Amitriptyline is a tricyclic antidepressant normally prescribed in the treatment of various disorders of the mental and neurological spheres, which, generally employed at lower dosages, can have an important effect on neuropathic pain. “It is precisely because of this action that the drug can be used in cases of vulvodinia, a condition that is linked to hypersensitivity of the nerves of the vulva,” explains Dr. Elisabetta Colonese, a gynecologist and expert in Couple’s Infertility Therapy in Milan. 
When it can be useful
“Amitriptyline is considered one of the most widely used drugs in centers specializing in vulvar pain,” the gynecologist continues. “It is prescribed if generalized vulvodinia, provoked vestibolodinia, or vulvar pain associated with pelvic floor hypertone is diagnosed. In any case, a thorough history before prescription remains essential. “It is necessary to assess whether the vulvar pain has lasted for at least three months, whether there is no active infection or dermatological pathology present,” the gynecologist continues.
“During the visit, it is important that the practitioner also assess whether the pain has neuropathic features, i.e., presents with burning, shaking, hypersensitivity to touch-this is what the swab test is for, for example-and whether any prescribed local treatments have not proven sufficient to reduce the symptomatology; before starting amitriptyline therapy, in essence, a full clinical evaluation is imperative, to rule out other causes of vulvar pain.” Further confirmation of how consultation and examination represent a key moment in the diagnosis and treatment of a complex condition such as vulvodinia
Prescription and dosages
Since it is a drug, the prescription of amitriptyline can only be made by a physician. “It can be a gynecologist who has a good knowledge of the pathology, but also a neurologist, a specialist in pain therapy, and the general practitioner on specialist indication,” Dr. Colonese continues. Antidepressants are generally prescribed for the treatment of vulvodinia in lower doses than those used for depression. “Generally, we start with low dosages, 5-10 mg, to be taken in the evening and then gradually go up to 20-50 mg, if deemed necessary,” the gynecologist points out. However, it should always be kept in mind that amitriptyline is a drug and as such should always be taken under medical supervision: increasing or decreasing daily doses are the sole responsibility of the specialist, drastically banning do-it-yourself
Results and side effects
“The first improvements in pain symptoms are noticed after 2-4 weeks of regular intake of the drug, but full effects only occur after 6-8 weeks,” Dr. Colonese points out. As with any other medication, possible side effects must be considered in the case of amitriptyline. “The most frequent are drowsiness, dry mouth, constipation and increased appetite: they should be reported promptly to the specialist so that he or she can proceed to the appropriate evaluations,” concludes the gynecologist
Therapies that can be combined with amitriptyline
The complexity of the disease in the case of vulvodinia, which is linked to the multifactorial nature of the causes, means that treatment is often articulated on different fronts ranging from physical therapies to psychotherapy interventions, from the use of topical products to the use of different categories of drugs. “Thus, the prescription of amitriptyline does not exclude the use of fisioterapia del pavimento pelvico, which, on the contrary, is of great advantage when vulvodinia is associated with a condition of muscle hypertone, that is, the constant contraction of the muscles that make up the pelvic floor,” Dr. Colonese points out. “Topical creams and other specific medications for neuropathic pain such as gabapentin may also be prescribed along with amitriptyline.”