# Vulvodynia - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain for the pathway, with the figures from Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683): "The initial dose should be 10 mg - 25 mg in the evening... Recommended doses are 25 mg - 75 mg daily in the evening. Doses above 100 mg should be used with caution... A single dose above 75 mg is not recommended." The SmPC states no 60 mg step, and it asks that anything above 75 mg be split into two doses rather than given as one nightly dose. · NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024) · Gabapentin 300 mg capsules SmPC sections 4.2 and 4.4 (eMC product 4122) - Verified date: 2026-08 ## Verified against - NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain for the pathway, with the figures from Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683): "The initial dose should be 10 mg - 25 mg in the evening... Recommended doses are 25 mg - 75 mg daily in the evening. Doses above 100 mg should be used with caution... A single dose above 75 mg is not recommended." The SmPC states no 60 mg step, and it asks that anything above 75 mg be split into two doses rather than given as one nightly dose. - NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024) - Gabapentin 300 mg capsules SmPC sections 4.2 and 4.4 (eMC product 4122) - Vulvodynia - disease-level clinical article (vulvodynia-clinical.txt) ## Treatment metadata - No drug therapy in primary care (Vulvar Care & Physio Referral) - Amitriptyline — 10 mg — oral.solid - Gabapentin — 300 mg — oral.solid - Lidocaine — topical ## Complete treatment card ```text VULVODYNIA Sources: NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain for the pathway, with the figures from Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683): "The initial dose should be 10 mg - 25 mg in the evening... Recommended doses are 25 mg - 75 mg daily in the evening. Doses above 100 mg should be used with caution... A single dose above 75 mg is not recommended." The SmPC states no 60 mg step, and it asks that anything above 75 mg be split into two doses rather than given as one nightly dose. · NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024) · Gabapentin 300 mg capsules SmPC sections 4.2 and 4.4 (eMC product 4122) Review status: REVIEWED against NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain for the pathway, with the figures from Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683): "The initial dose should be 10 mg - 25 mg in the evening... Recommended doses are 25 mg - 75 mg daily in the evening. Doses above 100 mg should be used with caution... A single dose above 75 mg is not recommended." The SmPC states no 60 mg step, and it asks that anything above 75 mg be split into two doses rather than given as one nightly dose., NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024), Gabapentin 300 mg capsules SmPC sections 4.2 and 4.4 (eMC product 4122), Vulvodynia - disease-level clinical article (vulvodynia-clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (3) - Pain that may be constant or come and go, and localized or widespread - Symptoms can be triggered by sex, prolonged sitting, or tight clothing - Anxiety, depression, and stress can worsen the pain [anxiety · low mood] SIGNS - what you find (3) - Cotton-swab testing maps tender points from the outer vulva inward to the vestibule, scored 1 to 10 - Pinprick testing at the same sites checks whether the response is normal, hypersensitive, or sharp/burning/shooting - Pelvic floor exam starts with the puborectalis muscle, then the rest of the pelvic floor TESTS (2) - There is no specific lab test for vulvodynia itself; it remains a diagnosis of exclusion - Cultures or biopsies may be done to rule out infection, a skin disorder, or a tumor IF NOT THIS - what else fits (5) - Vulvovaginal candidiasis, bacterial vaginosis, trichomoniasis, or genital herpes are infectious causes of vulvar pain to rule out - Skin disorders to rule out include lichen sclerosus, lichen planus, plus contact dermatitis or lichen simplex chronicus from irritation - Damage or entrapment affecting the pudendal, genitofemoral, or ilioinguinal nerves, or Tarlov cysts, can produce similar pain - Estrogen deficiency is a hormonal cause of vulvar pain to consider - Keratin trapped between the clitoris and its hood can cause irritation and pain Source StatPearls "Vulvodynia" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY IN PRIMARY CARE (VULVAR CARE & PHYSIO REFERRAL)[1st line] Adult General vulvar skin care: wash the vulva with water only (or a plain emollient as a soap substitute), avoid feminine hygiene sprays/wipes, avoid tight synthetic underwear, avoid irritant hair-removal products or methods. Refer for pelvic floor physiotherapy where history or examination suggests pelvic floor muscle hypertonicity, and for psychosexual counselling where sexual function is affected. Reassure the patient that vulvodynia is not an infection and not a marker of cancer. - Ongoing; reassess at 4-6 weeks and add the medical treatments below if pain persists Peds Not a prepubertal presentation. An adolescent presenting with this pattern should be referred to a gynaecologist with adolescent experience rather than managed in primary care alone. Source NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024) Why Vulvodynia is defined as vulval discomfort, often burning, in the absence of a relevant clinical finding or an identifiable neurological disorder - it is a diagnosis of exclusion. History and examination must first rule out candidiasis, dermatoses (lichen sclerosus, lichen planus, dermatitis), and, for any atypical skin change, vulval neoplasia, before treating as vulvodynia. General vulvar care and physiotherapy/psychosexual referral apply to every patient regardless of which medical treatment, if any, is added on top. Caution Vulvodynia is different from vaginismus, and the two are commonly confused or coexist: vulvodynia is a pain disorder (burning or stinging vulval discomfort, which can be present even without any attempt at penetration), while the vaginismus entry is a fear- driven involuntary spasm of the pelvic floor that specifically obstructs penetration - ask about pain independent of penetration AND about difficulty with penetration itself, since a patient can have either condition, or both together. Examine, with consent, before treating - inspect for skin disease (lichen sclerosus, lichen planus, dermatitis) and swab for candida/STI as the history suggests; do not assume vulvodynia in a patient with visible skin changes. Refer urgently (2-week-wait pathway) for any atypical, ulcerated, or pigmented vulval skin change - vulvodynia is a diagnosis of exclusion, not a default label for otherwise- unexplained vulval pain. Screen for anxiety and depression, which are significantly more common in women with vulvodynia, and address these alongside physical treatment. RED FLAG - Vulvodynia is a diagnosis of exclusion; cultures/biopsies are needed to rule out infections, dermatological conditions (lichen sclerosus/planus), pudendal nerve entrapment, or neoplasm. 2. AMITRIPTYLINE [3rd line] Adult 10 mg once daily at night initially, titrated by 5-10 mg every 2 weeks as tolerated to a usual effective dose around 60 mg nightly (maximum 100 mg nightly) - Trial for at least 2-3 weeks at an adequate dose before judging effect; continue long-term if effective, reviewed periodically Peds Not established in children for this indication; refer rather than prescribing in an adolescent with this pattern. Source NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain for the pathway, with the figures from Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683): "The initial dose should be 10 mg - 25 mg in the evening... Recommended doses are 25 mg - 75 mg daily in the evening. Doses above 100 mg should be used with caution... A single dose above 75 mg is not recommended." The SmPC states no 60 mg step, and it asks that anything above 75 mg be split into two doses rather than given as one nightly dose. Why Named in this guidance as an appropriate initial oral treatment for unprovoked/persistent vulvodynia; the source document draws this recommendation from the British Society for the Study of Vulval Disease (BSSVD) 2010 guideline and ACOG Committee Opinion No. 673: Persistent Vulvar Pain (2016), both cited by name within it. Reserve for pain persisting despite vulvar care, physiotherapy, and topical lidocaine - it is not a first-contact treatment. Caution Takes up to 2-3 weeks at an adequate dose to show benefit - warn the patient in advance so an early plateau is not mistaken for failure. Anticholinergic side effects (dry mouth, constipation, drowsiness) are common at these doses; taking it at night reduces daytime sedation. CONTRAINDICATED with, or within 2 weeks of, an MAOI; use with caution in cardiac disease - avoid after a recent myocardial infarction or with a significant arrhythmia. Discuss that side effects sometimes outweigh benefit, in which case the dose should be reduced or the drug stopped rather than pushed higher regardless. Avoid in elderly patients, and in severe cardiovascular disease or arrhythmias. Amitriptyline - StatPearls - NCBI Bookshelf (NBK537225) puts amitriptyline on the American Geriatrics Society's Beers list, to be avoided in the elderly because its anticholinergic effect is so strong. Egypt TRYPTIZOL 10 MG 20 TABS. KAHIRA 10.00 EGP (0.50/unit) TRYPTIZOL 10 MG 60 TABS. KAHIRA 30.00 EGP (0.50/unit) GRANITYLLIN 25MG/5ML SYP. 120 ML GRAND PHARMA ... 5.00 EGP -> ? strength differs, ? different route - not oral solid ZINOTRAVAL 25MG/5ML SYP. 120 ML DEBEIKY > PHA... 10.00 EGP -> ? strength differs, ? different route - not oral solid 3. GABAPENTIN [alternative] Adult 300 mg once daily initially, increasing in steps of 300 mg every 2-3 days as tolerated (in 2-3 divided doses) to an effective dose, typically in the range 900-1800 mg daily (maximum 3600 mg daily) - Titration over 3-8 weeks; continue if effective, reviewed periodically Peds Not established in children for this indication. Source Gabapentin 300 mg capsules SmPC sections 4.2 and 4.4 (eMC product 4122) Why The vulvodynia-specific source names gabapentin (with pregabalin) as an option for persistent pain, but states this is usually undertaken with specialist pain-service involvement rather than started independently in primary care - listed here as the next step after amitriptyline has failed or is not tolerated, best arranged together with a pain-service or gynaecology referral rather than as a routine primary-care first move. The vulvodynia-specific source does not publish a titration schedule, so the mg steps come from the gabapentin SmPC (eMC 4122) cited for the dose, which for peripheral neuropathic pain gives a 300 mg day-1 start and says "the dose can be further increased in 300 mg/day increments every 2-3 days up to a maximum dose of 3600 mg/day". Caution Usual practice is to involve a specialist pain service or gynaecology for this option rather than titrating it independently in primary care - arrange the referral alongside starting treatment, not instead of it. Sedation and dizziness are common during titration - warn about driving and operating machinery. Reduce the dose in renal impairment - check renal function before starting. Do not stop abruptly after regular use - taper to avoid withdrawal symptoms. Withdraw over at least a week, whatever the reason for stopping - never abruptly. Renal impairment sets the ceiling: 600-1800 mg/day at a clearance of 50-79, 300-900 at 30-49, 150-600 at 15-29, and 150-300 below 15. Alongside an opioid, watch for sedation and respiratory depression - that combination is how people die. It is misused and it is traded. Watch for tolerance, dose escalation and requests to come early. Monitor for suicidal thoughts. Egypt EZAPENTIN 300MG 10 CAPS. MULTI-APEX 11.00 EGP (1.10/unit) PENTALIPSY 300MG 10 CAPS. SAFE PHARMA 14.40 EGP (1.44/unit) OCTOCONVAL 300 MG 30 CAPS. OCTOBER PHARMA 72.00 EGP (2.40/unit) NEUROGLOPENTIN 300 MG 30 CAPS. GLOBAL NAPI P... 111.00 EGP (3.70/unit) SHALGATEN 300MG 30 CAPS. EGPI > MASH P... 126.00 EGP (4.20/unit) GABALEPSY 300MG 30 CAPS. EL-OBOUR 135.00 EGP (4.50/unit) GABAVERONA 300 MG 30 H.G. CAPS. AVERROES PHARMA 126.00 EGP SAJALIPSY 300 MG 30 H.G. CAPS. SAJA PHARMACE... 126.00 EGP STABLENTIN 6MG/120ML SYRUP MEPACO 21.60 EGP -> ? strength differs, ? different route - not oral solid ADAPTAN 250MG/5ML ORAL SOLUTION 100 ML EUROPEAN EGYPTIAN PHARM. IND. 37.00 EGP -> ? strength differs, ? different route - not oral solid 4. LIDOCAINE [add-on - not a substitute] Adult Apply 5% lidocaine ointment thinly to the affected vulvar area; can be used as regular treatment or applied approximately 20-30 minutes before intercourse to reduce entry pain. An ointment base is generally better tolerated than a cream, which tends to sting more on application. - Trial for 4-6 weeks before judging effect Peds Not indicated in children. Source NHS North East London ICB Primary Care Guidance: Vulvodynia - Vulval Pain (2024) Why This guidance states a topical local anaesthetic can be trialled in all patients with vulvodynia, alongside - not instead of - the general vulvar care and physiotherapy/psychosexual referral above. Caution There is local stinging on application, and numbness that can itself interfere with sensation during intercourse - use sparingly and warn the patient in advance. Can weaken latex condoms - advise an alternative contraceptive/barrier method while in use. Lidocaine is not a stand-alone fix - use it together with vulvar care and physiotherapy or psychosexual referral, not as a substitute for them. Applying it 20-30 minutes before intercourse is common practice rather than something the guidance states. What the guidance does give is the trial length: 4-6 weeks before deciding whether it helps. Egypt FARCO-CAINE 5% OINT. 20 GM PHARCO 4.25 EGP LIDOSINE 5% TOPICAL OINT. 20 GM AMRIYA 4.40 EGP LIDOGED 5% TOPICAL GEL 15 GM JEDCO INT. CO... 5.00 EGP ULTRACAINE 5% GEL 30 GM MEMPHIS 31.00 EGP XYLOTOP 4% TOP. CREAM 20 GM SIGMA 4.25 EGP XYLOTOP 4% TOPICAL GEL 20 GM SIGMA 5.00 EGP LIDOCAINE 2% GEL. 20 GM ALEXANDRIA 6.75 EGP XYLOCAINE JELLY 2% 30 GM ASPEN PHARMA ... 30.80 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)