From the Guidelines
Combined oral contraceptives (COCs) with ethinyl estradiol (20-35 mcg) and a progestin such as levonorgestrel or norgestimate are the recommended oral contraceptive for managing dysmenorrhea. These can be taken in a standard 21/7 regimen or continuously to reduce or eliminate menstrual pain, as supported by the American College of Pediatrics 1. The continuous regimen is particularly beneficial for severe dysmenorrhea as it prevents the withdrawal bleeding that triggers prostaglandin release and subsequent pain. COCs work by thinning the endometrial lining and suppressing ovulation, which reduces prostaglandin production—the primary mediator of menstrual pain. They also decrease menstrual flow volume, further alleviating symptoms.
Some key points to consider when prescribing COCs for dysmenorrhea include:
- Starting with a low-dose pill (containing ethinyl estradiol 35 mcg or less) is recommended 1
- Counseling patients on the importance of daily adherence and providing strategies to promote adherence, such as cell phone alarms and support from a family member or partner 1
- Informing patients about potential side effects, such as irregular bleeding, headache, and nausea, and managing these adverse effects appropriately 1
- Being aware of contraindications, including severe and uncontrolled hypertension, ongoing hepatic dysfunction, and complicated valvular heart disease 1
It's also important to note that while other guidelines, such as the 2018 AHA/ACC guideline for the management of adults with congenital heart disease, provide recommendations on contraceptive therapy, they do not specifically address the management of dysmenorrhea 1. Therefore, the recommendation for COCs in managing dysmenorrhea is based on the most relevant and recent evidence from the American College of Pediatrics 1.
From the Research
Recommended Oral Contraceptives for Dysmenorrhea
The following oral contraceptives are recommended for managing dysmenorrhea:
- Combined oral contraceptive pills (OCPs) with medium dose oestrogen (>35 mcg) and 1st/2nd generation progestogens 2
- Low dose oestrogen and medium dose oestrogen combined OCPs compared with placebo, for a combined total of 497 women, reported pain improvement 3, 4
- Ultra-low-dose oral contraceptive (NPC-01; 0.02 mg ethinyl estradiol and 1 mg norethisterone) 5
- Oral contraceptives containing drospirenone for premenstrual syndrome, which may also be effective for dysmenorrhea 6
Key Findings
- Combined OCPs with medium dose oestrogen and 1st/2nd generation progestogens were shown to be more effective than placebo for pain relief 2
- The pooled OR suggested benefit with OCPs compared to placebo for pain relief 3, 4
- The ultra-low-dose contraceptive NPC-01 relieved dysmenorrhea as effectively as IKH-01 5
- Drospirenone 3 mg plus ethinyl estradiol 20 μg may help treat premenstrual symptoms in women with severe symptoms 6