From the Guidelines
Combined oral contraceptives (COCs) are recommended as a first-line treatment for dysmenorrhea, with continuous or extended-cycle regimens often providing better symptom relief than traditional cyclic use. The use of COCs for dysmenorrhea is supported by their ability to suppress ovulation, reduce endometrial growth, and decrease prostaglandin production, which are key factors in menstrual pain 1. Standard COC options include monophasic formulations containing ethinyl estradiol (20-35 mcg) combined with progestins like levonorgestrel or norgestimate, as recommended for adolescents and applicable to adults as well 1.
Some key points to consider when prescribing COCs for dysmenorrhea include:
- Starting with a COC containing 30 to 35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate 1
- Informing patients that common transient adverse effects of COCs include irregular bleeding, headache, and nausea 1
- Counseling patients on strategies to promote daily adherence, such as cell phone alarms and support from a family member or partner 1
- Recommending extended or continuous cycles for treating severe dysmenorrhea, as these regimens may provide better symptom relief than traditional cyclic use 1
It's also important to note that COCs are contraindicated in women with certain conditions, including history of thromboembolism, uncontrolled hypertension, migraine with aura, and certain liver conditions 1. However, for women without these contraindications, COCs can provide significant relief from dysmenorrhea symptoms, as well as contraceptive benefits and cycle regularity.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Combination oral contraceptives act by suppression of gonadotropins. Although the primary mechanism of this action is inhibition of ovulation, other alterations include changes in the cervical mucus (which increase the difficulty of sperm entry into the uterus) and the endometrium (which reduce the likelihood of implantation)
The recommended treatment for dysmenorrhea (painful periods) using combined oral contraceptives (COCs) is to use them to suppress gonadotropins, which can help reduce pain by inhibiting ovulation and altering the endometrium.
- Key words:
- Suppression of gonadotropins
- Inhibition of ovulation
- Alterations in the endometrium 2
From the Research
Treatment Options for Dysmenorrhea
- Combined oral contraceptives (COCs) are recommended in the management of primary dysmenorrhoea, as they can effectively reduce menstrual pain by suppressing ovulation and lessening the endometrial lining of the uterus 3, 4, 5.
- The use of COCs has been shown to be effective in reducing dysmenorrhea, with a pooled odds ratio of 2.01 [95% CI 1.32,3.08] compared to placebo 4, 5.
- However, there is limited evidence for pain improvement with the use of low-dose estrogen COCs, and no evidence of a difference between different COC preparations 4, 5.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are also a first-line medical option for the treatment of dysmenorrhea, and may be used independently or in combination with COCs 6, 7.
Mechanism of Action
- COCs work by suppressing ovulation and lessening the endometrial lining of the uterus, which reduces menstrual fluid volume and the amount of prostaglandins produced, effectively reducing dysmenorrhea by decreasing uterine motility and cramping 3.
- NSAIDs work by inhibiting the production of prostaglandins, which are responsible for causing uterine hypercontractility and pain in dysmenorrhea 7.
Additional Considerations
- The diagnosis of primary dysmenorrhea is essentially clinical, based on the clinical history and normal physical examination, and it is important to exclude secondary causes of dysmenorrhea 7.
- Alternative treatments, such as topical heat, lifestyle modification, transcutaneous electrical nerve stimulation, dietary supplements, acupuncture, and acupressure, may be an option in cases of conventional treatments' contraindication 7.
- Surgical treatment is only indicated in rare cases of women with severe dysmenorrhea refractory to treatment 7.