What are the best treatment options for dysmenorrhea (painful menstruation)?

Best Treatment Options for Dysmenorrhea

NSAIDs are the first-line treatment for dysmenorrhea, with ibuprofen 400 mg every 4-6 hours or naproxen 440-550 mg every 12 hours being the most effective options, and for women desiring contraception, combined hormonal contraceptives should be added or used as monotherapy. 1, 2

First-Line Pharmacological Treatment

NSAIDs as Primary Therapy

• Start with ibuprofen 400 mg every 4-6 hours as needed for pain relief, beginning at the earliest onset of menstrual pain 2
• Alternative regimens include ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours, always taken with food 1
• Treatment duration should be short-term (5-7 days) during days of bleeding 3, 1
• Maximum daily ibuprofen dose should not exceed 3200 mg, though doses above 400 mg have not shown superior efficacy in controlled trials 2
• Naproxen provides superior pain relief compared to acetaminophen and ibuprofen at 6 hours post-administration 4
• NSAIDs work by inhibiting prostaglandin synthesis, which directly addresses the pathophysiology of dysmenorrhea by reducing uterine hypercontractility 5, 6

When NSAIDs Fail or Are Contraindicated

• Approximately 18% of women with dysmenorrhea are unresponsive to NSAIDs 1
• For women who desire contraception or fail NSAID therapy, combined oral contraceptives (COCs) are the preferred next step 7, 5
• COCs provide pain relief without additional risks beyond their contraceptive profile and eliminate NSAID-related gastrointestinal risks 7
• Hormonal contraceptives can be used alone or in combination with NSAIDs for enhanced efficacy 6, 8

Non-Pharmacological Adjunctive Treatments

Evidence-Based Complementary Therapies

• Heat therapy applied to the abdomen or back reduces cramping pain and should be recommended alongside NSAIDs 1, 8
• Physical exercise has strong evidence for reducing dysmenorrhea symptoms 8
• Acupressure on specific points: Large Intestine-4 (LI4) on the dorsum of the hand and Spleen-6 (SP6) located approximately 4 fingers above the medial malleolus 1
• Peppermint essential oil has demonstrated symptom reduction 1

Less Evidence-Based Options

• Dietary supplements, acupuncture, and transcutaneous electrical nerve stimulation (TENS) have limited evidence and should only be used in conjunction with first-line therapy after discussing risks and benefits 8

Treatment Algorithm

Step 1: Initial Assessment

• Confirm primary dysmenorrhea through clinical history and normal physical examination 5, 6
• Rule out secondary causes: endometriosis, adenomyosis, fibroids, polyps, STDs, or pregnancy 3
• Ultrasound is useful to exclude secondary causes like endometriosis and adenomyosis 6

Step 2: First-Line Treatment

• Start NSAIDs (ibuprofen 400 mg every 4-6 hours) at the earliest onset of menstrual pain 2
• Add heat therapy and recommend regular physical exercise 1, 8

Step 3: If NSAIDs Alone Are Insufficient

• For women desiring contraception: add or switch to combined oral contraceptives 7, 5
• For women not desiring contraception: consider increasing NSAID dose (up to ibuprofen 800 mg every 6-8 hours or naproxen 550 mg every 12 hours) 1

Step 4: Refractory Cases

• For suspected endometriosis: consider progestins, danazol, or GnRH agonists 1
• Counsel on alternative contraceptive methods if bleeding irregularities persist and are unacceptable 1
• Surgical options (endometrial ablation, presacral neurectomy, laparoscopic uterosacral nerve ablation) are reserved for severe cases refractory to all medical management 5, 8

Critical Pitfalls to Avoid

• Do not wait to start NSAIDs—they must be initiated at the earliest onset of menstrual pain for maximum efficacy 2
• Do not prescribe ibuprofen doses above 400 mg expecting better pain relief; controlled trials show no additional benefit 2
• Do not overlook the need to rule out secondary causes, particularly in women with new-onset severe dysmenorrhea or dysmenorrhea that worsens over time 3, 5
• Do not dismiss hormonal contraceptives as second-line; for women desiring contraception, they should be considered first-line alongside NSAIDs 7
• Always take NSAIDs with food to minimize gastrointestinal side effects 1, 2