What is the recommended management for dysmenorrhea (painful menstruation)?

Management of Dysmenorrhea

NSAIDs are the first-line treatment for dysmenorrhea, with ibuprofen 400mg every 4-6 hours or naproxen 500mg every 12 hours being the most effective options. 1, 2, 3

First-Line Pharmacological Treatment

• NSAIDs work by inhibiting prostaglandin synthesis, which reduces uterine hypercontractility that causes pain in dysmenorrhea 2, 4
• Recommended NSAID options:
  • Ibuprofen 400mg every 4-6 hours as needed for pain relief 2
  • Naproxen 500mg followed by 500mg every 12 hours or 250mg every 6-8 hours as required 3
• Treatment should be short-term (5-7 days) during days of bleeding 5, 1
• Take NSAIDs with food to minimize gastrointestinal side effects 5, 2
• Begin treatment at the earliest onset of pain for maximum effectiveness 3, 6

Non-Pharmacological Adjunctive Treatments

• Heat therapy applied to the abdomen or back reduces cramping pain and can be used alongside NSAIDs 1, 6
• Acupressure on specific points (LI4 on hand dorsum, SP6 above medial malleolus) can provide additional pain relief 1
• Peppermint essential oil has shown effectiveness in decreasing dysmenorrhea symptoms 1

Second-Line Treatment Options

• For women who desire contraception or have inadequate relief with NSAIDs, hormonal contraceptives are recommended 1, 7
• Combined oral contraceptives (COCs) provide both contraception and pain relief by reducing endometrial prostaglandin production 7, 8
• Approximately 18% of women with dysmenorrhea do not respond adequately to NSAIDs and may require hormonal treatment 1

Treatment Algorithm

1. Start with NSAIDs at the earliest onset of pain 2, 3

   • Ibuprofen 400mg every 4-6 hours OR
   • Naproxen 500mg followed by 500mg every 12 hours

2. Add non-pharmacological methods 1, 6

   • Heat therapy
   • Acupressure

3. If inadequate relief after 2-3 menstrual cycles or if contraception is desired: 1, 7

   • Add hormonal contraceptives (preferably combined oral contraceptives)

4. For persistent symptoms despite above treatments: 8, 6

   • Evaluate for secondary causes of dysmenorrhea (endometriosis, adenomyosis, fibroids)

Important Considerations

• NSAIDs provide effective relief in approximately 80% of women with primary dysmenorrhea 9
• Taking NSAIDs with food minimizes gastrointestinal side effects 5, 2
• If bleeding irregularities persist and are unacceptable despite treatment, consider alternative methods 5
• For severe cases unresponsive to NSAIDs and hormonal treatments, further evaluation for secondary causes is warranted 8, 6

Common Pitfalls

• Delaying treatment until pain is severe reduces effectiveness - start at earliest onset 3, 6
• Inadequate dosing of NSAIDs - follow recommended dosages for optimal pain relief 2, 3
• Failing to rule out secondary causes when treatment is ineffective 8, 4
• Not considering combined oral contraceptives for women with recurrent dysmenorrhea who also desire contraception 7, 8