TCA Therapy for Chronic Pelvic Pain

Department of Obstetrics and Gynecology
University of Iowa
First Published: 2000
Last Revised: October 2003
Peer Review Status: Internally Peer Reviewed

TCAs (Tricyclic antidepressants) are used in high doses (75-300 mg daily) to treat depression, and in low doses (10-50 mg daily) to treat chronic pain and sleep problems. They have been proven to work in patients with back pain, headache and chronic pelvic pain.

How does it work for pain?
It is thought that TCAs work by raising levels of a hormone called "endorphin." Endorphins are substances made in our brains and spine that decrease pain--your body's natural painkiller. Endorphin levels fall in people with chronic pain, sleep problems or depression. Low dose TCAs have been shown to reduce pain by raising endorphin levels to normal. They also improve "good" sleep (deep sleep and dream sleep) which improves energy and alertness. They are not habit forming, and have no known long-term risks.

How does it work for depression?
Studies have shown that there is a strong link between depression and chronic pain of any type. Over half of women with chronic pelvic pain report symptoms of depression. These include: Feeling sad or grouchy. Loss of interest or pleasure in doing things. Change in weight or appetite. Sleep problems. Feeling guilty, hopeless, helpless. Fatigue, decreased energy. Thoughts of suicide.

All of us go through ups and downs. As you would expect, people with chronic pain have more downs than ups. Many experts think that part of the problem is due to low levels of a chemical in the brain called "serotonin." Low serotonin levels are found in people with depression, sleep problems and chronic pain. These symptoms can often be improved by higher dose TCAs which can return serotonin levels to normal. It is important that any thoughts of suicide be discussed with a professional, especially if they become more frequent.

Dose:
The three TCAs used most often in the Pelvic Pain Clinic are:

• Imipramine (Tofranil)
• Doxepin (Sinequan)
• Amitriptyline (Elavil)

The usual starting dose is 10-25 mg at bedtime. It can take from one to four weeks for the drug to start working. It is best to consult with one of the Pain Clinic staff members before changing your dose.

Side Effects:
Many of the common side effects of antidepressants tend to go away in one or two weeks. This includes feeling sleepy, getting dizzy with standing up quickly, dry mouth, dry eyes, or constipation. Most of these effects are easy to treat. For example, a sip of water or hard candy can help with dry mouth. Increasing your fluids, fruits (especially prunes) and fiber will treat constipation if this occurs. It is important to discuss any side effects with your health care provider.

Cost:
This group of drugs cost very little. Drug stores vary in the amount they charge, so it is helpful to call and check on prices.

See related Patient Textbooks about Obstetrics and Gynecology.

See related Patient Topics Brain and Nervous System, Gynecology, Obstetrics and Gynecology, Pain, Symptoms and Manifestations, Women's Health or Women's Health--General.

See related Provider Textbooks about Obstetrics and Gynecology.

See related Provider Topics Brain and Nervous System, Gynecology, Obstetrics and Gynecology, Pain, Symptoms and Manifestations or Women's Health.

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