What are the treatment options for dysmenorrhea (painful menstruation)?

Treatment Options for Dysmenorrhea (Painful Menstruation)

NSAIDs are the first-line treatment for dysmenorrhea, with ibuprofen 400-800 mg every 4-6 hours for 5-7 days during menstruation being the most effective initial approach. 1, 2

First-Line Treatments

NSAIDs

• Mechanism: NSAIDs block prostaglandin synthesis, directly addressing the primary cause of menstrual pain 2
• Dosing options:
  • Ibuprofen: 400-800 mg every 4-6 hours (not exceeding 3200 mg daily) 2
  • Naproxen: 500 mg twice daily
  • Mefenamic acid: 500 mg three to four times daily
• Duration: Take for 5-7 days during menstruation 3
• Effectiveness: About 80% of women with primary dysmenorrhea experience adequate relief with NSAIDs 4
• Caution: Use lowest effective dose; monitor for gastrointestinal side effects; consider gastric protection if used long-term 1

Heat Therapy

• Apply local heat to lower abdomen
• Can be used alongside NSAIDs for enhanced pain relief
• Low cost and minimal side effects

Second-Line Treatments

Hormonal Contraceptives

If NSAIDs are ineffective or contraindicated, consider:

1. Levonorgestrel-releasing IUD (LNG-IUD):

   • Most effective option for reducing menstrual blood loss (71-95% reduction) 1
   • Also addresses pain effectively
   • Provides contraception for 3-7 years depending on type

2. Combined hormonal contraceptives (pills, patch, ring):

   • Effective for both pain control and bleeding regulation
   • Can be used continuously to avoid withdrawal bleeding
   • Evaluate cardiovascular risk factors before prescribing 1

3. Progestin-only methods:

   • Options include implants and pills
   • May cause irregular bleeding initially 3
   • Generally safer than combined methods for women with thrombosis risk factors 1

For Refractory Cases

Medical Options

• Tranexamic acid: More effective than NSAIDs for reducing blood loss; used during days of bleeding 1
  • Contraindicated in women with active thromboembolic disease or history of thrombosis

Surgical Options (for persistent, severe cases)

• Endometrial ablation: For women who have completed childbearing
• Hysterectomy: Definitive treatment when other options have failed

Treatment Algorithm

1. Rule out secondary causes of dysmenorrhea (endometriosis, adenomyosis, fibroids, PID)
2. Start with NSAIDs at appropriate dosing for 5-7 days during menstruation
3. If inadequate relief after 2-3 cycles:
   • Consider hormonal methods (LNG-IUD preferred if heavy bleeding is also present)
   • Combine NSAIDs with hormonal methods if needed
4. If still inadequate relief:
   • Reevaluate for secondary causes
   • Consider tranexamic acid for heavy bleeding component
   • Consider surgical options if quality of life significantly affected and childbearing completed

Important Considerations

• About 18% of women with dysmenorrhea are unresponsive to NSAIDs 5
• Counsel patients that irregular bleeding is common in the first 3-6 months of hormonal contraceptive use 3
• Amenorrhea with hormonal methods is common and not harmful 3
• Exercise has shown benefit and can be recommended as a complementary approach 6
• For women approaching perimenopause with dysmenorrhea, LNG-IUD provides both pain relief and endometrial protection 1

Regular follow-up is essential to assess treatment effectiveness and adjust therapy as needed. If symptoms persist despite appropriate treatment, further investigation for underlying conditions is warranted.