What is the treatment for dysmenorrhea?

Treatment of Dysmenorrhea

Start with NSAIDs as first-line therapy: 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

First-Line Pharmacological Treatment

• NSAIDs are the mainstay of treatment because they inhibit prostaglandin synthesis, which is the primary driver of dysmenorrhea pain through uterine hypercontractility and ischemia 1, 3, 4

• Specific dosing regimens:

  • Ibuprofen 600-800 mg every 6-8 hours with food 1, 2, 3
  • Naproxen 440-550 mg every 12 hours with food 1, 2
  • Mefenamic acid for 5-day treatment courses 2
  • Treatment duration should be short-term (5-7 days) during days of bleeding only 2, 3

• Higher doses of ibuprofen (600-800 mg) are more effective in clinical practice than lower doses, though doses above 400 mg every 4-6 hours showed no additional benefit in controlled trials 1, 3

• Critical timing: Begin NSAIDs at the earliest onset of menstrual pain for maximum effectiveness 3

Adjunctive Non-Pharmacological Measures

• Heat therapy applied to the abdomen or back reduces cramping pain and can be used alongside NSAIDs 1, 2

• Acupressure at specific anatomical points:

  • Large Intestine-4 (LI4) on the dorsum of the hand 1, 2
  • Spleen-6 (SP6) approximately 4 fingers above the medial malleolus 1, 2

• Peppermint essential oil has demonstrated symptom reduction 1, 2

Second-Line Treatment When NSAIDs Fail

• If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add hormonal contraceptives 1, 2

• For women desiring contraception, combined oral contraceptives (COCs) are preferred as second-line therapy:

  • Use monophasic formulations with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 2
  • Extended or continuous cycles are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 2
  • COCs provide additional benefits including decreased menstrual blood loss, improvement in acne, and are completely reversible with no negative effect on long-term fertility 2

• Approximately 18% of women are unresponsive to NSAIDs alone, and approximately 10% do not respond to NSAIDs plus hormonal contraceptives combined 1, 2, 5

When to Investigate for Secondary Causes

• Obtain transvaginal ultrasound if:

  • Abnormal pelvic examination findings are present 1
  • Symptoms suggest secondary dysmenorrhea (e.g., dyspareunia, abnormal bleeding, chronic pelvic pain) 1
  • Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles 1
  • Abrupt change in previously stable pain pattern 1

• Rule out:

  • Endometriosis, adenomyosis, fibroids, polyps, and other structural uterine pathology 1, 2
  • IUD displacement in patients with worsening dysmenorrhea 1
  • Sexually transmitted diseases and chronic pelvic inflammatory disease 1, 2
  • Pregnancy 1, 2

Management of Suspected Endometriosis

• Hormonal contraceptives are first-line for endometriosis-related dysmenorrhea 1

• If endometriosis is confirmed and medical management fails:

  • GnRH agonists for at least 3 months with add-back therapy to prevent bone mineral loss 1
  • Danazol for at least 6 months 1
  • Medical therapy alone may be insufficient for severe endometriosis requiring surgical intervention 1

Critical Pitfalls to Avoid

• Do not delay NSAID treatment while waiting for diagnostic workup - start empiric therapy immediately 1

• Do not underdose NSAIDs - use the full therapeutic doses of 600-800 mg ibuprofen or 440-550 mg naproxen 1

• Do not continue ineffective treatment beyond 2-3 cycles - this indicates need for investigation of secondary causes 1

• Do not forget to rule out STDs such as chronic pelvic inflammatory disease, which can present as worsening dysmenorrhea 1

• Do not use combined oral contraceptives to mask symptoms without first attempting to identify underlying pathology in treatment-refractory cases 6