What is the recommended birth control method for managing dysmenorrhea (painful menstruation)?

Combined Hormonal Contraceptives Are the Recommended First-Line Birth Control Method for Dysmenorrhea

Combined hormonal contraceptives (CHCs) are the recommended first-line birth control method for managing dysmenorrhea as they provide effective pain relief while also offering contraception. 1

Mechanism of Action and Effectiveness

• CHCs work by suppressing ovulation and reducing endometrial lining thickness, which decreases menstrual fluid volume and prostaglandin production, effectively reducing uterine cramping and pain 2, 1
• High-quality evidence shows CHCs provide moderate reduction in dysmenorrhea pain compared to placebo (standardized mean difference -0.58,95% CI -0.74 to -0.41) 1
• Women using CHCs have a 37-60% chance of pain improvement compared to 28% with placebo 1
• CHCs may reduce requirements for additional pain medication (RR 0.63,95% CI 0.40 to 0.98) and decrease absence from work or school (RR 0.63,95% CI 0.41 to 0.97) 1

Available CHC Options

• Three main types of CHCs are available 3:
  1. Combined oral contraceptive pills (COCs) - various formulations
  2. Transdermal contraceptive patch - releases 150 μg norelgestromin and 20 μg ethinyl estradiol daily
  3. Vaginal contraceptive ring - releases 120 μg etonogestrel and 15 μg ethinyl estradiol daily

Optimal CHC Regimen for Dysmenorrhea

• Continuous use of CHCs (without the hormone-free interval) may provide better pain relief than standard cyclic regimens (SMD -0.73,95% CI -1.13 to -0.34) 1
• There is no significant difference in pain improvement between different generations of COCs (third/fourth vs. first/second generation) (RR 0.99,95% CI 0.93 to 1.05) 1
• No significant difference has been found between ethinylestradiol 20 μg and 30 μg formulations for pain relief 1

Alternative Options

• For women who cannot or prefer not to use hormonal methods, NSAIDs are an effective first-line treatment for dysmenorrhea 4
• Limited evidence comparing CHCs directly with NSAIDs makes it uncertain whether one is superior to the other for pain relief 1
• NSAIDs may be used in conjunction with CHCs for breakthrough pain during menstruation 3

Potential Adverse Effects

• Common side effects of CHCs include 1:
  • Irregular bleeding (RR 2.63,95% CI 2.11 to 3.28)
  • Headaches (RR 1.51,95% CI 1.11 to 2.04)
  • Nausea (RR 1.64,95% CI 1.17 to 2.30)
• Continuous CHC regimens may have fewer adverse events than standard cyclic regimens (RR 1.11,95% CI 1.01 to 1.22 for standard vs. continuous) 1
• Women should be counseled about these potential side effects before starting treatment 3

Practical Recommendations

• CHCs can be initiated at any time if pregnancy is reasonably excluded 3
• If started within the first 5 days of menstrual bleeding, no additional contraceptive protection is needed 3
• If started >5 days since menstrual bleeding began, use additional contraception for the next 7 days 3
• For maximum pain relief, consider continuous or extended CHC regimens with infrequent or no hormone-free intervals 1

Special Considerations

• CHCs are contraindicated in women with certain conditions (e.g., history of venous thromboembolism, migraine with aura, certain cardiovascular conditions) 3
• Postpartum women who are breastfeeding should not use CHCs during the first 3 weeks after delivery due to increased risk of venous thromboembolism 3
• If dysmenorrhea persists despite CHC use, consider evaluation for underlying gynecological conditions such as endometriosis or adenomyosis 3