What is the recommended treatment for menstrual cramps?

Treatment of Menstrual Cramps

NSAIDs are the first-line treatment for menstrual cramps, with naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours taken with food for 5-7 days during menstruation. 1, 2

First-Line Pharmacological Treatment

NSAIDs should be started at the onset of bleeding and continued for 5-7 days only during menstruation. 1 The two most effective options are:

• Naproxen sodium 440-550 mg every 12 hours, which can also be used prophylactically starting 2 days before expected menstruation and continuing for 5 days 2
• Ibuprofen 600-800 mg every 6-8 hours (maximum 3200 mg daily), always taken with food to minimize gastric irritation 1, 3

The advantage of naproxen is its twice-daily dosing and option for perimenstrual prophylaxis, which may prevent cramps before they start. 2 Ibuprofen requires more frequent dosing but is equally effective. 1, 3

Important caveat: Use the lowest effective dose for the shortest duration, and exercise caution in patients at risk for bleeding or with renal impairment. 2 NSAIDs can cause gastric irritation, so gastric protection should be considered for prolonged use. 4

When NSAIDs Fail

Approximately 18% of women do not respond to NSAIDs. 1 If NSAIDs fail after 2-3 menstrual cycles, the next steps are:

• Verify the diagnosis and rule out secondary dysmenorrhea from underlying pelvic pathology (fibroids, polyps, endometriosis, STDs, pregnancy) 1, 2
• Consider hormonal contraceptives as second-line therapy 1, 2:
  • Combined oral contraceptives with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1
  • Monophasic formulations are preferred for simplicity 1
  • Extended or continuous cycles are particularly effective 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

Complementary Non-Pharmacological Treatments

These can be used alongside NSAIDs for additional relief:

• Heat therapy applied to the abdomen or back reduces cramping pain 1, 2
• Acupressure on specific points:
  • Large Intestine-4 (LI4) point on the dorsum of the hand 1, 2
  • Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus 1, 2
• Peppermint essential oil has been shown to decrease dysmenorrhea symptoms 1

Treatment Algorithm

1. Start with NSAIDs (naproxen or ibuprofen) for 5-7 days during menstruation 1, 2
2. Add heat therapy and acupressure for additional relief 1, 2
3. If no improvement after 2-3 cycles, rule out secondary causes (pelvic exam, ultrasound if indicated) 1, 2
4. If NSAIDs fail and no secondary causes found, initiate combined oral contraceptives, preferably in extended or continuous cycles 1
5. If suspected endometriosis, consider progestins, oral contraceptives, or refer for further gynecologic evaluation 1, 2

Common Pitfalls to Avoid

• Underdosing NSAIDs: Many women take insufficient doses (e.g., 200-400 mg ibuprofen instead of 600-800 mg) 3
• Starting treatment too late: NSAIDs work best when started at the first sign of bleeding or even 1-2 days before expected menses 2, 5
• Continuing NSAIDs beyond menstruation: Treatment should be limited to 5-7 days during bleeding only to minimize side effects 1
• Missing secondary dysmenorrhea: Always rule out pregnancy, STDs, and structural abnormalities if pain is severe or unresponsive to treatment 1