Fowler Gyn International

The Experts in Vaginal Health Care

Paradise Valley
Medical Plaza

5410 N. Scottsdale Rd

Suite B-200

Paradise Valley, AZ 85253



Call (480) 420-4001

Diagnostics: Altered Vaginal Micro-Flora & the VFA Test

Dr. Fowler has an on-site CLIA certified lab know as Fowler Gyn International Laboratory. For in-office clients, results are reported to clients within 10 minutes from which, in part, their individualized treatment protocol is formulated.


The Vaginal Fluid Analysis (VFA) Test is used to evaluate the characteristics and quantity of the vaginal constituents. The analysis can determine if your vaginal micro-flora is one of the normal healthy patterns or one of the abnormal “altered vaginal micro-flora patterns.” Secretions associated with abnormal patterns are believed to flow down and bathe the tissues at the vaginal opening where they act as irritants causing variable symptoms including discharge, odor, itching, burning, sense of urinary urgency and frequency depending on the innate sensitivity of a particular woman’s tissues AND even the propensity for recurrent bladder infections in some women. Vaginal treatment formulated to restore vaginal health and correct the micro-flora pattern is the signature of the FGI approach. The VFA Test helps determine which medications to include in the vaginal rejuvenate therapy to be most effective.

The Normal Vaginal Micro-flora

The vagina has a normal micro-flora ecosystem consisting of 30+ co-existing strains of bacteria at any one time. Normally, the “good” bacteria known as lactobacilli predominate and are numerous enough to coat the entire vaginal mucosal surfaces forming a protective barrier. Lactobacilli make certain chemicals that provide additional defense against other organisms. These include lactic acid, hydrogen peroxide, and bacteriocins. Lactobacilli make lactic acid by using the glycogen contained in the normal vaginal lining cells. The lining cells require estrogen to make glycogen. The low pH caused by the lactic acid in conjunction with the hydrogen peroxide and bacteriocins secreted by lactobacilli, suppress the other “bad” bacteria normally present in the vagina to keep them at low concentration levels where they usually don’t cause harm. Problems occur when a shift in bacteria milieu occurs and the “bad” strain proliferate and dominate the “good” strains. 

Altered Vaginal Micro-flora Patterns

Problems arise when the lactobacilli do not thrive and the 30+ other “bad” bacteria strains proliferate and dominate the micro-flora.  This results in one of several “altered vaginal micro-flora patterns.” The secretions from the altered vaginal micro-flora bathe the vaginal walls all the way down including the tissues at the vaginal opening.  In 2007, Dr. Fowler published a landmark study which expanded the known spectrum of altered vaginal flora patterns. Up until then, the medical literature commonly referred to ‘Vaginitis” as consisting of 4 types. Dr. Fowler proposed a new Vaginitis Classification System that expands the types of vaginitis to ten types. Reference: Fowler, R.S. Expansion of altered vaginal flora states in vaginitis. J Reprod Med. 2007 Feb;52(2):93-99. 

Symptoms Associated with Altered Vaginal Micro-flora Pattern

The “bad” bacteria that predominate in these patterns consist of a host of aerobic (oxygen loving), anaerobic (oxygen poor)  and facultative anaerobic organisms (capable of cellular respiration in both oxygen-rich and oxygen-poor environments). These include E. Coli, Klebsiella pneumonia, Enterococcus species, Group D streptococcus, Group B streptoccocus, Gardnerella vaginalis, Bacteroides species, Peptostreptococcus species, Mycoplasma species, and many others. The vaginal secretions that result from the altered flora flow down and bathe the  tissues surrounding the vaginal opening causing variable symptoms including discharge, odor, irritation, itching, burning, sense of urinary frequency and urgency depending on the innate sensitivity of a particular woman’s tissues AND even the propensity for recurrent bladder infections in some women. Altered vaginal micro-flora patterns are in and of themselves relatively harmless; but the symptoms that can occur in association with their presence can range from annoying to agonizing and lifestyle altering. They are not infectious or contagious. They represent a shift in bacterial milieu. About now you are probably wondering how this happened. There are a number of causes to which FGI calls “vaginal insults” that disrupt the micro-flora health of the vagina. The full list of vaginal insults will be provided to you in your personalized treatment protocol so you can avoid them in the future!

Detection and Diagnosis of Altered Vaginal Micro-Flora Patterns

The majority of healthcare providers are unaware of the existence of altered vaginal micro-flora states. To begin with, very few gynecologists specialize in vaginal conditions. Plus detecting altered vaginal micro-flora patterns requires extra time, training, an advance set of skills and expensive microscopic equipment. The standard evaluation by healthcare providers still consists of evaluating “vaginal wet preps” looking for yeast, bacterial vaginosis aka BV, trichomonas, or atrophic vaginitis, and preforming a vaginal culture. Commonly, the culture will grow out one of the 30+ “bad” bacterial strains such as Beta Strep, E. Coli, Klebsiella pneumonia, Group D streptococcus, Staph Epidermidis, etc. When antibiotics are prescribed for these bacteria, a transient response may occur then the sym[ptoms will return. But these organisms are not the cause of the vaginal problem; just a reflection of the underlying problem. At Fowler Gyn International, the approach is to fix the underlying vaginal problem and restore the normal flora to the vagina rather than providing a band-aide for the symptoms. If you are ready for expert help, click Potential Client-Sign Me Up.

The underlying cause of these perplexing symptom/s is that the vaginal mucosa is not in the best of health and the micro-flora has shifted to one of several types of altered vaginal micro-flora patterns. The FGI treatment approach uses vaginal rejuvenate therapy to change the altered vaginal micro- flora patterns towards one of the normal patterns. For FGI clients, the vaginal rejuvenate therapy can be monitored to see how effectively the particular treatment is moving the vaginal constituents towards a normal micro-flora pattern. This approach has been developed and used by Dr. Fowler with success for the treatment of thousands of women. Are you ready for expert help?

The VFA Test

The new revolutionary VFA Test developed by Dr. R. Stuart Fowler, formerly of the Mayo Clinic from 1992 to 2013, provides the quantitative analysis of the vaginal fluid constituents providing much more information than conventional “wet preps.” This represents a breakthrough in understanding alterations of vaginal micro-flora so that treatment can be directed towards correcting it. The parameters of the test have been published by Dr. R. Stuart Fowler in the respected peer- reviewed Journal of Lower Genital Tract Disease, October Issue 2012;16(4):437-441. Since there seems to be no incentive in sight for gynecologists to learn advanced microscopic skill, invest in expensive phase-contrast microscopic equipment, and spend the extra time analyzing slides, it is not likely for the VFA Test to be routinely offered in gynecology offices anytime soon.

The VFA Test reveals the following vaginal constituents: 1) the percentage of squamous cells in each degree of maturation, 2) the relative concentration of squamous cells present, 3) the presence and concentration of lactobacilli- the “good” bacteria, and the percentage of lactobacilli present in normal vs. abnormal forms, 4) the presence, type, and concentration of any white blood cells, 5) the relative concentration of non-lactobacilli bacteria, the “bad” bacteria, and 6) the presence and relative concentration of yeast in terms of either blastospores and/or pseudohyphae present.

The Details and Significance 

1. The maturation stage of your vaginal squamous cells

The squamous cells are the normal vaginal mucosal cells lining the vagina and cervix. Some women are fearful when they hear the word “squamous cell” because many skin cancers start from this cell line and are called “squamous cell cancers.” However, squamous cells in and of themselves are a normal and healthy constituent of the vagina. There are four layers of squamous cells. Those being newly formed at the basement layer of the vaginal mucosa are called Basal Cells. As the maturation process begins, these move upward and become Parabasal cells. With further maturation they migrate upward again and become Intermediate Cells then when they are fully mature they become  Fully Maturated cells which are now located on the surface of the vaginal mucosa and are loaded with glycogen which provides nutrient for the “good” bacterial in the vagina known as lactobacilli. The VFA test reveals the percentage of cells which are fully maturated cells, intermediate cells, parabasal or basal cells. If the majority of cells are not fully maturated, this suggests that 1) the vaginal mucosa is not getting enough nutrient or 2) the vaginal mucosa receptors are not responding to the natural nutrients in the circulation or to the type, frequency or dosage being supplemented, and/or 3) there is a process going on increasing the exfoliation of cells prematurely. The most common senarios are the former two dealing with relative vaginal mucosal nutrient deficiency. Imparative in successful treatment is to supply these nutrients to the vagina.

2. The concentration of squamous cells present.

This parameter reflects how fast the squamous cells are being exfoliated from the vaginal mucosal surface. This represents a second measure of proper mucosal cell maturation AND the degree of stimulus or irritation present on the vaginal mucosa causing possible premature exfoliation of the vaginal lining squamous cells. In this case, consideration for treatment with certain types of vaginal products to reduce vaginal irritation or inflammation can be necessary.

3. The presence and concentration of lactobacilli.

These are the “good” bacteria of the vaginal. In reproductive age women they are present in concentrations that literally coat the entire vaginal mucosal surface. Between the barrier effect and the secretion of hydrogen peroxide and bacteriocins, lactobacilli prohibit the proliferation of other bacteria and yeast in the vagina.  If the lactobacilli counts are low, in certain women who have the propensity, there is risk of developing altered vaginal micro-flora patterns where the other 30+ bacterial which are normally in the vagina at very low concentrations, proliferate and take over. In this setting, vaginal therapy directed at correcting the nutrient supply for lactobacilli is warranted. 

4. The type and concentration of white blood cells (wbc’s).

The types of wbc’s fall into two categories: 1. Agranulocytes which consist of lymphocytes, monocytes, and macrophages. 2. Granulocytes which consist of neutrophils that subdivided into toxic vs. non-toxic appearing, basophils and eosinophils.  Over eighty percent of healthy vaginal flora patterns show the absence of white cells. Fourteen percent of women with wbc’s in their vaginal fluids, have predominately lymphocytes in relatively low concentrations and good concentrations of lactobacilli, the “healthy” vaginal bacteria. All other “normal women” i.e. without vaginal symptoms have no wbc’s present. If you are found to have wbc’s present in your vaginal fluids, the type and concentration determine whether you have Inflammatory Vaginitis (IV) or Desquamative Inflammatory Vaginitis (DIV). The wbc’s last for 3-4 days and then decompose releasing their contents that can irritate the vaginal mucosa. This situation calls for treatment directed to reduce vaginal inflammation. It tends to require longer treatment for effect when the wbc’s are Granulocytes rather than Agranulocytes.

5. The relative concentration of non-lactobacilli bacteria present.

Excess non-lactobacilli bacteria manifest in five patterns: 1) bacteria  clumping onto the squamous cells obscuring their borders, known as clue cells, 2) bacterial speckling the background fluid which is normally clear, 3) bacterial causing the background fluid to appear hazy and 4) bacterial so concentrated that it is "shoulder to shoulder" and appear to vibrate with brownian motion, and 5) backgroung fluids have curved rod like organisms known as Mobiluncus that apperar to wiggle. When lactobacillus counts are low, these 30+ other bacteria that are normally in the vagina at low concentrations proliferate and can become the dominant strains. If a vaginal bacterial culture is done in this setting, it will likely grow out one of the "bad" bacteria like Beta strep, Enterococcus, E. coli, Klebsiella, Gardnerella Vaginalis or some other bacteria that can be normally found in the vagina. This simply reflects what specie of bacteria has become dominate in the vagina at that time. In does not represent an infection (except in the rare cases of Staph associated wth Toxic Shock).  If antibiotics are prescribed, only a transient response will likely occur and it actually perpetuates the underlying problem by causing further damage to the flora. Sound familiar? The treatment really needed is to correct the underlying reason for the shift in altered vaginal micro-flora.

6. The presence or absence of yeast.

When lactobacilli counts are low and the other 30+ bacteria proliferate it does set up a micro-environment culture media that allows yeast to grow more readily. Also when the vaginal mucosa is only partially estrogenized, it’s a better culture media for yeast species to thrive. To solve the recurrent yeast problem, the underlying condition of the vagina reflected by the above parameters evaluated in the VFA test need to be optimized. If yeast is identified then it is helpful to identify the strain of the yeast to determine the length and type of anti-yeast treatment required while ongoing therapy is directed to the vaginal mucosa. The “standard” vaginal yeast strain is called Candida albicans. This responds to most antifungals. The non-albican strains include C. galbrata, C. tropicalis, C. krusei, C. parapsilosis, C. pseudotropicalis/ kefyr, etc. do not respond to the standard antifungals known as imidazoles but require triazoles. The strain identification is not included in the VFA Test therefore if the VHF Test shows yeast then proceeding with a Yeast Strain Test might be recommended. Treating the yeast alone will only give a transient response at best. Treatment needs to be directed at fixing the underlying vaginal mucosal condition.

So there you have it…that’s the basis of the VFA Test. The actual testing requires collecting a "known amount" of vaginal secretion, adding chemicals and stains to the specimens to expose certain features, injection of the resulting fluids into micro-plastic grids and viewing the slides under a phase-contrast microscope with high power objectives. This is by no means standard equipment for a gynecologist’s office from the standpoint of cost, maintenance, or physician training. FGI makes this advanced diagnostic technique to you! The question is…are you ready for expert help?

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