Best Treatments for Dysmenorrhea
First-Line Treatment: NSAIDs
NSAIDs are the first-line treatment for dysmenorrhea, with ibuprofen 400 mg every 4-6 hours being the most evidence-based choice, started at the earliest onset of pain. 1, 2
NSAID Dosing Protocols
- Ibuprofen: 400-800 mg every 4-6 hours with food (FDA-approved dosing for dysmenorrhea is 400 mg every 4 hours; doses >400 mg showed no additional benefit in controlled trials) 2, 1
- Naproxen: 440-550 mg every 12 hours with food 1
- Mefenamic acid: Effective for 5-day treatment courses 3
- Treatment duration should be short-term (5-7 days) during days of bleeding 1, 3
Evidence for Specific NSAIDs
Among NSAIDs, flurbiprofen demonstrated superior efficacy in network meta-analysis, outperforming aspirin significantly (OR 0.10,95% CI 0.03-0.29) 4. However, given limited availability, ibuprofen and naproxen remain practical first-line choices with strong evidence showing superiority over acetaminophen and placebo 5, 4. Naproxen 400 mg provided greater pain relief than acetaminophen within 30 minutes and superior relief to ibuprofen at 6 hours 5.
Important caveat: Approximately 18% of women with dysmenorrhea are unresponsive to NSAIDs 1, necessitating alternative approaches.
Second-Line Treatment: Hormonal Contraceptives
For women desiring contraception or those unresponsive to NSAIDs, combined oral contraceptives (COCs) are the preferred second-line therapy. 1, 6
When to Consider Hormonal Treatment
- NSAID failure or intolerance 1
- Desire for contraception 6
- Persistent symptoms despite adequate NSAID trial 1
COCs provide dual benefit of contraception plus dysmenorrhea relief without additional risks beyond standard contraceptive use, making them more suitable for long-term management than repeated NSAID courses 6. For severe cases unresponsive to NSAIDs, hormonal treatments including COCs should be considered 1.
Adjunctive Non-Pharmacological Treatments
These should be used in addition to, not instead of, first-line pharmacological therapy:
- Heat therapy applied to abdomen or back reduces cramping pain 1
- Acupressure at specific points: Large Intestine-4 (LI4) on dorsum of hand and Spleen-6 (SP6) approximately 4 fingers above medial malleolus 1
- Peppermint essential oil has demonstrated symptom reduction 1
- Physical exercise shows strong evidence for benefit 7
Treatment Algorithm for Suspected Secondary Dysmenorrhea
If symptoms suggest underlying pathology, rule out:
- Endometriosis: Consider medical management with progestins, danazol, oral contraceptives, or GnRH agonists 1
- Adenomyosis: Evaluate with ultrasound 8
- Structural abnormalities: Fibroids, polyps, or other pathologic uterine conditions 3, 9
- Sexually transmitted diseases 3, 9
- Pregnancy 3, 9
If underlying gynecological problem is identified, treat the specific condition or refer for specialized care 3, 9.
Safety Considerations
Indomethacin carries higher adverse event risk than other NSAIDs 4, while tiaprofenic acid and mefenamic acid demonstrate the best safety profiles 4. All NSAIDs should be taken with food to minimize gastrointestinal complaints 2.
When to Escalate Treatment
If bleeding irregularities or pain persist despite adequate trials of NSAIDs and hormonal contraceptives and remain unacceptable to the patient, consider alternative contraceptive methods or referral for evaluation of surgical options (endometrial ablation, presacral neurectomy, laparoscopic uterosacral nerve ablation) 1, 7.