Treatment of Menstrual Pain (Dysmenorrhea)
NSAIDs are the first-line treatment for dysmenorrhea, with 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, 3
First-Line Pharmacological Treatment: NSAIDs
- Start ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours, always taken with food 1, 2, 3
- Treatment duration should be short-term (5-7 days) during days of bleeding only 1, 2
- For optimal effectiveness, naproxen can be started 2 days before expected menstruation as perimenstrual prophylaxis and continued for 5 days 2
- NSAIDs work by blocking prostaglandin production, which is the primary cause of menstrual cramping 4, 5
- Approximately 18% of women will not respond to NSAIDs, requiring investigation for secondary causes 1, 3, 6
Adjunctive Non-Pharmacological Measures
- Heat therapy applied to the abdomen or back reduces cramping pain and should be recommended alongside NSAIDs 1, 2, 3
- Acupressure at specific points provides additional pain relief: 1, 2
- Large Intestine-4 (LI4) point on the dorsum of the hand (bilateral stimulation)
- Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus
- Peppermint essential oil has demonstrated symptom reduction in dysmenorrhea 1, 3
Second-Line Treatment: Hormonal Contraceptives
- If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add combined oral contraceptives (COCs) 1, 3
- Use monophasic formulations with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1
- Extended or continuous cycle COCs are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 1
- COCs provide additional benefits including decreased menstrual blood loss and improvement in acne 1
- Approximately 10% of women will not respond to the combination of NSAIDs and hormonal contraceptives 3, 7
When to Investigate for Secondary Causes
Obtain transvaginal ultrasound if: 3
- Abnormal pelvic examination findings are present
- Symptoms suggest secondary dysmenorrhea (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
Rule out the following conditions: 1, 3
- Pregnancy
- Sexually transmitted diseases (chronic pelvic inflammatory disease can present as worsening dysmenorrhea)
- Structural abnormalities (fibroids, polyps, other uterine pathology)
- Endometriosis or adenomyosis
- IUD displacement in patients with worsening dysmenorrhea
Management of Suspected Endometriosis
- Hormonal contraceptives remain first-line for endometriosis-related dysmenorrhea 3
- If endometriosis is confirmed and medical management fails, GnRH agonists for at least 3 months or danazol for at least 6 months are equally effective 3
- Add-back therapy with GnRH agonists prevents bone mineral loss without reducing efficacy 3
- Medical therapy alone may be insufficient for severe endometriosis 3
Critical Pitfalls to Avoid
- Do not underdose NSAIDs - higher doses (ibuprofen 600-800 mg) are more effective than lower doses in clinical practice 3, 4
- Do not delay NSAID treatment while waiting for diagnostic workup 3
- Do not continue ineffective treatment beyond 2-3 cycles - this indicates need for alternative therapy or investigation 3
- Do not use NSAIDs without food - this increases gastrointestinal adverse effects 1, 2, 3
- Use the lowest effective dose for the shortest duration, and exercise caution in patients at risk for bleeding or with renal impairment 2
Adverse Effects Profile
- NSAIDs carry a 29% increased risk of overall adverse effects compared to placebo 8
- Gastrointestinal adverse effects occur with 58% increased risk 8
- Neurological adverse effects (headaches, drowsiness) occur with 174% increased risk 8
- If 10% of women taking placebo experience side effects, between 11-14% taking NSAIDs will do so 8