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Pain with Sex


Many women report pain in the vagina. It is typically “outside” pain, mainly located where the moist tissue of the vagina meets the dry skin right around the opening. The pain may begin as a yeast infection. Yeast medicine may, or may not help the pain. In any case, the yeast infection comes back, and it comes back often. Sometimes a woman is treated for multiple urinary tract infections. The infections are diagnosed based on painful urination, and her doctor may call in antibiotics, regularly. And for some reason the pain with urination comes back, often. The pain continues to come and go, but it always seems to come back, and it never really gets much better, no matter what medicine is used.

A woman may have pain with intercourse. The pain is not really “inside pain,” rather it is pain with insertion of the penis into the vagina. She may have similar pain at other times too. Certain underwear or tight clothes can give her pain or itching. Again, the itching is often treated with yeast medicine, but the itching keeps coming back.

Vaginal pain, itching, pain with intercourse, frequent yeast infections which don’t get better with yeast medicine, and frequent urinary tract infections treated with antibiotics… these are all symptoms of a pain problem called vulvodynia.


Vulvodynia is a common, well recognized, well described condition that can make women really frustrated. For some reason, a reason which we have not been able to actually find, a group of women have vaginal pain without any findings. The cultures are all negative and biopsies of the tissue are normal. Topical steroids don’t work, yeast medicine doesn’t work, and treating urine with antibiotics does not work, either. Vulvodynia is pain, but it is NOT dangerous. Just because we can not find the source of the pain does not mean we can not treat it.

Treatment Options

The first line treatment of vulvodynia is a medicine in the tricyclic antidepressant category.  The medicine is called Amitriptyline. Taking this medicine usually starts at 25 mg at bedtime, with a goal of increasing to 75 mg at bedtime, increasing the dose every 7-14 days, depending on how well one is tolerating the medication. The results may not be apparent for 6 or more weeks.

We don’t really know why the amitriptyline works but we do know that is does work and it is safe.

Side Effects

The primary side effects of the medication can include dry mouth, drowsiness, dizziness, headache, nausea, weakness, diarrhea, sweating, heartburn, and weight gain. When started at a low dose an increased slowly these side effects are quite rare. Most patients who stop the medication do so because it does not help them rather than stop the medicine because of  its side effects.

Things to Consider

Vulvodynia is a diagnosis that has no test to prove it is there. In young healthy women we can appropriately diagnose vulvodynia based on how you explain the pain and an examination. We may test for gonorrhea, chlamydia, yeast and a urine infection. Some women will have a biopsy of the painful skin. As long as all these tests are negative we can consider the diagnosis of vulvodynia.

Vulvodynia is managed, not cured. It the medicine works then we can try stopping the pills after 6 months. If the pain comes back we will consider taking the medicine again. This is not a life-long problem, but it can come and go, for years.