What is the first line of treatment for dysmenorrhea?

First-Line Treatment for Dysmenorrhea

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for dysmenorrhea due to their inhibition of prostaglandin synthesis, which directly addresses the underlying pathophysiology of menstrual pain. 1

Recommended NSAID Regimens

Ibuprofen

• Dosage: 400-800 mg every 6-8 hours with food 2
• Maximum daily dose: 3200 mg 2
• Timing: Begin at earliest onset of pain 2
• Duration: Continue for first 24-48 hours of menstruation or until pain resolves

Naproxen (Alternative NSAID)

• Dosage: 440-550 mg every 12 hours with food 3
• Timing: Begin at earliest onset of pain
• Duration: Continue for first 24 hours post-onset 3

Mechanism of Action

NSAIDs work by inhibiting cyclooxygenase enzymes, thereby blocking prostaglandin formation 1. In patients with dysmenorrhea, NSAIDs have been shown to:

• Reduce elevated prostaglandin levels in menstrual fluid
• Decrease resting and active intrauterine pressure
• Reduce frequency of uterine contractions 2

Evidence for Efficacy

• NSAIDs provide superior pain relief compared to placebo in multiple randomized controlled trials 4
• Naproxen 400 mg has demonstrated greater pain relief than acetaminophen and ibuprofen 200 mg in some studies 5
• Approximately 80-85% of women with primary dysmenorrhea respond to NSAID therapy 6

Second-Line Options for NSAID Non-Responders

If NSAIDs fail to provide adequate relief (occurs in approximately 18% of women 6), consider:

1. Hormonal contraceptives:

   • Combined oral contraceptives (COCs)
   • Particularly beneficial for women who also desire contraception 4

2. Non-pharmacologic adjuncts:

   • Heat therapy: Application to lower abdomen/back may reduce cramping pain 3
   • Acupressure: Stimulation of specific points such as Large Intestine-4 (LI4) and Spleen-6 (SP6) 3

Important Considerations

• Use the lowest effective dose for the shortest duration to minimize side effects 2
• Take with food to reduce gastrointestinal side effects 2
• Begin treatment at the earliest onset of pain for maximum effectiveness 2
• For women with contraindications to NSAIDs, consider progestin-only or non-hormonal contraceptive methods 7

Treatment Algorithm

1. Start with standard-dose NSAID at earliest onset of symptoms
2. If inadequate relief after 1-2 cycles:
   • Try alternative NSAID (switch from ibuprofen to naproxen or vice versa)
   • Consider increasing dose within safe limits
3. If still inadequate relief:
   • Add hormonal contraception (if not contraindicated)
   • Consider evaluation for secondary causes of dysmenorrhea

Pitfalls to Avoid

• Delayed initiation: Starting NSAIDs after pain is established reduces effectiveness
• Inadequate dosing: Subtherapeutic doses may not effectively inhibit prostaglandin synthesis
• Premature discontinuation: NSAIDs should be continued throughout the painful period
• Failure to recognize secondary dysmenorrhea: Persistent pain despite appropriate therapy warrants further investigation 8