What is the workup and treatment for a 39-year-old woman with chronic dysmenorrhea (painful periods)?

Workup and Management of Chronic Dysmenorrhea in a 39-Year-Old Woman

Start with NSAIDs as first-line therapy—specifically ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours, taken with food for 5-7 days during menstruation—and only pursue imaging if symptoms suggest secondary causes or if the patient fails to respond to initial treatment. 1, 2

Initial Clinical Assessment

Key History Elements to Obtain

• Timing and pattern of pain: Primary dysmenorrhea presents with cramping pain in the lower abdomen occurring just before or during menstruation 3, 4
• Red flags for secondary causes: Abnormal uterine bleeding, dyspareunia (painful intercourse), noncyclic pelvic pain, changes in intensity/duration of pain over time 4
• Response to prior treatments: Approximately 18% of women are unresponsive to NSAIDs, which should prompt investigation for secondary causes 1

Physical Examination

• Perform a pelvic examination if the patient has had vaginal intercourse 4
• Normal pelvic exam findings support primary dysmenorrhea; abnormal findings (enlarged uterus, adnexal masses, tenderness) suggest secondary causes requiring imaging 4

First-Line Treatment Protocol

NSAID Therapy

Ibuprofen is the preferred initial agent with FDA-approved dosing for dysmenorrhea of 400 mg every 4 hours as needed, starting at the earliest onset of pain 2

However, higher doses are more effective in clinical practice:

• Ibuprofen 600-800 mg every 6-8 hours with food 1
• Alternative: Naproxen 440-550 mg every 12 hours 1
• Treatment duration: 5-7 days during bleeding only 1
• NSAIDs work by inhibiting prostaglandin synthesis, which reduces uterine contractions and ischemic pain 2, 5

Adjunctive Non-Pharmacological Measures

• Heat therapy applied to abdomen or back reduces cramping 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

When to Escalate Treatment

Hormonal Contraceptives (Second-Line)

If NSAIDs fail or are contraindicated, add hormonal contraceptives:

• Combined oral contraceptives are effective for dysmenorrhea and appropriate if contraception is desired 6, 1
• Oral or depot medroxyprogesterone acetate are effective alternatives 6
• These work by suppressing endometrial prostaglandin production 5

Important Caveat

About 10% of women do not respond to NSAIDs and hormonal contraceptives combined 3. This treatment failure mandates investigation for secondary causes.

Indications for Imaging Workup

When to Order Transvaginal Ultrasound

Obtain transvaginal ultrasound if:

• Abnormal pelvic examination findings 4
• Symptoms suggesting secondary dysmenorrhea (noncyclic pain, dyspareunia, abnormal bleeding) 4
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles 3, 5
• Abrupt change in previously stable pain pattern 6

What to Look For

• Endometriosis (most common cause of secondary dysmenorrhea) 4
• Adenomyosis: uniformly enlarged uterus with dysmenorrhea and menorrhagia 6
• Structural abnormalities: fibroids, polyps, other uterine pathology 1
• Rule out pregnancy if indicated 1

Management of Suspected Endometriosis

If endometriosis is suspected based on clinical presentation or imaging:

• GnRH agonists for at least 3 months or danazol for at least 6 months are equally effective for pain relief 6
• Add-back therapy with GnRH agonists prevents bone mineral loss without reducing efficacy 6
• Hormonal contraceptives are first-line for endometriosis-related dysmenorrhea 4
• Medical therapy alone may be insufficient for severe endometriosis 6

Common Pitfalls to Avoid

• Don't delay NSAID treatment waiting for workup: Primary dysmenorrhea is a clinical diagnosis in typical presentations 3, 5
• Don't underdose NSAIDs: The FDA-approved 400 mg ibuprofen dose is often insufficient; 600-800 mg is more effective 1, 2
• Don't continue ineffective treatment: If no improvement after 2-3 cycles of appropriate NSAID therapy, investigate for secondary causes 5
• Don't forget to rule out STDs: Chronic pelvic inflammatory disease can present as worsening dysmenorrhea 1