As recent as ten years ago, many docs did’t know the term “vulvodynia.” The condition has been around since the first report of symptoms consistent with the condition published in the medical literature in the 1870’s. That’s 150 years ago. Most docs had not heard of vulodynia even by the turn of the century in 2000. Today nearly all gynecologists know the term vulvodynia and understand the symptoms. But there is nobody I know of,  except myself, claims to have a treatment that consistently works.  I 1997 all the vulvovaginal experts in the world who were gathered at Beveno, Italy for the ISSVD XIV World Conference scoffed at me for suggesting external irritants had anything to do with vulvodynia. Today, avoidance of external irritants is the first thing knowable vulvologists teach their patients. There are many names for vulvodynia, all of which make no sense because none of them are etiology based. Because I believe I have discovered the etiology of vulvodynia, I have divided the vulvodynia patients into two diagnostic groups; EIV stands for External Irritant Vulvodynia and AFV stands for Altered Vaginal Microflora Vulvodynia. I find vast majority are AFV patients. It’s easy to know the distinction because, AFV patients have Altered Vaginal Microflora on Vaginal Fluid Analysis. I presents these findings at the ISSVD  World Congress XVII in Queenstown New, Zealand in 2006. All but four of the worlds vulvovaginal experts scoffed at me.  EIV have normal flora. It’s an objective finding. However, once the vestibule gets sensitized by the irritant vaginal secretions in AFV, they act just like EIV patients because external irritants exacerbate their symptoms as well.

So now you understand, all vulvodynia starts from irritation of the vestibule which is made of different embryologic tissue called Endoderm compared to the tissues lining the vagina above bing Ectoderm and lining the ‘more exterior’ vulva below also derived from Ectoderm. In some patients, the irritation at the vestibule level triggers pelvic muscle tightness called Levator Ani Syndrome or Pelvis Floor Spasm or Pelvic Floor Tension Myalgia. This is why you hear of some docs prescribing PT. This is miss-guided because it will usually make the symptoms worse for several months then the symptoms will get perhaps 30-40% better. It’s expensive. If the vulvodynia is treated correctly so that the burning resolves, the pelvic floor muscle tightness goes away with no more trigger factor. I believe most docs that are experiencing success with vulvodynia patients, are treating those of the EIV type. EIV will completely resolve with just avoidance of irritants, it doesn’t matter what else from the long list of treatments available. See my Blog of Jan 2023.  AVF patients usually respond between 30-50% from just avoidance of external irritants alone. But this large group will not be cured unless they have treatment to fix the altered vaginal microflora. This is where The Fowler Gyn Approach stands above and beyond what else is out there.

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.

The etiology of chronic vaginal burning pain, a condition come to be known as Vulvodynia, eluded physicians for over a century. Hope for relief from the pain was dismal. Internet stories abound of women having their lives ruined due to inability to concentrate at work, engage in intercourse, exercise or enjoy social functions. That all changed when a Mayo Gynecologist,  R Stuart Fowler, M.D. discovered the underlying etiology. There proved to be two types. The most common etiology is altered vaginal microflora where the vaginal secretions turn from a neutral to an irritant. Dr. Fowler created the designation, Altered Flora Vulvodynia, AVF. The second much less common etiology arises from irritants in common hygienic products, designated External Irritant Vulvodynia or EIV. This resolves with the change in products that  get in contact with the vulva. It took years for Dr. Fowler to develop a way to correct the underlying vaginal microflora of women with AFV. It proved difficult because each woman requires an individualized approach. Although it’s one approach that fits all, it’s not one treatment fits all. Now Dr. Fowler has 42 protocols for women with Altered Flora Vulvodynia. Each woman goes into the algorithm based on her Hormone Profile (HP) and results of the VFA Test. The VFA test is a quantitative analysis of the constituents of the vagina. During treatment, this test also provides objective evidence of how close the flora is approaching normal. This treatment has proved a success in thousands of women. Unlike the dozens of “bandaid” therapy available for vulvodynia patients, the Fowler Gyn International approach provides a cure for both underlying etiologies of vulvodynia.

There is trick to getting Vulvodynia to totally resolve. One must have a treatment formula that will allow the vulvar skin, particularity located in the vestibule, to totally turn over several times under perfect non-irritated conditions. It seems all gynecologists in the world have been taught and believe, except for the experts at FGI, that vulvodynia is a condition of the vulvar skin and nerves. In truth, that’s secondary to the real etiology. But the vulvar skin, especially the vestibule is where the pain emanates from. Treating the skin and/or the nerves is only bandaid therapy covering over where the stimulus acts. However, to have an effective treatment, it must protect the vulvar skin from irritants until the skin has turned over 5-6 times. In the forth thru sixth time when the skin turns over, the cells lying next to the nerves are no longer irritated and no longer stimulate the nerves.

The vulvar/vestibular skin is constantly turning over. The newly forming cells start at the bottom of the skin known as the basement membrane and gradually push their way to the top layer as they maturate. When they reach the top, they detach and break away to join the vaginal secretions, making room for newer cells growing up from below. It takes roughly one month for new cells to get all the way to the top layer, meaning the vestibular skin you have now will be totally replaced in 4 weeks!

The turnover or shedding of maturated cells provides vaginal secretions with a high nutrient content for lactobacilli. The turnover varies from a few in number to a larger number of cells over a given time frame. This exposes more or less immature cells to external/internal stimulants. This is why as FGI treatment proceeds, symptomatically it is common to have a few good days followed by some bad days, then a good week or two followed by a few bad weeks and so forth. The more new cells exposed to irritants, the more sensitive the vestibule feels. After approximately 4-6 turnovers, the sensitized skin cells are fully replaced by non-sensitized cells which no longer stimulate the nerves and then the symptoms finally resolve for good, until another “vaginal insult” occurs. However, the longer the vulvar skin does not get influenced by external irritants or vaginal insults, the more reserve the skin develops. After 1 year of being asymptomatic, the vulvar skin can withstand normal insults like exposure to harsh hair shampoo, saliva, perspiration, fragrance, vigorous intercourse, brief hormonal changes, etc. Once most FGI clients are out 3-5 years, they often nearly forget their horrible years with vulvodynia. Unfortunately, most women do get occasional extreme exposure to irritant or significant hormonal change which causes a relapse every 5-10 years or so. Fortunately, the experts at FGI know how to adjust their protocol based on VFA testing and the condition remits quite quickly again for years more symptom free living.

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.

I suffered for nearly 20 years with discharge, painful sensitivity and feelings of inadequacy because of my condition. Other gynecologists dismissed my symptoms.  It got to the point I couldn't even consider having sex with my husband. Finally, a new gynecologist recommended Dr. Fowler. He was the first physician to take my problem seriously, and to actually know what was wrong with me and have a solution! It took a minimum of 6 months to really start to feel better, but after 20 years of misery, what is 6 months? I actually started feeling like a regular woman. I could enjoy sex again. I didn't have to constantly change my underwear or wear pads all day because I wasn't wet and sticky. I didn't tear constantly. I didn't itch uncontrollably. By the time I'd been on Dr. Fowler's regimen for a year, I could hardly believe I'd spent so much of my life in such misery. I am still on his regimen years later because it works! I can't thank him enough for giving me quality of life again.  J. Tempe, AZ