Ms. A, a 78-year-old woman, had developed prolonged major depression after a herpes zoster infection. The infection had involved the left T10 or T11 dermatome and had remitted with no residual post-therapeutic neuralgia; her depression had responded partially to trials of 40 mg/day of paroxetine, 225 mg/day of venlafaxine, 15 mg/day of mirtazapine, and 20 mg/day of citalopram. She had no past psychiatric history, and her past medical history was positive only for hypertension. During the same time that the depression developed, she began to complain of a severe burning sensation around her vaginal introitus with no clear exacerbating or relieving factors. She was not sexually active, and there was no history of sexual trauma. A pelvic examination was remarkable only for atrophic vaginitis; there was minimal to no inflammation and no discharge.
Over the subsequent 2 years, Ms. A was treated empirically with estrogen cream, as well as a variety of topical and vaginal antifungal creams, topical hydrocortisone cream, and, ultimately, viscous lidocaine and oral codeine. Neither these treatments nor the antidepressants proved effective for pain control. Ultimately, it was decided to change her antidepressant to a tricyclic agent to improve the vaginal pain as well as the depression. Ms. A began taking nortriptyline, 25 mg at bedtime, which yielded a serum level of 92 ng/ml. Nortriptyline proved quite effective for her depression and, fortuitously, also resulted in complete resolution of the vaginal pain.