What treatment options are available for an 18-year-old patient with dysmenorrhea (painful menstruation) unresponsive to Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) or Combined Oral Contraceptives (COC)?

Management of Dysmenorrhea Unresponsive to NSAIDs and COCs in an 18-Year-Old

For an 18-year-old with dysmenorrhea unresponsive to NSAIDs and combined oral contraceptives (COCs), a levonorgestrel-releasing intrauterine device (LNG-IUD) is the recommended next treatment option. 1

Treatment Algorithm for Refractory Dysmenorrhea

First-Line Options (Already Tried)

• NSAIDs for 5-7 days during menstruation 2
• Combined oral contraceptives with 30-35 μg ethinyl estradiol 3

Second-Line Options

1. LNG-IUD (Recommended)

   • Provides highly effective pain relief for dysmenorrhea 1
   • Superior to copper IUDs for improving dysmenorrhea 1
   • Beneficial for symptom management even in cases of endometriosis 1
   • Effective even in adolescent females 1

2. Depot Medroxyprogesterone Acetate (DMPA)

   • Can be considered if LNG-IUD is not acceptable 3
   • For breakthrough bleeding with DMPA, NSAIDs for 5-7 days may be effective 2
   • Amenorrhea is common after ≥1 year of continuous use, which may help with dysmenorrhea 2

Management of Bleeding Irregularities with Second-Line Options

• For implant users with spotting or light bleeding:
  • NSAIDs for 5-7 days 2
• For implant users with heavy or prolonged bleeding:
  • NSAIDs for 5-7 days 2
  • Hormonal treatment (e.g., low-dose COCs or estrogen) for 10-20 days 2
  • Antifibrinolytic agents (e.g., tranexamic acid) for 5 days 2

Alternative Approaches for Refractory Cases

• Vitamin B1 (Thiamine)
  • Shown to be effective when taken at 100 mg daily 4
• Magnesium Supplementation
  • Promising treatment for dysmenorrhea, though optimal dosing is unclear 4
• Omega-3 Fatty Acids
  • Fish oil supplements may provide pain relief 4

Important Considerations

Follow-up Recommendations

• No routine follow-up visit is required 2
• Patient should return if experiencing side effects or concerns 2
• At follow-up visits:
  • Assess satisfaction with the method 2
  • Assess any changes in health status 2
  • Monitor blood pressure for patients on hormonal methods 2, 3

Potential Complications and Management

• If bleeding persists with any method and is unacceptable to the patient:
  • Counsel on alternative contraceptive methods 2
  • Offer another method if desired 2

Emerging Treatments

• Recent case report suggests GLP-1 agonists (semaglutide) may help manage refractory dysmenorrhea through potential anti-estrogenic and anti-inflammatory properties 5
• This is preliminary evidence only and requires further research before clinical implementation

Diagnostic Considerations

• If dysmenorrhea remains unresponsive to both first-line and second-line treatments, consider laparoscopy to evaluate for underlying conditions such as endometriosis 6
• Approximately 10% of females with severe dysmenorrhea symptoms may have pelvic abnormalities such as endometriosis or uterine anomalies 6