What are the management options for dysmenorrhea?

Management of Dysmenorrhea

First-Line Treatment: NSAIDs

Start with NSAIDs as the primary treatment for dysmenorrhea, 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. 1, 2

NSAID Dosing Protocol

• Ibuprofen: 600-800 mg every 6-8 hours with food, or 400 mg every 4-6 hours for milder cases 1, 3
• Naproxen: 440-550 mg every 12 hours, or for acute severe pain, start with 750 mg followed by 250 mg every 8 hours 1, 4
• Treatment duration: Short-term only (5-7 days) during days of bleeding 1, 2
• Timing: Begin at the earliest onset of pain or menstrual flow for maximum effectiveness 3

Higher doses of ibuprofen (600-800 mg) are more effective in clinical practice than lower doses, though doses above 400 mg in controlled trials showed no additional benefit over 400 mg for mild-to-moderate pain 3. Naproxen provides superior pain relief compared to acetaminophen and ibuprofen at 6 hours post-administration 5.

Critical NSAID Considerations

• Approximately 18% of women are unresponsive to NSAIDs and require investigation for secondary causes 1, 2
• Do not underdose NSAIDs—use therapeutic doses from the start 2
• If no response after 2-3 menstrual cycles, proceed to imaging and evaluation for secondary causes 2

Adjunctive Non-Pharmacological Treatments

These can be used alongside NSAIDs to enhance pain relief:

• Heat therapy applied to the abdomen or back reduces cramping pain 1, 2
• Acupressure at Large Intestine-4 (LI4) point on the dorsum of the hand and Spleen-6 (SP6) point approximately 4 fingers above the medial malleolus 1, 2
• Peppermint essential oil has demonstrated symptom reduction 1, 2
• Physical exercise has strong evidence for reducing dysmenorrhea 6

Second-Line Treatment: Hormonal Contraceptives

If NSAIDs fail, are contraindicated, or the patient desires contraception, add combined oral contraceptives as second-line treatment. 1, 2, 7

• Hormonal contraceptives are particularly appropriate for women who want contraception, as they provide dual benefit without additional risk 7
• Combined oral contraceptives are first-line for endometriosis-related dysmenorrhea 2
• Approximately 10% of women fail both NSAIDs and hormonal contraceptives combined, requiring further investigation 2

When to Investigate for Secondary Causes

Obtain transvaginal ultrasound if: 2

• Abnormal pelvic examination findings
• Symptoms suggesting secondary dysmenorrhea (progressively worsening pain, pain outside menstruation, dyspareunia)
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles
• Abrupt change in previously stable pain pattern

Conditions to Rule Out

• Endometriosis, adenomyosis, fibroids, polyps, or other structural uterine pathology 1, 2
• Sexually transmitted diseases (chronic PID can present as worsening dysmenorrhea) 1, 2
• Pregnancy 1, 2
• IUD displacement (if applicable) 8

Management of Suspected Endometriosis

If endometriosis is suspected based on clinical presentation or imaging: 2

• First-line: Hormonal contraceptives (combined oral contraceptives or progestins)
• Second-line: GnRH agonists for at least 3 months with add-back therapy to prevent bone mineral loss, or danazol for at least 6 months
• Medical therapy alone may be insufficient for severe endometriosis requiring surgical intervention

Treatment Algorithm Summary

1. Start NSAIDs at therapeutic doses (ibuprofen 600-800 mg q6-8h or naproxen 440-550 mg q12h) for 5-7 days during menstruation 1, 2
2. Add adjunctive measures (heat, acupressure, exercise) 1, 2
3. If inadequate response after 2-3 cycles: Add hormonal contraceptives (especially if contraception desired) OR investigate for secondary causes 2
4. If both NSAIDs and hormonal contraceptives fail: Obtain imaging to evaluate for structural pathology or endometriosis 2
5. For confirmed endometriosis: Consider GnRH agonists with add-back therapy or refer for possible surgical management 2

Common Pitfalls to Avoid

• Do not delay NSAID treatment while waiting for workup 2
• Do not underdose NSAIDs—use full therapeutic doses from the start 2
• Do not continue ineffective treatment beyond 2-3 cycles without investigation 2
• Do not forget to rule out STDs, particularly chronic PID 2
• Do not accept treatment failure without imaging—18% of women are NSAID non-responders requiring alternative approaches 1, 2