Antidepressants and anticonvulsants
Treatments available from your doctor
Tricyclic antidepressant tablets
Pain that originates from nerve fibres is best treated with drugs that alter the way in which the nerve fibres send their impulses to the spinal cord and give the sensation of pain. The most experience to date in treating vulvodynia has been with the tricyclic antidepressants. These can be prescribed by your doctor in doses lower than those used to treat depression. The drugs are used because they alter the way in which the nerve fibres transmit the sensation of pain, not because the doctor thinks it’s all in your mind! Some women do gain some benefit from different types of creams and lotions applied to the vulval area which do act as soothing agents, but it is generally best to avoid all creams unless they have been prescribed by your doctor.
The drugs are given in tablet form, starting at a low dose and then increasing every few days until the pain subsides. The response to treatment is not overnight and may take several weeks. It is often necessary to continue with treatment for three to six months. Examples of tablets include amitriptyline, nortriptyline and dothiepin. Other antidepressants such as venlafaxine can also be tried.
The major drawback for some women on treatment is the side-effects; however, these usually settle within the first few weeks of treatment and are not usually exacerbated by increasing the dose. The commonest effect is that of tiredness which affects many women. If this occurs try taking the tablets before you go to bed. If this makes you sleepy in the morning and you have difficulty getting out of bed, try taking the dose slightly earlier, for example at teatime. Constipation, having a dry mouth and occasional blurred vision are other complaints whilst on treatment. If you are constipated try taking senna or psyllium/ispaghula husk which are weak bowel stimulants. You should tell your doctor if you are pregnant or have suffered liver and heart problems prior to treatment. Remember that treatment is only for a limited time and not forever! Take the medication at night time to minimise drowsiness.
An example of dosing the treatment with amitriptyline is given in the table below. The average dose is 60mg per day, however, many women will need to increase the dose beyond this sometimes up to 100mg per day.
Case
Helen complained of vulval pain for several years but was only recently diagnosed. She had the usual story of repeated thrush treatments for years with no help. She complained of constant vulval soreness and burning, which was often worse at night after a day’s work when she tended to focus on the pain. She was diagnosed with vulvodynia and given amitriptyline as a treatment together with avoidance of all creams and scented products on the vulva. She was advised to use aqueous cream on the vulva as a soap substitute. She took the amitriptyline at night as detailed in the table below.
Helen’s reaction to increased amitriptyline dosage over the course of ten days
| Day | Dose of amitriptyline | Helen’s comments |
|---|---|---|
| Day 1 | 10mg per day | Pain present. |
| Day 2 | 10mg per day | No difference in pain. Dry mouth today. |
| Day 3 | 10mg per day | No difference in pain. Dry mouth today. Tired in the morning. |
| Day 4 | 20mg per day | Pain present. Still tired. |
| Day 5 | 20mg per day | Pain present. Dry mouth better. |
| Day 6 | 20mg per day | Pain still present! |
| Day 7 | 30mg per day | Dosage increase. Tiredness better. |
| Day 8 | 30mg per day | Possible improvement. |
| Day 9 | 30mg per day | Better! Pain reduced. |
| Day 10 | 30mg per day | Pain much better. Continue at this dosage. Just slight tiredness. |
Helen continued with the dosage and her pain was manageable. Side-effects are commonly reported with these drugs but they should not last more than a week or two. She supplemented the drug treatment with acupuncture which she found great for relaxation and vulval massage. It is important to know this as many women do not give the treatment a proper chance to work! There are other antidepressants available which you might want to discuss with your doctor.
Anticonvulsant tablets
Gabapentin is a drug which has long been established in chronic pain management as an effective way of curing pain. It consisits of tablets taken by mouth and works well for nerve-related pain. The tablets are prescribed for a number of conditions affecting the central nervous system and they influence pain at the level of the spinal cord.
Pregabalin is a new drug which has been released. It is very similar to gabapentin; however, it is reported to have fewer side-effects and is possibly more effective. The dosages of this drug are different and you will need to discuss these with your doctor. There are other drugs prescribed for chronic pain such as venlafaxine. These should be discussed with your doctor.
Drugs are only one part of a strategy for vulval pain. You should consider other treatments in conjunction with the tablets.
Research
Discussion of one particular study examining the use of amitriptyline to treat women with unprovoked vulvodynia can be found on our Published research page. For further or more recent research, visit the PubMed database, which allows you to search for studies online.