Nortriptyline for Depression and Vulvodynia
To the Editor: There is an intimate and complex relationship between depression and pain, and patients suffering from depression are at a greater risk for developing various chronic pain syndromes than individuals without depression (1). Vulvodynia, a neuropathic pain syndrome that affects the vulva and external genitalia, is often associated with depression (2, 3). It has been suggested that the condition may respond favorably to antidepressant treatment (2), but to date we are aware of no specific case reports, much less controlled studies, on the topic. We recently cared for a patient with major depression and vulvodynia who responded dramatically to treatment with a tricyclic antidepressant.
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.
To our knowledge, there has been only a single positive open trial of antidepressants for chronic pelvic pain (4), but vulvodynia is felt to be a distinct syndrome (3). Its dysesthetic character, lack of associated tissue pathology, and strong association with depression are reminiscent of other neuropathic syndromes, such as facial neuralgia and glossodynia. Our patient responded dramatically to treatment with a tricyclic antidepressant but not to a variety of other agents. (Spontaneous remission is a possibility but seems unlikely after 2 years of unremitting symptoms.) It is unclear whether this was because of her better response to nortriptyline or to the inherent superior efficacy of tricyclics in the treatment of neuropathic pain (5). Further studies will be necessary to establish the efficacy of antidepressants in general, and tricyclics in particular, in the treatment of vulvodynia.
1. Von Korff M, LeResche L, Dworkin SF: First onset of common pain symptoms: a prospective study of depression as a risk factor. Pain 1993; 55:251-258Crossref, Medline, Google Scholar
2. Ridley CM: Vulvodynia: theory and management. Dermatol Clin 1998; 16:775-778, xiiiCrossref, Medline, Google Scholar
3. Bodden-Heidrich R, Kuppers V, Beckmann MW, Ozornek MH, Rechenberger I, Bender HG: Psychosomatic aspects of vulvodynia: comparison with the chronic pelvic pain syndrome. J Reprod Med 1999; 44:411-416Medline, Google Scholar
4. Walker EA, Roy-Byrne PP, Katon WJ, Jemelka R: An open trial of nortriptyline in women with chronic pelvic pain. Int J Psychiatry Med 1991; 21:245-252Crossref, Medline, Google Scholar
5. Lynch ME: Antidepressants as analgesics: a review of randomized controlled trials. J Psychiatry Neurosci 2001; 26:30-36Medline, Google Scholar
