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.

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.

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.