What is the recommended treatment for dysmenorrhea?

Treatment of Dysmenorrhea

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

First-Line Pharmacological Treatment

• NSAIDs are the most effective first-line treatment for dysmenorrhea due to their inhibition of prostaglandin synthesis, which is the primary cause of menstrual pain 1, 3
• Ibuprofen 400mg every 4 hours as needed is the FDA-approved dosage specifically for dysmenorrhea 2
• Alternative NSAIDs include naproxen 440-550mg every 12 hours, which may provide longer duration of action 1
• Treatment should be short-term (5-7 days) during days of bleeding for optimal effect and to minimize side effects 1
• NSAIDs work by inhibiting prostaglandin synthesis, directly addressing the pathophysiological mechanism of dysmenorrhea 2

Second-Line Treatments

• For women who desire contraception or who have inadequate response to NSAIDs, hormonal contraceptives are recommended 1, 4
• Combined oral contraceptives are preferred for women without contraindications to estrogen, as they provide both contraception and pain relief 4
• Progesterone-only pills are an alternative for women with contraindications to estrogen-containing contraceptives, though they are not typically first-line for dysmenorrhea management 5
• The levonorgestrel-releasing intrauterine device may be more effective than oral progestin-only methods for dysmenorrhea management 5

Non-Pharmacological Adjunctive Treatments

• Heat therapy applied to the abdomen or back can effectively reduce cramping pain and can be used alongside pharmacological treatments 1, 3
• Acupressure on specific points (Large Intestine-4 and Spleen-6) has shown benefit for pain relief 1
• Peppermint essential oil may decrease symptoms of dysmenorrhea 1
• Regular physical exercise has shown strong evidence for reducing dysmenorrhea symptoms 3

Treatment Algorithm

1. Start with NSAIDs at the earliest onset of pain:

   • Ibuprofen 400mg every 4 hours as needed 2
   • Continue for duration of menstrual pain (typically 2-3 days) 6

2. If inadequate response to NSAIDs or contraception is desired:

   • Consider combined hormonal contraceptives if no contraindications to estrogen 4
   • Consider progesterone-only methods if estrogen is contraindicated 5

3. Add non-pharmacological approaches:

   • Heat therapy 1, 3
   • Physical exercise 3
   • Acupressure 1

Important Considerations and Pitfalls

• Approximately 18% of women with dysmenorrhea may not respond to NSAIDs, requiring alternative treatment approaches 1
• NSAIDs should be taken with food to minimize gastrointestinal side effects 2
• If dysmenorrhea persists despite appropriate treatment, secondary causes (such as endometriosis, adenomyosis, or fibroids) should be considered 7
• For severe cases unresponsive to medical management, surgical options may be considered, though these are rarely needed 3
• The diagnosis of dysmenorrhea is primarily clinical, based on history and normal physical examination 7