Vulvodynia talk with doctors.

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HI all this is something I've had for a long time but there just might be something in here that strikes a cord. (Sandi I noticed one asked about the planquinel) Sorry the link no longer exists.

VULVODYNIA RESPONSES FROM SEVERAL DOCTORS IN A CONVERSATION. * * * * * VULVODYNIA ------------------------------------- 1) imidazoles 2) amitriptyline 3) calcium citrate, low oxalate diet 4) The Vulvar Pain Foundation 5) isoprenosine 6) doxepin 7) biofeedback 8) SSRIs 9) capsaicin 10) Aquanil HC 11) CAM 12) zonolon 13) dibucaine 1. ------------I have been caring for a 40 year old woman with dysplastic nevi for the past 6 or 7 years - one year ago she developed vulvar inflammation which has clinically cleared but has left her with vulvodynia which is severe enough to completely disrupt her life She has been seen by some of the best gynecologists in New York and they really have little to offer - she and I would be very happy to receive some clinical suggestions.

She has been treated with Zovirax orally and topically, steroids topically, zinc oxide paste, silvadene,local anaesthetics, and topical antibacterials. A friend recently told here to use Crisco which helps a bit but the problem persists. What are the therapeutic pearls which I have not yet learned?

Irwin Freedberg

-------------- It is possible that the original inflammation was due to yeast, and that now she has the chronic low grade yeast described by Marilyn Mackay (?sp) which causes mild tender erythema of the vault. She treats with long term, months, of p.o. azoles. If she needs a lubricant the word in the community is Astroglide. Diane Thaler ----------- The literature on vulvodynia is confusing, the nomenclature is ambiguous and the data is often sparse. One framework in which to approach vulvodynia is to try to differentiate it into vulvar vestibulitis, essential vulvodynia and cyclic vulvovaginitis. Topical treatment, though we all use it as first-line therapy, often is not sufficient in controlling the symptoms of any of these subtypes. Essential vulvodynia often responds to tricyclic anti-depressants such as amitriptyline. If you choose to use a tricyclic anti-depressant, to aid in compliance you might consider emphasizing its effect in altering the sensation of pain rather than its effect on depression. Concurrent emotional and psychological support can be invaluable. The use of oral calcium citrate along with a low oxalate diet is controversial but may help some women; the "natural" and nutritional approach is certainly attractive to many people. Even if these dietary measures are not helpful, they probably will not hurt your patient and may indeed assist in buying some time for other modalities to be efficacious. If finances permit, you might also consider referral to one of the nationally known vulvar specialists outside of NYC, as patients with vulvodynia are often desperate. A support group can be beneficial. While I have limited experience with "The Vulvar Pain Foundation", one patient of mine was grateful that I alerted her to them, as she no longer feels so isolated and embarrassed. The Vulvar Pain Foundation also publishes a newsletter. The address that I have is: The Vulvar Pain Foundation Post Office Drawer 177 Graham, NC 27253 Telephone, Tuesdays and Thursdays ; Fax Good luck with your patient---vulvodynia is a complex disorder that is frequently frustrating to both practitioner and patient. Some recent references: Dysesthetic ("Essential") Vulvodynia Treatment with Amitriptyline. McKay M. Jour Reprod Medicine 1993;38:9-13. Vulvar Pain Syndrome: A review. CME Review Article. Baggish MS, Miklos JR. Obstet and Gyn Survey 1995;50:618-27. Diagnosis and Treatment of Vulvodynia. Paavonen J. ls of Medicine 1995;27:175-81.

L. Comite MD

------------------- Here's one to try: sen CS and Weismann K, Isoprenosine improves symptoms in young females with chronic vulvodynia, Acta Dermatovenereologica, 1996:76(5) 404. Ten patients with chronic vulvodynia were treated with 1g po TID for 12 weeks. 4 of 10 became asymptomatic, 2 showed marked reduction of symptoms, no effect on the other 4. No adverse reactions were seen.

Haines Ely

---------------- Amitriptyline or doxepin are the most helpful in my experience. I start with 25mg 2 to 3 hours before bedtime and then increase by 25mg increments at 1 to 2 week intervals as tolerated. The entire dose is given in the evening. Most women (and men with penile and scrotal pain) who will respond, do so at about 75mg per day. 60% of patients get enough relief to make life tolerable and about 40% will clear completely. Gae Rodke MD, a gynecologist in New York is doing some excellent work on biofeedback to allow pelvic floor relaxation. She is the best person in NYC for vulvodynia, I think. Her address is 146 Central park West, Suite 1G; tele # 496-9891.

Lynch ----------- What does pelvic floor relaxation have to do with vulvodynia for goodness sake!

Does this mean that women who do Kegel exercises (which I find suspect as well) will be at greater risk for vulvodynia? May we try oropharnx relaxation for glossodynia, or, do as Freud did and offer surgeries on the nose, removing bone and cartilage, as it is the organ most resembling the genitals, at least the male's?

Diane Thaler ----------- Re: the several posts questioning the rationale for the use of tricyclics and biofeedback for vulvodynia. First, definition and diagnosis. Before using the term vulvodynia it is, of course, necessary to rule out any recognizable (clinical or histological) disease such as LP, LS, candidiasis etc. Assumming that has been done, you are left with what (given today's level of knowledge, at least) is an idiopathic process. This idiopathic vulvar pain is then divided into two groups: those with visible (often punctate)vestibular redness (vestibulitis) and those with no visible change (essential vulvodynia). Second, is the process inflammatory? Biopsies from either vestibulitis (with redness) and from vulvodynia (without redness) reveal a few inflammatory cells (lymphocytes and plasma cells). However Moyal-Barracco et al note that redness of the type seen in vestibulitis occurs with equal frequency in a control population and Nylander Lundquist et al found about the same number of inflammatory cells in vulvar biopsies from control women. (I do not believe that either of these studies are as yet in press.) This suggests to me that inflammation is not a critical part of the condition. In any event, anti-inflammatory therapy does not work. Third, as is true with most idiopathic processes, treatment plans are arrived at empirically. Taking a leaf from the treatment of other chronic pain syndromes, tricyclics were tried. They worked. Published and presented reports indicate about a 60% response rate. It is interesting to speculate on why they might work. Since effectiveness, if it is to occur at all, begins more quickly, and at lower doses, than are required for the treatment of depression, the effect is probably via a different mechanism. That is, there may be a biochemical effect on neuropeptides that has nothing whatsoever to do with "psychologic" considerations. Fourth, tricyclics (and biofeedback) seem to me to represent a far safer approach to the treatment of pain than the laser and surgical options that are favored by many gynecologists. I have no problem with the use of other "reversible" medical forms of therapy but none of these has the established track record of tricyclics. Retin A and Zostrix, for instance have been tried and have failed to help. Fifth, I use tricyclics for men with penile and scrotal pain (as indicated earlier) as well as for lip, tongue, facial and scalp pain. They are equally (that is about 60%) effective in these conditions as well.

Lynch ----------- Agreed that tricyclics work for certain pain. I agree with the distaste for the gyn approach. What about the pelvic floor relaxation, though. Or is the biofeedback working some other way. Another interesting idea in terms of pain is the SSRIs increasing ones pain threshold-maybe these could be given along with/without the tricyclics. And seriously, I have never seen a patient of Elavil informed of its obesity side effect.

Diane Thaler

----------- SSRIs don't work for pain in post-herpetic neuralgia (according to Dr. of Toronto, a world authority on that subject.) Elavil is thought to work (when it works) by increasing the tone in the adrenergic descending spinothalamic tracts which INHIBIT ascending pain impulses, preventing permanent (or long-lasting) modification of pain perception at the level of the CNS. This is why I give Elavil on Day One to people with zoster - to prevent post-herpetic neuralgia. A little Elavil early on saves a lot of trouble later. By analogy with PHN, I would choose Elavil over SSRI for vulvodynia - and I would administer it early rather than saving it for a last resort when all else has failed. Having said all of that, I have had better CLINICAL results in burning mouth and burning vagina with SSRIs than with Elavil, perhaps because what I'm treating in these cases is not a chronic pain syndrome per se, but a manifestation of depression. I've now moved on from SSRIs to the RIMA class of MAOIs - notably Manerix - because of a better side effect profile and almost complete absence of effect on sexual function.

C. MD FRCPC ---------------------- The sexual dysfunction with SSRIs may be overcome with amantadine, in some reports. Also, there is an OTC antihistamine which also works, but I have blanked out on which one. Wellbutrin also is a good one for people experiencing this problem on Prozac and Zoloft.

Diane Thaler. ----------- Periactin is probably the antihistamine you were trying to think of - has been reported to counter SSRI-associated sexual dysfunction. KC MD FRCPC ----------------- How much will That cost? I can't even imagine the costs for this type of therapy near Park Avenue!

I. Rudolph, M.D., FACP ------------------------- In reply to Dr. Rudolph regarding the cost of biofeedback (for vulvodynia) in NYC, I'm sorry, I don't know. Gae Rodke and her co worker presented their work as part of a study and I don't know if the study is ongoing or not.

Lynch ----------- Two additional references on Vulvodynia Fitzpatricks's Journal of Clincial Dermatology Sept?Oct 1995 vol3 #5 pp9-12 Articles by Caroline S. Koblenzer, MD andLibby , MD Same Journal Jan/Feb 1994 pp37-38 Author Elaine T. Kaye, MD

Bill Liss -------- I might consider MRI of lower spine to r/o metastatic OR occult melanocytic disease or other disease, such as, degenerative osteoarthritis of spine with neural compression. Then, I would consider capsaicin, diluted in vehicle of your choice, with gradual increase in strength titrated to efficacy (as long as mucous membrane isn't involved).

Carrington, M.D. --------------------- I have long considered that some cases of vulvodynia...and related pain syndromes at the same segments...might be related to occult entrapment syndromes similar to meralgia paresthetica. I was a bit hesitant to suggest same in a public forum, but since Dr. Carrington brings up the subject, I think such an etiology merits some consideration. I might think of the situation in the same way as meralgia paresthetica, or even notalgia paresthetica. I am not sure how to prove it. I have been working with a very creative physiatrist in designing some tests to prove or disprove my theory. Certainly, Elavil is a very good agent in neuropathies of various types...I agree with Lynch, and I use a similar approach. At the risk of being pilloried, would any of you wonder if standard chiropractic manipulations of the lumbar and sacral segments be of any value? Is accupunture to be considered?

Elliot Puritz ----------- Is the vulvodynia chronic or intermittant. If you do try Elavil, please warn the patient about weight gain. It brings to mind a survey done several years ago. When women were asked would they rather have a happy marriage or lose 10 pounds, they chose the weight loss. This might apply. I assume that vestibul'itis" implies histological/clinical inflammation. Clinically I understand the diagnosis is based on minute erythematous dots in the vestibule, associated with pain with Q tip pressure. For the life of me I can't understand why this "itis", as opposed to other inflammatory dermatoses, is treated with tricyclics and surgical excision.

Where is the Plaquenil, the Dapsone, the ASA, the Doxycyline, and yes, the Accutane (as it is "glandular"). Dr. Fishers column in Cutis this month is about the perplexing problem of men who can't tolerate their pants. Elavil was not listed as therapies attempted, nor was surgical excision of their thighs (yet they'd do that for women)

Diane Thaler ----------- For topical Rx: 1. Topical doxepin is absorbed too much and ends up being sedating. It also occasionally behaves as a severe irritant. 2.. For local Rx of vulvar and perianal dermatoses I like Aquanil HC - lathered gently with a cotton ball or bare hand, then wiped off with a soft tissue. Not rinsing it leaves a thin soothing layer of it on raw tender skin. For daily cleansing plain Aquanil is great - less irritating than water when tested on diaper dermatitis.

Gene Sienkiewicz, M. D. -------------------- Gene, when I give acne patients samples of Aquanil, Cetaphil, SFC, and CAM lotion to try (along with Retin A), they always chose CAM. Have you tried the other soapless soaps? (CAM is made by Herald)

Diane Thaler ----------- Irwin, you might consider a consultation with a neurologist for a TCA, sometimes used in a variety of chronic pain syndromes.

Jay Barnett

---------- Have you tried Zonolon cream? I recently had a similar patient who was helped tremendously by this.

Jeff Marmelzat, M.D. ------------------ I know it is not a cure for her problem, but perhaps Nupercainal ointment might afford her some relief. It is a vaseline base and delivers 1% dibucaine, an amide type anesthetic like lidocaine. She can buy it without a prescription next to the Anusol and Preparation H type stuff.

E. Zabawski, DO, RPh ------------------ I had a patient with intractable vulvdynia respond to capsacian cream. It might be worth a try, however, you would first warn her of the initial burning sensation accompanying the substance P depletion. Nortryptiline might also be worth trying.

Rhett Drugge

http://matrix.usdavis.edu/rxderm-archives/vulvodynia

[Guest guest]

Rather interesting discussion in particular the latter part that

was in the thread about MRI of the lower spine. I'm getting one

done soon. But I wish I could have an actual MRI of the vulvar

area like I thought one of the girls on this list did. Dee,

have you come across any kind of info about PET Scans in

relation to vulvodynia in all your searching?

Kristy

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>-------------- It is possible that the original inflammation was due to yeast,

and that

>now she has the chronic low grade yeast described by Marilyn Mackay (?sp) which

>causes mild tender erythema of the vault. She treats with long term, months, of

>p.o. azoles. If she needs a lubricant the word in the community is Astroglide.

>Diane Thaler

>

Today I received the following information from Dr. Marilynne McKay referring to

the above.

These two paragraphs summarize the management of low-grade Candida colonization

as of 1997. It is very likely that new treatment programs are now available, but

I have not kept up with the literature and I do not have access to these

articles. —M.McKay

CYCLIC VULVOVAGINITIS is characterized by periodic flares of symptomatic

irritation and burning with normal intervals that may last several weeks at a

time. It is a relatively common problem most likely associated with chronic

low-grade local inflammation in response to Candida colonization. These patients

rarely have a typical “cottage cheese” discharge because the problem is not due

to candida overgrowth. It is more like the localized hypersensitivity that

occurs in nasal mucosa in response to ragweed. Cultures are often negative at

the time of a symptom flare because organisms have been eliminated by the local

inflammatory response. This inflammation accounts for irritant (rather than

allergic) reactions to a variety of topical medications. Previous bouts of

vulvovaginitis occurring when the patient is given antibiotics suggest that she

is colonized with Candida (about 1 of every 6 women.) The relationship of cyclic

vulvo-vaginitis to hormones has not been established except that it seems more

likely in the presence of estrogen; serum hormone levels have not been helpful

in diagnosis or therapy, nor has testing for diabetes. Eliminating Candida

enables the inflamed vaginal mucosa to regain its normal barrier function. At

that time the antifungal can be tapered gradually and the patient may need it

only once a month or when symptoms recur. A standard Candida suppression regimen

is oral Diflucan 150 mg once weekly for 2 months, tapering to once every other

week for 2 months, then one tablet monthly. (Sobel J: Pathogenesis and treatment

of recurrent vulvovaginal candidiasis. Clin Infect Dis 14:48-53, 1992.) Recovery

occurs gradually over the first few months of therapy, so a one-month treatment

trial is not adequate to rule out Candida as a factor, particularly when

symptoms have been present for years. Hydrocortisone 1% ointment can also be

applied 2-3 times daily for discomfort. Recurrences are not unusual and the

regimen may need to be repeated from time to time; Diflucan on day 3 and the

last day of antibiotic therapy is a good preventative.

>Some recent references: Dysesthetic ( " Essential " ) Vulvodynia Treatment with

>Amitriptyline. McKay M. Jour Reprod Medicine 1993;38:9-13. Vulvar Pain

Syndrome:

>A review.

{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\froman\fcharset0 Times New Roman;}{\f1\froman\fcharset0 Bookman Old Style;}{\f2\fswiss\fcharset0 Arial;}} {\colortbl ;\red0\green0\blue0;} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\cf1\i\f0\fs44 Dysesthetic \i0\par \i ("Essential") \i0\par \i Vulvodynia \i0\par \pard\sa500\i\fs34 Treatment with Amitriptyline \i0\par \pard\fs24 Marilynne McKay, M.D. \par \pard\qj\i\fs20 Twenty patients with chronic vulvar burning (vuvodynia) who had relief of symptoms only after treatment with low-dose amitriptyline were studied retrospectively. These patients had several factors in common, which suggested a possible neurologic component for their symptoms. The dosage of amitriptyline (initiated at 10 mg, gradually in-creased to 40-60 mg daily) was not sufficient to treat de-pression, but was in the range effective for other cutane-ous dysesthesias. This study defines dysesthetetic ("essen-tial") vulvodynia, and describes a typical profile and symptom pattern for patients most likely to respond to treatment with amitriptyline (an average age of 66 with vulvodynia for three years). Dysesthetic vulvodynia ap-pears to be a subset different from vulvar vestibulitis and other types of vulvodynia that are less responsive to treatment with tricyclic antidepressants. \i0\par \pard From the Departments of Dermatology and of Gynecol-ogy, Emory University School of Medicine, Atlanta, Georgia. \par Dr. McKay is Associate Professor. \par Address reprint requests to: Marilynne McKay M.D., The Emory Clinic, Dermatology Section, 1365 Clifton Road, NE, Atlanta, GA 30322. \par \pard\sb100\qj\b\f1 Introduction \b0\par \pard\sb40\qj\fs18 The International Society for the Study of Vulvar Disease (ISSVD) defines vulvodynia as chronic vulvar discomfort, especially that characterized by the patient's complaint of burning, stinging, irri-tation or rawness. Multiple factors appear to he associated with the complaint of vulvodynia, and no single treatment program has proven uni-formly effective for all patients. Careful exami-nation of patients with vulvodynia can reveal di-agnostic clues that facilitate selection of the best mode of therapy. The author has conducted a multi-regional vulvar diagnostic clinic for more than 12 years, and patient files include hundreds of women with chronic vulvar itching or burning. As more has been learned about the multifactorial nature of vulvodynia, retrospective review of these records has helped to characterize patients who are most likely to respond to treatment with spe-cific modalities. \super\up6 12,34\nosupersub\up0\par \pard\fi200\sb40\qj Objective evaluation of burning is difficult; itching at least results in visible evidence of rub-bing or excoriation. Although some cases of vul-vodynia are clearly related to cutaneous diseases or typical physical findings, other patients have normal-looking skin and nonlocalizing discomfort. These patients usually deny a consistent associa-tion of pain to intercourse or point tenderness to touch, unlike patients with vulvar vestibulitis. Since these cases did not seem to fit into a mor-phologically defined category, they were originally called "essential" vulvodynia, which was a diagno-sis of exclusion. Some believed that many or the majority of these patients might represent psy-chosomatic vulvitis.\super\up6 567 \nosupersub\up0\par Because some patients described burning pain similar to the pattern of discomfort described for glossodynia (burning tongue) or postherpetic (post-zoster) neuralgia, it was postulated that there might be a problem with cutaneous percep-tion, either centrally or at the nerve root. Since tricyclic antidepressant therapy has proven effi-cacious for other cutaneous dysesthesias, an empiric trial of amitriptyline hydrochloride was prescribed for patients with vulvodynia when other causes could not be determined. \super\up6 8\nosupersub\up0\par \pard\sb120\qj\b Methods \b0\par \pard\sb40\qj A retrospective chart review was conducted to identify patients who had relief of vulvar symp-toms that could he clearly ascribed to the use of daily oral doses of amitriptyline. No other vul-vovaginal therapy was permitted during the evaluation period except for local lidocaine (5%) ointment, which patients were encouraged to use "as needed" for symptomatic relief. Since this topical medication also acted on nerve endings, it was considered to be adjunctive therapy for \par \pard\par \pard\qr\f0\fs20 0024-7758/93/3801-09/S1.50/0 \'a9 The Journal of Reproductive Medicine, Inc.\par \pard\ri3380\sb140\sa20 Journal of Reproductive Medicine ,\bullet \par \pard\par \pard\qc 9\par \pard\par \i The Journal of Reproductive Medicine\cf0\i0\fs24\par \pard\sb40\qj dysesthesia. In none of these cases was topical lidocaine alone effective in controlling symptoms. \par \pard\fi200\sb40\qj Patients were excluded if they had vulvar der-matoses of any type (lichen sclerosus, lichen planus, lichen simplex chronicus, human papil-lomavirus infection), because these conditions could be managed successfully with other medi-cations. For the same reason, patients were ex-cluded if they reported cyclic symptomatic in-flammatory vulvovaginitis and/or had obtained significant relief with a candidal suppression regimen. On the other hand, the skin could not always be said to he completely "normal." A vari-able degree of mild or dusky local vulvar ery-thema was common; without dermatitic changes in the skin surface or visible telangiectatic ves-sels, this erythema was considered to be within a normal variable range and was not believed to be related to symptoms. \par At initial examination, four patients had an ery-thematous, fine-textured, papular eruption; these pa tients were using potent topical corticosteroids on the vulva (without relief of symptoms). This secondary erythema was believed to represent a corticosteroid side effect, because it subsequently resolved when the topical medication was discon-tinued. These patients were included in the study group if they reported similar symptoms of burn-ing before and after steroid use and if their symp-toms resolved with amitriptyline. \par Every patient was examined for erythema and point tenderness to palpation of the minor vesti-bular glands. While some degree of sensitivity was occasionally noted over Bartholin's gland ostia, patients denied this finding to be typical of their usual pattern of burning pain. Likewise, sexually active patients consistently denied dyspareunia at entry, another finding typical of vulvar vestibu-litis. \par All patients received amitriptyline (10 mg) at bedtime. They were advised to increase the dose by 10 mg every one to two weeks (or as tolerated), to a goal dosage of 50 mg daily. If undesirable side effects (usually drowsiness) occurred, and they could not increase the amount, they were advised to continue at the highest daily dose they were able to tolerate. Patients were seen for fol-low-up visits at two-month intervals. It improve-ment, but not resolution, was obtained with 50 mg daily, the dose was usually changed to 25 mg tablets and increased to 75 mg or, rarely, 100 mg daily. When relief had been obtained for four to six months, the dose was gradually decreased to the minimum required for control of symptoms. In some patients, the medication was discontinued and symptoms did not recur. \par \pard\sb120\qj Results \par \pard\fi200\sb40\qj A comparison of the clinical characteristics of patients is shown in Table I. For purposes of com-parison, they were arranged by age, with the youngest listed first. Dysesthetic vulvodynia ap-pears to be much more common in perimeno-pausal and postmenopausal women; ages ranged from 43-85 years (average, 66). At initial examina-tion, one patient was menstruating, and 7/20 (35%) were taking estrogen replacement therapy (ERT). ERT did not seem to be a significant factor in the development of symptoms, nor did hyster-ectomy, reported by 9/20 (45%), an average of 23 years earlier. It is interesting to note, however, that the four patients with positive vaginal candi-dal cultures were on ERT. (Treatment of Candida was not effective in relieving symptoms.) \par Back pain was relatively common in this age group; chronic problems were reported by 8/20. Perineal discomfort was noted in seven cases; rec-tal and urinary symptoms were described by five patients each (two patients had both). Altogether 55% (11/20) had some combination of back or pelvic floor problems. Pain with intercourse did not seem to be related to any particular combina-tion of other findings. Of the five patients who reported this problem, four had constant vulvar burning and one described intermittent symp-toms; none described the entry dyspareunia pat-tern typical of vulvar vestibulitis. Four patients with dyspareunia had symptomatic back pain; of these, two also had other perineal discomfort. Twelve of 20 patients denied coital activity, citing lack of opportunity (they were widowed or had no current partner) rather than avoidance because of pain. \par \pard\sb120 Discussion \par \pard\fi200\sb40\qj This retrospective review was conducted to de-termine the diagnostic profile of patients who are likely to respond to amitriptyline for the treat-ment of vulvodynia. Patients suffered for an aver-age of three years with symptoms, although some sought help sooner (often because of a daughter's concern). Compounding the problem of accurate diagnosis is the often multi-systemic nature of perineal pain. The gynecologist should be pre-pared to recognize this symptom complex, bec-ause referral for urologic, colorectal or orthopedic work-up is rarely beneficial, and even neurolo-gists seem less prepared to evaluate subtle perin-eal symptoms in the female.\par \pard\par 10 The Journal of Reproductive Medicine\par \pard\sb60 Volume 38, Number ]/January 1993 11 \par \pard\ul Table I Improvement With Amitriptyline: Patient Profile \ulnone\par Pain Genito- \par Patient Years of with Pattern Back urinary Rectal Hyster- Estrogen Vaginal Dose \par \ul (no.) Age symptoms coitus of pain pain symptoms pain ectomy replacement culture (mg) \ulnone\par 1 43 0.75 Yes Intermit Yes Yes Yes No n/a Yeast 20 \par 2 44 1.2 Yes Constant No No No 10 yr No Neg 50 \par 3 47 1 No Constant No No Yes 4 yr Estrace Yeast 30 \par 4 54 4 n/a Daytime No No No No No Neg 50 \par 5 55 1.75 No Intermit Yes No No No No Nog 30 \par 6 66 12 Yes Constant Yes No No No Premarin Neg 30 \par 7 66 3.5 No Daytime Yes No No No No Neg 20 \par 8 67 1 n/a Constant Yes No No 20 yr Estraderm Neg 25 \par 9 67 10 Yes Constant Yes SUI Yes 30 yr Premarin Yeast 50 \par 10 68 0.5 n/a Daytime No No No No Premarin Nog 50 \par 11 69 1 n/a Constant No Yes No 16 yr No Neg 100 \par 12 69 1.75 n/a Constant Yes Yes Yes 30 yr No Neg 40 \par 13 69 3 n/a Constant No No Yes No Premarin Neg 50 \par 14 70 3 n/a Constant No No No No No Neg 40 \par 15 72 0.5 No Constant No Yes No 40 yr No Neg 30 \par 16 74 7.5 n/a Constant No SUI No 24 yr Premarin Yeast 50 \par 17 75 0.5 n/a Constant No No No 34 yr No n/a 25 \par 18 75 5 n/a ConMant No No No No No Neg 40 \par 19 79 2 Yes Constant Yes No No No No Neg 50 \par 20 85 0.5 n/a Constant No No No No No Neg 20 \par \ul 66* 3.02* 40* \ulnone\par n/a = not applicable \par SUI = stress urinary incontinence \par Neg = negative \par Intermit = intermittent \par *Averages \par \pard\fi200\sb40\qj In this group of patients, it is difficult to inter-pret the relationship of ERT to vulvodynia; in an attempt to control symptoms, topical or systemic hormones were often either started or discontin-ued by the numerous physicians these patients had seen prior to referral to Emory. Since ma-nipulation of hormone therapy had not proven successful in this series, it can be assumed that it is either of little value or that these patients represent treatment failures. \par Patients who had pain for many years had often been told that it was most likely psychosomatic ("It's all in your head"); many despaired of finding relief. Despite the chronicity of their discomfort, clinical depression was rarely apparent at the time of the patient's initial evaluation. Antide-pressants have been shown to be effective in the management of certain types of pain whether or not depression is present. Because some patients may resent the implication of being given a psy-chiatric drug, it is important to explain that this medication has been prescribed because of its effect on cutaneous nerves.\super\up6 9 \nosupersub\up0\par Alternatives to amitriptyline (Elavil, Stuart Pharmaceuticals, Wilmington, DE) for pain relief include two other tricyclics, imipramine (Tofranil, Geigy Pharmaceuticals, Ardsley, NY) and desip-ramine (Norpramine, n Merrell Dow Inc., Kansas City, MO), trazodone (Desyrel, Mead Pharmaceuticals, ville, IN) and a benzodiazepine, clonazepam (Klonopin, Roche Laboratories, Nutley, NJ). Unfortunately, fluoxet-ine (Prozac, Dista Products Company, Indianapo-lis, IN) has not proven helpful for pain, despite its therapeutic similarity to the tricyclics for treat-ment of depression with fewer side effects. \par In our clinic, a diagnostic-therapeutic trial of amitriptyline is now used to identify a potential neurologic component of nonspecific vulvar burn-ing. In some cases, there is no perceptible benefit; in others, this therapy is extraordinarily effective. It seems to be most helpful for older women, par-ticularly those who are postmenopausal or eld-erly. (The latter group, incidentally, is also most likely to suffer from postherpetic neuralgia or glossodynia.) \par \pard Because of the high incidence of annoying side effects in this age group, it is essential to initiate\par \pard\fi200\sb40\qj therapy at the lowest dose of amitriptyline (10 mg daily). The average dose of amitriptyline required to see improvement was 40 mg daily; five patients improved with

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