What are the treatment options for dysmenorrhea?

Treatment Options for Dysmenorrhea

First-Line Pharmacological Treatment

NSAIDs are the definitive 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

NSAID Protocol

• Ibuprofen 600-800 mg every 6-8 hours with food is the preferred initial agent, as it inhibits cyclooxygenase enzymes and blocks prostaglandin formation that causes uterine cramping 1, 4, 3
• Alternative: Naproxen 440-550 mg every 12 hours with food 1, 2
• Alternative: Mefenamic acid 500 mg three times daily, which is particularly effective for reducing both pain and menstrual blood loss 1, 4
• Treatment duration should be 5-7 days during days of bleeding only 1, 3
• Start NSAIDs at the earliest onset of pain for maximum effectiveness 3
• Approximately 18% of women are unresponsive to NSAIDs, which should prompt investigation for secondary causes 1, 2

The FDA label for ibuprofen specifically states that for dysmenorrhea, "beginning with the earliest onset of such pain, ibuprofen tablets should be given in a dose of 400 mg every 4 hours as necessary for the relief of pain," though clinical guidelines recommend higher doses of 600-800 mg for better efficacy 3, 2.

Second-Line Pharmacological Treatment

If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add hormonal contraceptives as second-line therapy. 1, 2, 4

Hormonal Contraceptive Options

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are the preferred hormonal option 1
• Monophasic formulations are recommended 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 provide additional benefits including decreased menstrual blood loss, improvement in acne, and are completely reversible with no negative effect on long-term fertility 1
• Levonorgestrel IUD improves dysmenorrhea and heavy menses, particularly useful when estrogen is contraindicated 5
• Progestin-only pills are an alternative if estrogen is contraindicated 4
• Approximately 10% of women do not respond to NSAIDs and hormonal contraceptives combined, requiring further evaluation 2

For women desiring contraception, COCs are preferable as first-line therapy since they provide pain relief without the additional risks of NSAIDs and are more suitable for long-term use 6.

Non-Pharmacological Adjunctive Treatments

Heat therapy and acupressure have demonstrated efficacy and should be offered alongside pharmacological treatment. 1, 2, 4

Evidence-Based Non-Pharmacological Options

• Heat therapy applied to the abdomen or back reduces cramping pain 1, 2, 4
• Acupressure on Large Intestine-4 (LI4) point on the dorsum of the hand 1, 2, 4
• Acupressure on Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus 1, 4
• Peppermint essential oil has demonstrated symptom reduction 1, 2
• Aerobic exercise and stretching may provide benefit 7

When to Investigate for Secondary Causes

Obtain transvaginal ultrasound if NSAIDs fail after 2-3 menstrual cycles, if there are abnormal pelvic examination findings, or if there is an abrupt change in previously stable pain pattern. 2

Conditions to Rule Out

• Pregnancy - must be ruled out immediately, especially if vomiting or systemic symptoms are present 2, 4
• Sexually transmitted infections - screen for gonorrhea and Chlamydia, as chronic PID can present as worsening dysmenorrhea 2, 4
• Structural abnormalities - fibroids, polyps, adenomyosis 1, 2, 4
• Endometriosis - suspect if pain is severe, progressive, or unresponsive to standard treatment 2, 7
• IUD displacement - in patients with worsening dysmenorrhea who have an IUD 2

Management of Suspected Endometriosis

If endometriosis is suspected, hormonal contraceptives are first-line, with GnRH agonists reserved for refractory cases. 2

• Hormonal contraceptives (COCs, progestins) are first-line for endometriosis-related dysmenorrhea 2
• GnRH agonists for at least 3 months or danazol for at least 6 months are equally effective for pain relief in confirmed endometriosis 2
• Add-back therapy with GnRH agonists prevents bone mineral loss without reducing efficacy 2
• Medical therapy alone may be insufficient for severe endometriosis, requiring surgical intervention 2

Management of Severe Dysmenorrhea with Systemic Symptoms

Urgent evaluation is required when dysmenorrhea presents with vomiting, difficulty breathing, severe headache, or dizziness to exclude severe anemia, acute complications, or pregnancy-related issues. 4

Red Flags Requiring Immediate Assessment

• Difficulty breathing - not typical of dysmenorrhea, requires urgent cardiopulmonary assessment 4
• Severe headache with dizziness - could indicate severe anemia, hypertension, or other serious conditions 4
• Persistent vomiting - risks dehydration and electrolyte abnormalities; consider antiemetics and rule out pregnancy 4

Common Pitfalls to Avoid

• Do not underdose NSAIDs - use 600-800 mg ibuprofen, not 400 mg, for better efficacy 2
• Do not delay NSAID treatment while waiting for workup 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 - chronic PID can mimic primary dysmenorrhea 2
• Do not assume all dysmenorrhea is primary - approximately 18% of women are unresponsive to NSAIDs, indicating possible secondary causes 1, 2