The most unique feature is the use of advanced diagnostic testing with qualitative Vaginal Fluid Analysis testing (VFA Test). Other gynecologists continue to use the century old technique of Wet Preparations. Fowler Gyn International Laboratory is CLIA certified and utilizes reagents, staining and quantification techniques with analysis under phase contrast microscopy. It appears that Dr. Fowler is the only gynecologist in the US that has CLIA certified laboratory dedicated to the complex analysis of vaginal constituents. Moreover, Dr Fowler discovered the etiology  of a set of related chronic vulvovaginal conditions; vulvodynia, chronic vaginal bacterial infections, recurrent yeast infections, urinary frequency & urgency w/o bladder cause, recurrent UTI’s w/o bladder cause. For instance, the rest of the world believes that vulvodynia is a nerve condition involving the skin of the vulva. Dr. Fowler discovered vulvodynia and the rest of these conditions have a common underlying etiology known as vaginal dysbiosis. He has developed and perfected treatment protocols over several decades which required numerous patient-years observation. There has not been another medical practice in the country posting the number of testimonies as shown for the Fowler Gyn Approach. Its’ quite clear that the exceptionally high response rate has led to more social media buzz than virtually any other vulvovaginal physician in the country.

Based on your age, hormone profile and results of the VFA test, Dr. Fowler selects the proper place in the algorithm of mixed bio-identical hormone doses that you should start with. There are 42 different doses in the FGI algorithm. It takes 4 months to allow the majority of the response that will be induced by a particular dosage. The progress is measured by the change in the six VFA parameters.

Dr. Fowler has found that each woman has a narrow band-width to which they respond. There is no response with too little hormone and there is no response if too much hormone is given. Women with these conditions are different than the general population of women in that their vaginal mucosa only responds to the higher echelon of hormone levels and it must be the proper ratio of bio-identical hormones and it must be formulated in a base that will not cause any reaction. If any of these three things is wrong, the treatment will fail. The base is the medium through which the hormone is delivered. These are all vaginal preparations; the treatments are NOT given orally.

Women who have these conditions should look at it this way. You have a vagina like that of a jet engine compared to and automobile engine. As long as the jet gets it’s high octane Jet A fuel then the engine produces amazing horsepower. If it receives the lower octane fuel of Mogas, it sputters and spurts. In real terms, the vagina shrinks in caliber and length, the mucosa becomes dry, and an altered vaginal microflora pattern develops. This micro-environment is conducive to the growth of aberrant bacteria and yeast.  The vaginal secretions change from being soothing to an irritant. These secretions may have a new odor and plentiful enough to cause a new discharge. These secretions work their way down the vagina and onto the vestibule at the opening of the vagina. The vestibule is about 1/2” wide and made of endoderm. It is the endoderm that gets sensitized and causes burning, stinging or rawness. This tissue is flanked on both sides by ectoderm of the vagina and the ectoderm of the vulva. The ectoderm is more resilient and generally does not get sensitized.

The VRT treatment is aimed  at getting the flora to change back to normal, then the secretions are no longer irritating and the variable symptoms of burning, rawness, stinging, itching and/or urinary frequency/urgency resolve. Symptoms which are a direct result of the altered flora such as dryness, odor and discharge also resolve.

Based on the VFA test results and your hormone profile(HP), the FGI Approach uses two to six vaginal ingredients, collectively known as the Vaginal Rejuvenate Therapy (VRT) for therapy.

The considerations in the HP are as follows: your age, proximity to menopause, factors that influence your endogenous estrogen production such as lifestyle stress, exercise and body weight, whether you still have sexual arousal wetness and a q-tip assay for vaginal moisture which you can preform.

While the rest of the medical world still believes that vulvodynia is a condition limited to the vulvar skin and nerves, the FGI Approach recognizes that it is secondary to the underlying etiology. Specifically, the conditions of vulvodynia, chronic bacterial infections from Gardernella Vaginalis which is an indicator of possible BV or one of the the other 30+ bad bacteria, recurrent yeast, chronic vaginal odor or discharge, or urinary frequency/urgency without a blabber cause, are all caused by altered vaginal microflora or in some cases of vulvodynia, by exposure to external irritants.

The vaginal secretions in cases of altered vaginal microflora change from neutral to an irritant. This does not hurt the tough Ectoderm of the vagina but just up inside the opening of the vagina, the lining of the vagina changes to Endoderm, a rim about 1/2” wide, flanked on both sides by Ectoderm. The Endoderm is of different embryologic origin than the Ectoderm. In fact this is the only area in the human body, including men and women, where Endoderm is exposed to the outside environment. It is the Endoderm that is prone to getting irritated by stimulants and becoming inflamed. It is the inflamed Endoderm that stimulates the underlying nerves of the vulva. You see everybody else in the world as far as Dr. Fowler can determine, treats Vulvodynia in particular as a condition of the skin and the nerves. Now you see that’s not; the skin and nerve irritation are secondary to the underlying cause of altered vaginal microflora and/or external irritant exposure.

These conditions require two-six vaginal medications to correct, known as Vaginal Rejuvenate Therapy.

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.