What is the initial treatment for severe dysmenorrhoea?

Initial Treatment for Severe Dysmenorrhoea

Start with NSAIDs at the earliest onset of menstrual pain, using ibuprofen 400 mg every 4 hours or naproxen 440-550 mg every 12 hours, taken with food for 5-7 days during bleeding. 1, 2

First-Line Pharmacological Treatment

NSAIDs are the mainstay of therapy and should be initiated at the first sign of menstrual cramping, as they work by inhibiting prostaglandin synthesis—the primary mediator of dysmenorrhoeic pain. 1, 2, 3, 4

Specific NSAID Regimens:

• Ibuprofen 400 mg every 4 hours as needed for pain relief (FDA-approved dosing for dysmenorrhoea) 2
• Naproxen 440-550 mg every 12 hours with food 1
• Ibuprofen 600-800 mg every 6-8 hours can be used for more severe pain, though doses above 400 mg have not shown superior efficacy in controlled trials 2
• Treatment duration: 5-7 days during menstrual bleeding only 1

Evidence Supporting NSAIDs:

NSAIDs demonstrate substantial superiority over placebo, with approximately 45-53% of women achieving moderate to excellent pain relief compared to only 18% with placebo (OR 4.37,95% CI 3.76-5.09). 4 This represents a clinically meaningful improvement in pain control and quality of life. 4

Important Prescribing Considerations

Always advise taking NSAIDs with food to minimize gastrointestinal adverse effects. 1, 2 Women taking NSAIDs have an increased risk of side effects (11-14% vs 10% with placebo), including gastrointestinal complaints (OR 1.58) and neurological symptoms like headache (OR 2.74). 4

Do not exceed 3200 mg total daily dose of ibuprofen, and use the lowest effective dose for the shortest duration. 2

Adjunctive Non-Pharmacological Measures

While NSAIDs are being initiated, recommend:

• Heat therapy applied to abdomen or back to reduce cramping pain 1
• Acupressure at specific points: Large Intestine-4 (LI4) on the dorsum of the hand and Spleen-6 (SP6) located 4 fingers above the medial malleolus 1
• Peppermint essential oil has demonstrated symptom reduction 1

When to Escalate Treatment

Approximately 18% of women with dysmenorrhoea are unresponsive to NSAIDs. 1 If NSAIDs fail after 2-3 menstrual cycles:

Second-Line: Hormonal Contraceptives

• Combined oral contraceptives should be considered if bleeding irregularities persist or NSAIDs provide inadequate relief 1
• Hormonal contraceptives reduce endometrial prostaglandin production and menstrual fluid volume 3
• The American Academy of Family Physicians recommends hormonal treatments for severe cases unresponsive to NSAIDs 1

Critical Exclusions Before Treatment

Before diagnosing primary dysmenorrhoea and initiating NSAIDs, rule out secondary causes:

• Pregnancy must be excluded 1
• Screen for sexually transmitted infections and treat if present 1
• Evaluate for structural abnormalities (fibroids, polyps, other uterine pathology) 1
• Consider endometriosis in women with severe symptoms unresponsive to first-line therapy; these patients may require progestins, danazol, oral contraceptives, or GnRH agonists 1

Common Pitfalls to Avoid

Do not wait until pain is severe to start NSAIDs—they are most effective when initiated at the earliest onset of menstrual symptoms or even prophylactically. 2, 3

Do not use combined oral contraceptives as first-line monotherapy unless there is a contraceptive indication, as NSAIDs are more appropriate initial treatment with better evidence for primary dysmenorrhoea. 5, 1

Do not assume treatment failure after one cycle—allow 2-3 menstrual cycles to assess NSAID efficacy before escalating therapy. 6

Do not overlook the 10% of women who fail both NSAIDs and hormonal therapy—these patients require thorough evaluation for secondary causes, particularly endometriosis. 6, 7