What is the first line of treatment for dysmenorrhea?

First-Line Treatment for Dysmenorrhea

NSAIDs are the first-line treatment for dysmenorrhea, with ibuprofen 400 mg every 4-6 hours as needed being the recommended regimen. 1, 2

Pathophysiology and Treatment Rationale

• Dysmenorrhea is characterized by painful uterine cramping associated with menstruation, primarily caused by overproduction of prostaglandins in the endometrium 3
• NSAIDs work by inhibiting cyclooxygenase enzymes, thereby blocking prostaglandin formation that causes uterine hypercontractility, ischemia, and pain 3
• In patients with primary dysmenorrhea, ibuprofen has been shown to reduce elevated prostaglandin activity in menstrual fluid and decrease resting and active intrauterine pressure 1

NSAID Treatment Protocol

• For dysmenorrhea treatment, ibuprofen should be given at a dose of 400 mg every 4 hours as necessary, beginning with the earliest onset of pain 1
• Alternative NSAIDs include naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours, taken with food 4
• Treatment should be short-term (5-7 days) during days of bleeding 5
• NSAIDs should be taken with food to minimize gastrointestinal side effects 1

Second-Line Treatment Options

• If NSAIDs are ineffective or contraindicated, hormonal contraceptives (particularly combined oral contraceptives) are recommended as second-line therapy 6, 7
• For women who desire contraception, combined oral contraceptives may be the preferred first-line option as they provide both contraception and pain relief 6
• Hormonal treatment with low-dose combined oral contraceptives can be used for short-term treatment (10-20 days) 5

Non-Pharmacological Adjunctive Treatments

• Heat therapy applied to the abdomen or back may reduce cramping pain based on dysmenorrhea studies 4
• Acupressure on specific points can help with pain relief:
  • Large Intestine-4 (LI4) point on the dorsum of the hand 4
  • Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus 4
• Peppermint essential oil has been shown to decrease symptoms of dysmenorrhea 4

Treatment Algorithm

1. Start with NSAIDs at recommended dosages at the earliest onset of pain 1
2. If inadequate relief or contraindications to NSAIDs exist, add or switch to hormonal contraceptives 6
3. Consider non-pharmacological adjuncts like heat therapy and acupressure alongside medication 4
4. If no response to initial treatments, consider evaluation for secondary causes of dysmenorrhea 7

Important Considerations

• Dysmenorrhea is often underdiagnosed, undertreated, and undervalued by women themselves 3
• Approximately 10% of affected women do not respond to NSAIDs and hormonal treatments, warranting investigation for secondary causes 8
• If bleeding irregularities persist and are unacceptable to the patient despite treatment, consider alternative contraceptive methods 4
• For severe, refractory cases not responding to medical management, surgical options may be considered as a last resort 2