usually have “toxic” appearing neutrophils. Another category is non-inflammatory vaginosis (NV), this is in the same spectrum as BV but lacks clue cells and pH is variably elevated but shows a dominance of anaerobic bacteria, lack of wbc’s and low lactobacilli concentration. So if one adds trichomonas, lactobacillosis, and mobiluncus, and divides yeast vaginitis into two groups, albicans and non-albicans then that makes TWELVE types of vaginitis; NOT four or five that most articles site.

The authors are correct about the following statements: 1) “During a woman’s reproductive years, the vaginal microbiome appears to be principally influenced by the effects of estrogen on vaginal epithelial cells, the predominance of lactobacilli, and low pH.” 2) “The vaginal microbiome can also be transiently influenced by several other factors, such as use of antimicrobial agents, sexual activity, and menses.” Others include all the factors that can alter estrogen production by the ovaries AND a genetic variant in some women with high estrogen demand vaginal mucosa. 3) “Desquamative inflammatory vaginitis is a newly recognized clinical syndrome characterized by persistent purulent vaginal discharge and vaginal erythema, often with submucosal cervico- vaginal petechiae.” While it may be “newly recognized” it was described the the medical literature over 30 years ago but still most authors who write articles on vaginitis don’t include it among the differential. 4) Clinical manifestations of desquamative inflammatory vaginitis include purulent vaginal discharge and a strong inflammatory reaction. The vaginal discharge is homogeneous and yellowish, with no fishy smell. Vulvar irritation and vaginal mucosal erythema with ecchymotic lesions or erosions are present in severe cases.” Notice the phrase “vulvar irritation,” in other words it is one of the causes of vulvodynia. They just don’t quite put two-and-two together. Of course there are a lot more correct statements in the article, just not pertinent to my practice dealing with vulvodynia, chronic bacterial infections, recurrent yeast infections, chronic discharge and odor. In my clinical experience, BV has never been implicated in these conditions. BV is an acute polymicrobial vaginal dysbiosis that readily responds to metromidazole or clindamycin with underlying healthy vaginal mucosa conditions.