What is the best treatment for a 23-year-old with dysmenorrhea (painful menstruation) and lower abdominal pain during periods?

Treatment for Dysmenorrhea in a 23-Year-Old

NSAIDs are the first-line treatment for dysmenorrhea, with ibuprofen 400mg every 4-6 hours as needed for pain relief being the most effective option. 1, 2

First-Line Pharmacological Treatment

• Ibuprofen 400mg every 4-6 hours as necessary for pain relief, beginning with the earliest onset of menstrual pain 1
• Alternative NSAIDs include naproxen 440-550mg every 12 hours, taken with food 2
• Treatment should be short-term (5-7 days) during days of bleeding 2
• Take NSAIDs with meals or milk if gastrointestinal complaints occur 1
• Use the lowest effective dose for the shortest duration to minimize side effects 1

Non-Pharmacological Adjunctive Treatments

• Heat therapy applied to the abdomen or back can significantly reduce cramping pain 2
• Acupressure on specific points can help with pain relief:
  • Large Intestine-4 (LI4) point on the dorsum of the hand 2, 3
  • Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus 2, 3
• Peppermint essential oil has been shown to decrease symptoms of dysmenorrhea 2
• Regular exercise may help reduce symptoms, though evidence is limited 4

Second-Line Treatment Options

• If NSAIDs are ineffective (approximately 18% of women don't respond to NSAIDs), consider hormonal contraceptives 2
• Combined oral contraceptives are effective for severe cases that don't respond to NSAIDs 2
• For women with suspected endometriosis, medical management with progestins, oral contraceptives, or GnRH agonists may be appropriate 2

When to Consider Secondary Causes

• If pain does not respond to first-line treatment, consider secondary dysmenorrhea 5
• Warning signs that suggest secondary dysmenorrhea include:
  • Abnormal uterine bleeding 5
  • Dyspareunia (painful intercourse) 5
  • Noncyclic pain 5
  • Changes in intensity and duration of pain 5
  • Abnormal pelvic examination findings 5
• Endometriosis is the most common cause of secondary dysmenorrhea 5, 6
• Adenomyosis symptoms include dysmenorrhea, menorrhagia, and a uniformly enlarged uterus 5

Treatment Algorithm

1. Start with NSAIDs (ibuprofen 400mg every 4-6 hours) at the first sign of menstrual pain 1
2. Add non-pharmacological approaches like heat therapy and acupressure 2
3. If inadequate relief after 2-3 menstrual cycles, consider hormonal contraceptives 2
4. If symptoms persist or worsen, evaluate for secondary causes with transvaginal ultrasonography 5
5. Tailor treatment based on identified underlying pathology 6

Common Pitfalls and Caveats

• Dysmenorrhea is often underdiagnosed, undertreated, and undervalued by women themselves, who accept it as part of the menstrual cycle 4
• About 10% of affected women do not respond to NSAIDs and hormonal contraceptives, necessitating consideration of secondary causes 7
• There is not enough evidence to support the use of yoga, massage, or dietary supplements despite their popularity 5
• Delaying treatment can lead to school/work absenteeism and reduced quality of life 4
• The diagnosis of primary dysmenorrhea is clinical and should be made after excluding secondary causes 6