If any orthopedic, neurologic, dermatologic, or urologic findings are contributing to the pain, the woman should be treated or referred, as appropriate. Physical therapy with a focus on the back or pelvic floor also may be helpful. If the patient experiences frequent recurrences of herpes simplex or an active outbreak of the varicella zoster virus, herpes suppression is important. However, acyclovir alone will not relieve vulvar pain. Any vaginal atrophy should be treated with topical estrogen.
Many oncologists now permit breast cancer patients to use the vaginal estrogen ring.
VDY.1 Nortriptyline is the least sedating tricyclic and has the fewest anticholinergic side effects, e.g., dry mouth, constipation, sweating, palpitations. While amitriptyline was the tricyclic originally used for nociceptic and neuropathic pain, nortriptyline appears to offer equal efficacy. However, if one tricyclic is not helpful, other members of the family should be tried, i.e., desipramine, imipramine, doxepin, amitriptyline. Unfortunately, besides taking weeks to work, tricyclics work unevenly, so that good days and bad days are common. The leading reasons for failure are an inadequate dosage over too short a period of time or an intolerance of side effects.