The Journal of Obstetrics and Gynecology published a study in September 2023 that investigated whether treating with vaginal estrogen for vulvovaginal symptoms of menopause posed a safety risk to breast cancer survivors, particularly the risk of breast cancer recurrence. The conclusion, that they found NO increase in risk and therefore the use of vaginal estrogen appears to be safe in breast cancer survivors, regardless of whether they had estrogen receptor positive (ER+) versus estrogen receptor negative (ER-) breast cancer.1

In the United States, breast cancer is the #2 cancer affecting women and will likely affect 1 in 8 women within their lifetime.2 Of women diagnosed and treated systemically for breast cancer, an estimated 70% of them will develop vulvovaginal symptoms of menopause which presents with symptoms such as genital dryness/burning/irritation, lack of vaginal lubrication, pain with intercourse, urinary urgency, pain with urination, and recurrent urinary tract infections.3 The root cause of these symptoms is the lack of estrogen. Up until present day, the use of Vaginal Estrogen for treatment of vulvovaginal symptoms has been contraindicated in women with a history of breast cancer. Many physicians believe it to be a major contraindication, and so this treatment has been uncommon in this patient population. Only an estimated 5 in 100 women with a history of breast cancer were treated with vaginal estrogen for vulvovaginal symptoms of menopause, and 4 in 100 women who had a history of ER+ breast cancer were treated.

The findings of this recent study is good news for patients with a history of breast cancer. Both women and their healthcare providers can feel more confident when deciding whether the benefits of treatment with vaginal estrogen outweigh the overall risks. The quality of the study is more good news for healthcare providers, because 1) the study looked at a substantial patient group of more than 42,000 breast cancer survivors and 2) the study followed these women for up to 5 years.

While this study is robust and encouraging, there was likely variability in what was considered treatment with vaginal estrogen and dosages/formulations varied. At Fowler Gyn International, treatment for chronic vulvovaginal conditions associated with altered vaginal microflora may use doses of vaginal estrogen that are higher than the doses commonly prescribed by gynecologists. If you are one of the many proud breast cancer survivors and still fear the use of any estrogen supplementation, the FGI Approach also offers effective non-estrogen treatment for vulvovaginal conditions. Inquire here thru Talk-to-Doc!

References:
1. Agrawal P, Singh SM, Able C, Dumas K, Kohn J, Kohn TP, Clifton M. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023 Sep 1;142(3):660-668. doi: 10.1097/AOG.0000000000005294. Epub 2023 Aug 3. PMID: 37535961.
2. American Cancer Society: information posted on their website.
3. Kim HK, Kang SY, Chung YJ, Kim JH, Kim MR. The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 2015 Aug;21(2):65-71. doi: 10.6118/jmm.2015.21.2.65. Epub 2015 Aug 28. PMID: 26357643; PMCID: PMC4561742.

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.

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.

Why would women fly from all across the United States to see Dr. Fowler? What makes  his practice so unique? In 2016 alone, women came from 49 states to undergo treatment by Dr. Fowler at Fowler Gyn International in Phoenix, Arizona. Consider a Pennsylvania woman’s testimony below:

“I can remember thinking that the trip across the country to see Dr. Fowler would be the last time I would go to a doctor for this chronic condition I had been dealing with for over three years. I was severely depressed and fed up with the doctors who all seemed to be the same. By this point I had been to so many different gynecologists that I had lost count, but I decided to give it one last try. Doctors I had seen all said my symptoms were just in my head, but I knew that the discharge and odor that I was experiencing was far from normal. My self esteem was at rock bottom and the thought of sex gave me anxiety; all the enjoyment was gone from it. I don’t remember how I came across Dr. Fowler’s practice online - most likely during my hours of research trying to find ways to cure myself, a period of time where I felt extremely lost – but I am grateful beyond measure that I did. Immediately, I was amazed by Dr. Fowler’s intelligence. He knew exactly what he was talking about and was sensitive and caring, something I desperately needed during that vulnerable time. Dr. Fowler diagnosed me with Inflammatory Vaginitis and told me every way in which things down there were not healthy and explained how they should be. I can’t explain how much just knowing what to call this condition meant to me, as well as the hope I felt about the future. Dr. Fowler told me that for my case in particular, treatment would be a long road, but in 8 months I have seen notable improvement. I fully trust his expertise and his methods and I can’t thank Dr. Fowler enough for what he has done for me.” N. Philadelphia, PA.

So what makes Dr. Fowler’s practice so unique to make it is worth a cross-country flight? Dr. Fowler practiced exclusively gynecology (only two years of obstetrics) his entire career. Additionally, he specialized in hormones and vulvovaginal conditions from the onset of his practice. This kind of emersion in narrow fields of investigation is nearly unheard of in gynecology. Aside from his 26 years of such experience, 22 of which were at Mayo Clinic, his gynecologic practice is one of a few if not the only one with a CLIA certified laboratory. Known as Fowler Gyn International Laboratory, Dr. Fowler conducts  advanced vaginal fluid analysis which includes a quantitative determination the vaginal constituents. His research includes first to publish the vaginal micro-flora patterns found in healthy women with no vulvovaginal symptoms. After centuries of medical research in numerous countries, this had never been investigated. It is critical to know this so that treatments can be formulated to “push” the vaginal flora towards one of the normal patterns. Vulvovaginal conditions which have the underlying etiology of altered vaginal micro-flora patterns then can be successfully treated. If you seek the expertise at Fowler Gyn International, like this Pennsylvania women above, it’s likely you’ll be glad you did. If you are experiencing chronic vulvovaginal symptoms for which you have seen multiple providers and failed numerous treatment, Dr. Fowler encourages you to come for an evaluation.

Hello, this is Dr. Fowler. I’m a board certified gynecologist and have devoted my career to helping women achieve relief from chronic vulvovaginal disorders. Yes, I’m the "real deal" and I help real patients and they write real testimonies. I have spent decades doing research and making clinical observations. The advanced diagnostic tests and treatment algorithms I have developed for a number of interrelated vaginal conditions have worked with outstanding success in thousands of women. I wish to thank all my clients who have written testimonies expressing their gratitude for how my medical expertise has improved the quality of their lives. This is in contrast to numerous online horror stories of women being told there is no known cause or cure for their condition.  After reading the testimonies of my clients, if you are still not convinced about the superiority of the advanced diagnostic techniques and treatment approach I advocate, then click on the eChat button where you can communicate with a number of my patients via email or phone.

So why all the favorable reports? The reason so many glowing testimonies are posted is that once women get relief from their horrible condition, it's a life changing event and they are ecstatic about it. They wish to play it forward, to help women like you who are looking for a solution to their difficult vaginal problem. Their gratitude and desire to make it available to other women is rewarding otherwise my practice can be emotionally taxing because women with these conditions are distraught, frustrated and often cry while telling me how their lives are in shambles due to the condition. Collectively, my clients have seen a considerable number of providers including specialists and have experienced multiple failed therapies. Truth be known, most gynecologists don’t even want to see patients with a chronic vulvovaginal condition come through their door. I contrast, I openly advertize to help these women.

On average, it takes between 2.5 to 3.5 months for response to begin and 8-10 months for significant improvement. Specifically, for the conditions of vaginal burning, recurrent vaginal bacterial and/or yeast infection, I have developed an algorithim of over 30 protocols to be used in sequence that improves the chance of response. It’s like anything in medicine; this is biology. Tissue response to a medicine from person to person is quite consistent but then there are always a few who do not respond as optimal as the others. So it is with the vaginal medications. But even these women who have more refractory vaginal mucosa, if they will just stick with the program and allow me to make periodic protocol changes as necessary, my experience has shown that most of them too will ultimately respond.

If you are one of these women that relate to the stories conveyed by the testimonies of my clients, I hope for your benefit that you too choose to become one of my clients. Lets  get you fixed.

Best Wishes,

R. Stuart Fowler, M.D.

Board Certified Gynecologist and Fellow of the ACOG and the ISSVD.