Therapy	Proposed mechanism	Beginning dosage	Continuing dosage	Side effects	Precautions	Evidence
Oral therapies
Amitriptyline	Decreases neuronal hypersensitivity	25 mg at bedtime for 10 days, then 50 mg at bedtime daily	50 to 100 mg at bedtime (higher dosages to 225 mg occasionally are successful)	Dry mouth, fatigue (often transient), constipation, weight gain (uncommon)	Start at lower dosages in older patients.	Case reports9,38,39
						Retrospective reports9,39
Calcium citrate	Decreases oxalate deposition in tissues	2 tablets twice daily	2 to 4 tablets twice daily	Minimal	Used in conjunction with other treatments.	Case reports40
						Anecdotal evidence when used in conjunction with a low-oxalate diet41
Desipramine (Norpramin)	Decreases neuronal hypersensitivity	25 mg at bedtime for 10 days, then 50 mg at bedtime daily	50 to 100 mg at bedtime (higher dosages to 225 mg occasionally are successful)	Same as amitriptyline but less common	Start at lower dosages in older patients.	None. Based on similarity to amitriptyline and use in other painful neuropathies42
Gabapentin (Neurontin)	Decreases neuronal hypersensitivity	300 mg daily, increasing every five days by 300 mg per day (to three-times-per-day dosing)	300 mg three times daily, to maximum of 900 mg three times daily (2,700 mg)	Headaches, nausea, vomiting, fatigue, and dizziness (often transient or mild)43	—	Case reports suggest benefit.43
Paroxetine (Paxil)	Decreases neuronal hypersensitivity	10 mg daily	20 to 60 mg daily	Rarely fatigue, anorgasmia, or weight gain	Discontinuation should be gradual.	Case reports9
Venlafaxine (Effexor)	Decreases neuronal hypersensitivity	37.5 mg daily	75 to 150 mg daily	Anorgasmia, gastrointestinal side effects, anxiety	Blood pressure, electrolyte levels, and lipid levels should be monitored periodically.	Used in other painful neuropathies
Dietary changes
Low-oxalate diet	Decreases the possible role of oxalate deposition in vulvar tissue	Ranges from a highly oxalate-restrictive diet to avoidance of a short list of foods that increase oxalate levels significantly44	—	A low-oxalate diet is very restrictive. If initiated, it should be continued only if clear benefits are noted.	—	The role of oxalates in vulvodynia is controversial.40,41 A case report40 suggested benefit when used in conjunction with calcium citrate supplementation.
Surgical therapy
Perineoplasty and vestibulectomy	Removal of hypersensitive tissue and replacement with vaginal mucosa advancement	—	—	Acute discomfort and job absenteeism. Rarely, bleeding, infection, hematoma, wound separation, vaginismus, vaginal stenosis	Only useful in localized (vestibular) cases. Most physicians reserve surgical treatment for patients who have not had success with other therapies.	Case series45,46
						Contolled treatment trial47 (70 percent response)
Topical therapies
Lidocaine gel or cream (5%)	Local anesthetic to decrease hypersensitivity	Apply topically to introitus.	Apply as needed before intercourse or nightly on a cotton ball in the introitus.	—	—	Case series48
Cromolyn cream (4%)	Decreases possible mast cell degranulation in vulvar tissue	Apply three times daily to introitus.	Continue three-times-daily application to introitus.	—	Not commercially available; must be formulated in a bland cream or ointment.	Case report suggested benefit.49
						Blinded treatment trial49 suggested no improvement.
Avoidance of irritants (e.g., perfumes, harsh soaps, colored underwear, nylon)	Decreases exposure to foreign antigens and heat	—	—	—	—	Unknown efficacy50
Other therapies
Biofeedback and/or physical therapy	Improves the electrodiagnostic pattern of pelvic floor musculature via biofeedback and muscle conditioning	Evaluation by physical therapist and instruction in home biofeedback exercises, with or without other physical therapy modalities and portable electromyographic feedback instrumentation	Continue home biofeedback daily for 16 weeks.47,51 Six to 16 physical therapy sessions, if used	Discomfort during treatment	Biofeedback requires home electromyographic monitor. Physical therapy typically uses instrumentation during therapy and exercises and stretching at home.	Nonblinded case series21,51 of biofeedback with six-month follow-up indicated benefit.
						Controlled trial47 of biofeedback indicated 30 percent improvement.
						Retrospective case series52 of physical therapy suggested improvement in most patients.
Cognitive behavioral therapy	Increases understanding of the disorder and encourages patients to find ways to minimize symptoms	Eight two-hour group sessions over 12 weeks	—	—	Recommended duration can be up to 1.5 years.53	Randomized treatment trial47 (30 percent response)