What are the treatment options for dysmenorrhea?

Treatment Options for Dysmenorrhea

NSAIDs are the first-line treatment for dysmenorrhea due to their ability to inhibit prostaglandin synthesis, which is the primary cause of menstrual pain. 1, 2

First-Line Pharmacological Treatments

• NSAIDs should be started at the earliest onset of menstrual pain or prophylactically at the beginning of menstruation 1, 3:

  • Ibuprofen 400-800 mg every 6-8 hours (maximum 2400 mg daily) 1
  • Naproxen 440-550 mg initially, followed by 220-275 mg every 12 hours 4, 3

• For optimal pain relief with NSAIDs:

  • Begin treatment at the earliest sign of menstrual pain 3, 5
  • Use a loading dose (typically twice the regular dose) initially 5
  • Continue regular dosing for the first 24-48 hours of menstruation 4, 3
  • Take with food to minimize gastrointestinal side effects 1

Non-Pharmacological Approaches

• Heat therapy applied to the lower abdomen or back reduces cramping pain 4
• Physical exercise has strong evidence for reducing dysmenorrhea symptoms 2
• Acupressure at specific points can provide relief 4:
  • Large Intestine-4 (LI4, also called Hegu) point
  • Spleen-6 (SP6, also called SanyinJiao) point

Second-Line Treatments

• Combined hormonal contraceptives (pills, patch, or ring) should be offered if NSAIDs are ineffective after three menstrual cycles 5, 6:

  • Continuous or extended regimens may be particularly beneficial for severe dysmenorrhea 4
  • These methods work by reducing endometrial growth and prostaglandin production 4, 2

• For patients with heavy menstrual bleeding and dysmenorrhea:

  • Levonorgestrel-releasing intrauterine device (LNG-IUD) can effectively reduce both symptoms 4

Algorithm for Management

1. Initial Treatment:

   • Start with NSAIDs at the earliest sign of pain 3, 5
   • Add heat therapy and acupressure techniques 4

2. If inadequate relief after 3 menstrual cycles:

   • Add hormonal contraception (pills, patch, ring, or LNG-IUD) 4, 5, 6

3. If no improvement within 6 months of combined therapy:

   • Refer for laparoscopy to evaluate for secondary causes (e.g., endometriosis) 5, 6

Secondary Dysmenorrhea Considerations

• If dysmenorrhea is accompanied by abnormal bleeding patterns, pelvic pain outside menstruation, or fails to respond to first-line treatments, consider secondary causes 4, 2:

  • Endometriosis
  • Adenomyosis
  • Uterine fibroids or polyps
  • Pelvic inflammatory disease

• For suspected endometriosis:

  • More aggressive hormonal suppression may be required 4, 2
  • Surgical evaluation and treatment may be necessary 2, 6

Common Pitfalls to Avoid

• Inadequate NSAID dosing or timing - starting too late after pain onset reduces efficacy 3, 5
• Not considering secondary causes when pain is severe or unresponsive to treatment 2, 6
• Discontinuing NSAIDs too early during the menstrual cycle 4, 3
• Using acetaminophen alone, which is less effective than NSAIDs for dysmenorrhea 3

Special Populations

• Adolescents with severe dysmenorrhea that doesn't respond to NSAIDs should be evaluated for endometriosis, which can present early in reproductive life 5, 6
• Athletes with dysmenorrhea may have associated menstrual dysfunction requiring specialized treatment approaches 4