Gynaecologist, Specialist Pain Medicine Physician

Amitriptyline – a bit confusing, but often helpful

Amitriptyline is a useful medication for some women with pelvic pain, but it’s often hard for women to understand why it has been recommended. It doesn’t suit everyone, but if you are someone with pain on most days of the month, it can add a bit more to the other treatments we offer. Around 1 in every 2 women who try it find it helpful.

Amitriptyline isn’t a pain killer, so you don’t feel better straight away, but when taken every day in very small doses it can help these type of problems:

  1. A sharp or burning pain.
  2. An overactive bladder. You may need to go to the toilet often, get up at night to pass urine or rush to the toilet.
  3. A pelvis where everything just feels ‘sensitive’.
  4. Painful pelvic muscles or tender points in other muscles around the body like your neck or shoulders
  5. Migraine or other headaches
  6. An irritable bowel
  7. Poor sleep
  8. Painful vulval skin
  9. A bloated feeling

A long time ago, Amitriptyline used to be used in high doses (around 150mg daily) to treat depression, and it is still called an ‘anti-depressant’ on the packet insert, even though no-one uses it for that anymore. If you are depressed there are many newer and better medications you can use, if you need them.

We are talking about Amitriptyline in low doses (5-25mg daily) for pain, or bad sleep.

Starting amitriptyline:

When you first start amitriptyline, you will often find that you sleep better at night. Some women still feel sleepy in the morning, but many wake up easily and have no problems. Always take it early in the evening around 3 hours before bed. Take it every evening, not just on the days you have pain and then ask yourself in a few weeks time ‘Do I feel better?’, ‘Is my life a bit easier now?’. ‘How are my headaches?’ ‘How is my bladder?’. If you are feeling generally better, then you should continue to take it. It is not addictive and can be taken long term if needed.

Each blue tablet contains 10mg amitriptyline. It can be broken in half by placing it on a bench and pushing down on both sides with two fingers, or by using a pill-cutter. You should start with a dose of 5mg taken early in the evening, preferably 3 hours before bed.

You should stay on this dose until not sleepy in the mornings then increase to 10mg. After around a week or so on 10mg you can increase it slowly by adding 5mg every few days or so. If you are sleepy on the medication, then stay on the dose you are on, or a slightly lower dose. The sleepiness usually wears off in around a week.

Some women find that just 5-10mg at night makes a big difference to their pain. It is all they need and there is no need to try a higher dose. Other women, especially those with an irritable bladder or bad headaches, may be better on a higher dose, up to 25mg in the evening.

You are the one to decide which dose helps your pain most but doesn’t make you too sleepy. It is better to be on a smaller dose that you are happy to continue taking, than a larger one that you stop using due to side effects. There is a 25mg tablet (yellow) available if that dose suits you best.

Problems on Amitriptyline:

You should start it the evening before a quiet day when you won’t be driving to check you are not drowsy on it. While on amitriptyline you may find that alcohol affects you slightly more than usual so be careful when drinking. If you still feel sleepy, even on a small dose, then ring your doctor. There are alternative medications available if it doesn’t suit you.

Amitriptyline and other medications

There is a small chance of problems if you are also taking an SSRI medication (for anxiety and depression) because both amitriptyliine and SSRI’s affect a chemical called serotonin. However, the risk is small and many people use both these medications without any problems. Remember to tell your doctor if you use tramadol for pain.

Amitriptyline does not affect the pill, ibuprofen, naprosyn, diclofenac, paracetamol or codeine. Avoid Cisapride (for stomach problems) and MAOI medications (an older treatment for depression) when on amitriptyline.

Other side effects of amitriptyline include:

  • slightly more constipation. Not usually severe in low doses
  • dry eyes and dry mouth. Not usually severe. Extra water, or chewing gum can help.

You should not take amitriptyline if you have:

  • An eye condition called glaucoma
  • Had a heart attack, or have an irregular heart rate or other heart condition
  • Epilepsy (fits)

Stopping amitriptyline:

Amitriptyline is safe to use long term. However if you decide to stop it, then stop it slowly. Do not stop it suddenly. You should reduce the dose by 5mg (half a blue tablet) every few days. Once you get down to 10mg or less, you can stop it.

If you stop amitriptyline, it may take weeks or sometimes months for the pain to return. If the pain does come back you should start the amitriptyline again. Some women choose to use low doses of amitriptyline for short periods of a few weeks or so during times when their pain is a problem. Other people stay on the same dose longer term.

Amitriptyline and pregnancy:

In the past, when it was used for depression, many women took amitriptyline in pregnancy because their depression symptoms were severe. We therefore have a lot of information on this medication in pregnancy. The risk to the baby is very small, especially as the doses we use for pain are much lower than those used in the past. However, we recommend that you stop this medication if you are trying to get pregnant so that there is no risk to the baby at all. We also recommend that you use contraception while on amitriptyline if you are sexually active.

If you have found the amitriptyline so helpful for your pain that you are unwilling to stop it, you should discuss this further with your doctor.