The Essential Guide to Tricyclic Antidepressants (TCAs) for Vulvodynia

If you have been trying to find a solution for your vulvar pain with no luck then antidepressants might be an effective treatment for your pain.

Antidepressants are the main pain-blocking medications and often first-line agents prescribed by the medical community especially for generalized vulvodynia.

Additionally, recent reports have found that antidepressants can also be helpful in the treatment of vulvar vestibulitis (also called vestibulodynia).

Tricyclic Antidepressants (TCAs) are an older type of antidepressant created in the late 1950s. Their names derive from their chemical structure (which contains three rings of atoms).

TCAs are mainly used to treat depression, which from the chemical point of view is caused by an abnormal communication between the brain’s cells (known as neurons). This miscommunication is caused by an imbalance of chemicals called neurotransmitters (serotonin and norepinephrine).

TCAs alter the function of brain regions that are controlled by these neurotransmitters by increasing their levels. Thanks to this process, there are more neurotransmitters accessible in the body and brain, which elevates a person’s mood.

Serotonin and norepinephrine are neurotransmitters that are also responsible for modulating pain sensations.

Because of it, TCAs also have off-label use as a pain reliever to treat chronic pain. The medication modifies the way in which nerves send impulses to the spinal cord to produce the pain.

TCAs work best for burning, stabbing or shooting pain that originates from malfunction of the nerve due to, for example, injury, surgery or diseases, called neuropathic pain.

If you have any suspicion or got a diagnosis that your vulvodynia (especially generalized vulvodynia or vulvar vestibulitis) is linked to neuropathic pain, then your pain might be altered with TCAs.

The most popular TCAs used in modulating vulvar pain are:

Usually, TCAs for vulvodynia are administered in tablet form, however topical cream is also used.

Oral doses of antidepressants like amitriptyline, start with a low dose (to avoid side effects) of as little as 10 mg/day. They are usually increased by 10mg-to-25mg each week or two till the pain subsides. The average dose of amitriptyline, for example, is 60mg per day (however, many need to increase the dose up to 100mg per day to see results). The maximum dose generally should not exceed 150 mg daily.

TCAs don’t work overnight. Response to treatment can take up to several weeks. Often it is necessary to continue with treatment for three to six months to see results.

However, usually, only moderate pain relief is experienced.

If you suffer from localized pain or vaginismus you might find a combination of topical amitriptyline 2% and baclofen 2% in a water washable base helpful. Doctors recommend applying 0.5ml of the compound to the affected area one to three times per day.

Some doctors also use topical doxepin 5% cream for vulvar pain. They recommend to apply it to affected skin daily, gradually increasing the number of daily applications to as many as four times.

TCAs can cause a wide range of unpleasant side effects.

A topical version of the TCAs for vulvodynia might produce fewer side-effects because of its lower systematic absorption (which means that your body absorbs less of it than if you take it orally).

Side effects include:

TCAs interact with:

Antidepressants, in general, can produce withdrawal symptoms, also known as discontinuation syndrome. You can minimize these symptoms by gradually reducing the dosage (from 10 to 25mg every few days if possible or slower) over a period of weeks to months.

Remember that you can also suffer from withdrawal symptoms if you miss a few doses!

Withdrawal symptoms might include: