What is the first line of treatment for dysmenorrhea?

First-Line Treatment for Dysmenorrhea

NSAIDs are the first-line 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 only. 1, 2, 3

NSAID Treatment Protocol

• Start NSAIDs at the earliest onset of menstrual pain and continue for 5-7 days during bleeding only 1, 3
• Ibuprofen should be dosed at 600-800 mg every 6-8 hours with food, which is more effective than lower doses in clinical practice 2
• Naproxen is an acceptable alternative at 440-550 mg every 12 hours 1
• For dysmenorrhea specifically, the FDA label recommends ibuprofen 400 mg every 4 hours as necessary, though higher doses (600-800 mg) are commonly used in practice 3
• Do not exceed 3200 mg total daily dose of ibuprofen 3

The key pitfall is underdosing NSAIDs—doses of 400 mg are often insufficient, and 600-800 mg every 6-8 hours provides superior pain relief. 2

When NSAIDs Fail or Are Contraindicated

Approximately 18% of women with dysmenorrhea are unresponsive to NSAIDs, which should prompt investigation for secondary causes 1, 2, 4

If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add hormonal contraceptives as second-line treatment: 2, 5

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are recommended 1
• Use monophasic formulations for simplicity 1
• Extended or continuous cycles are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 1
• COCs are completely reversible with no negative effect on long-term fertility 1

For women who desire contraception, COCs should be considered as first-line therapy alongside NSAIDs, as they provide both contraception and pain relief without additional risk. 5

Adjunctive Non-Pharmacological Measures

These can be used alongside NSAIDs but should not replace them:

• 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

When to Investigate for Secondary Causes

Obtain transvaginal ultrasound if: 2

• Abnormal pelvic examination findings are present
• Symptoms suggest secondary dysmenorrhea (e.g., pain outside of menstruation, dyspareunia, abnormal bleeding)
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles
• Abrupt change in previously stable pain pattern

Before starting treatment, rule out: 1

• Pregnancy
• Sexually transmitted diseases (chronic PID can present as worsening dysmenorrhea)
• IUD displacement in patients with worsening dysmenorrhea
• Structural abnormalities such as fibroids, polyps, or other uterine pathology

Common Pitfalls to Avoid

• Do not delay NSAID treatment while waiting for workup 2
• Do not underdose NSAIDs—use 600-800 mg ibuprofen, not 400 mg 2
• Do not continue ineffective treatment—if NSAIDs fail after 2-3 cycles, add hormonal contraceptives or investigate for secondary causes 2
• Do not forget to rule out STDs, as chronic pelvic inflammatory disease can present as worsening dysmenorrhea 2