Vulvodynia, or chronic vulvar pain, which often is accompanied by dyspareunia, is quite prevalent and difficult to treat effectively. Neuropathic pain typically is described, and findings that sensitization to pain is increased at sites removed from the vulva suggest that systemic treatment for nerve hypersensitivity might prove helpful. Today antidepressants, especially tricyclic antidepressants (TCAs) such as amitriptyline, are commonly used in low dosage to treat vulvodynia. This retrospective study included 271 affected women, 209 of whom were initially treated with a TCA. Amitriptyline was administered to 183 women, while smaller numbers received desipramine or other TCAs. A total of 162 women, including 122 started on a TCA, were followed up for a median time of 3.2 months. The typical starting TCA dose was 25 mg each night (or 10 mg for elderly patients), and the maximum nightly dose was 225 mg. Patients rated their pain on a 0-to-10 scale.
Localized pain was somewhat more frequent than generalized vulvar pain in these women, whose average age was 37 years and who had experienced pain for nearly 5 years on average. During a median follow-up of 3.2 months, 59% of women who had taken a TCA improved by more than 50%, compared with 38% of those not taking a TCA at follow-up; the odds ratio (OR) was 2.35, with a 95% confidence interval (CI) of 1.23–4.42. Multivariate analysis showed that taking a TCA at the first follow-up assessment correlated strongly with improvement (OR, 4.23; 95% CI, 1.98–9.01). Among the factors not associated with the outcome were age, severity of pain, localized versus generalized vulvar pain, duration of untreated pain, age at menarche, oral contraceptive use, and the number of previous pregnancies. A repeat analysis limited to women taking amitriptyline yielded similar results. Of 51 women not taking any antidepressant or anticonvulsant drug when followed up, one-third reported improvement.
Most women with vulvodynia who take TCAs in general, or amitriptyline in particular, tolerate the medication and are likelier than other affected women to report at least 50% improvement at follow-up. Randomized controlled trials comparing TCAs with other treatments are needed.
Department of Family Medicine, University of Michigan, Ann Arbor; University of Michigan Medical School, University of Michigan, Ann Arbor; and Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
J Lower Genital Tract Disease 2006;10:245–251