I give nortriptyline as a first-line agent to women who have both provoked and unprovoked pain. In general, it has fewer anticholinergic side effects than amitriptyline and is generic—it also is taken once daily. For women who have unprovoked pain, I use gabapentin as a second-line agent.
Dr. Lonky: Are any other antidepressants useful in the treatment of vulvar pain?
Dr. Haefner: I sometimes give duloxetine [Cymbalta], starting with an oral daily dose of 30 mg for 1 week. If symptoms persist, I increase the daily dose to a total of 60 mg. (If the patient is depressed, I have her take 30 mg twice daily; if she isn’t depressed, I have her take the full dose of 60 mg in the morning.) I also occasionally utilize venlafaxine [Effexor XR] for pain control, starting with an oral morning dose of 37.5 mg. This dose can be increased to 75 mg/day.
Dr. Edwards: Literature on venlafaxine for neuropathic pain suggests maximal effects at doses of 150 to 225 mg of the extended release formulation, which is often well tolerated. I start patients on 37.5 mg and increase weekly until I reach the 150-mg threshold.12
Are anticonvulsants effective pain relievers?
Dr. Lonky: How effective are oral anticonvulsants such as gabapentin [Neurontin]?
Dr. Haefner: Gabapentin has been used to treat chronic pain conditions. The drug is available in 100-mg, 300-mg, 400-mg, 600-mg, and 800-mg tablets. It is typically initiated at an oral dose of 300 mg daily for 3 days. The dosage is then increased to 300 mg twice daily for 3 days and, finally, to 300 mg three times daily. If necessary, it can gradually be increased to a total of 3,600 mg daily (usually divided into three doses). No more than 1,200 mg should be administered in a single dose. Side effects include somnolence, mental changes, dizziness, and weight gain.
Dr. Edwards: After tricyclic medications, I find gabapentin to be the most beneficial and easily tolerated agent. I give it to patients who have contraindications to tricyclics and who lack a strong component of depression.
Dr. Gunter: Retrospective reviews have found gabapentin to produce improvement of 80% or more in pain scores for 64% to 82% of women who have generalized unprovoked vulvodynia. And a small open-label, prospective trial of lamotrigine [Lamictal] found that it produced statistically significant improvement for generalized vulvodynia.13-15
Dr. Lonky: What do you know about the use of the anticonvulsants pregabalin [Lyrica] and topiramate [Topamax] to treat vulvar pain syndromes?
Dr. Gunter: Pregabalin was reported to reduce symptoms by 80% for generalized, unprovoked vulvodynia in one case report.16
Dr. Edwards: I find that pregabalin is less well tolerated (and more expensive) than gabapentin, so it is one of the last agents I prescribe. I reported a small, uncontrolled series of patients who were treated with pregabalin. Of those who tolerated the drug, two thirds of the women improved by approximately 62%, as judged by a visual analog scale.
Dr. Haefner: Pregabalin is a relatively new addition to the armamentarium. I give 50 mg orally for 4 days to start. If symptoms persist, I increase the dose to 50 mg twice a day for 4 days. If symptoms still persist, I up the dose again to 50 mg three times daily and gradually increase it to 100 mg three times daily, if necessary. Some reports describe a dose as high as 300 mg twice daily (maximum).
As for topiramate, I have been using it much more frequently for vulvodynia and noticing many fewer side effects than with gabapentin.
How do you decide which therapies to use? And in what order should
you offer them?
you offer them?
A patient who has a short duration of pain often responds to topical medications. In contrast, someone who has experienced pain for years is unlikely to get adequate relief from topical medications alone. These patients often require oral tricyclic antidepressants or anticonvulsants, or both. I often start these medications before deciding whether physical therapy is necessary. If the drugs do not provide adequate relief, then I refer the patient to physical therapy.
In some cases, I begin with physical therapy and add other treatments, if necessary. A patient who has localized vulvodynia who tightens her bulbocavernosus and levator ani muscles upon gentle touch may benefit from starting with physical therapy.
I reserve surgery—vestibulectomy—for the patient who has localized pain that has not responded to numerous treatments.
—Hope K. Haefner, MD
Does capsaicin interrupt the pain circuit?
Dr. Lonky: Capsaicin has been mentioned in the literature as a therapy for vulvar pain. Is it effective? How does it work?