What is the recommended treatment for dysmenorrhea?

Treatment of 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

First-Line Pharmacological Treatment

NSAIDs work by inhibiting prostaglandin synthesis, which is the primary driver of dysmenorrhea pain through uterine hypercontractility and ischemia. 1

Specific NSAID Dosing Regimens

• Ibuprofen 600-800 mg every 6-8 hours with food - Higher doses (600-800 mg) are more effective in clinical practice than lower doses 1, 3
• Naproxen 440-550 mg every 12 hours with food 1, 2
• Mefenamic acid 500 mg three times daily for 5 days 4, 2
• Treatment duration: 5-7 days during menstruation only 1, 2, 5

The FDA label for ibuprofen specifically states: "For the treatment of 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." 5 However, clinical guidelines recommend higher doses of 600-800 mg for optimal efficacy. 1, 3

Adjunctive Non-Pharmacological Measures

These can be used alongside NSAIDs to enhance pain relief:

• Heat therapy applied to the abdomen or back reduces cramping pain 1, 2, 6
• Acupressure at Large Intestine-4 (LI4) on the dorsum of the hand and Spleen-6 (SP6) approximately 4 fingers above the medial malleolus 1, 2, 3
• Peppermint essential oil has demonstrated symptom reduction 1, 2
• Physical exercise has strong evidence for reducing dysmenorrhea 6

Second-Line Treatment: When NSAIDs Fail

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

Hormonal Contraceptive Options

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1, 2
• Monophasic formulations are recommended for simplicity 2
• Extended or continuous cycles are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 2

Additional Benefits of COCs

• Decreased menstrual blood loss 1, 2
• Improvement in acne 1, 2
• Completely reversible with no negative effect on long-term fertility 1, 2
• Safe throughout reproductive years 2

For women who desire contraception, COCs are the preferential therapy as they provide pain relief without the risks associated with long-term NSAID use. 7

When to Investigate for Secondary Causes

Approximately 18% of women with dysmenorrhea are unresponsive to NSAIDs, prompting investigation for secondary causes. 2, 3

Indications for Transvaginal Ultrasound

Obtain imaging if: 1, 3

• Abnormal pelvic examination findings are present
• Symptoms suggest secondary dysmenorrhea
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles
• Abrupt change in previously stable pain pattern

Secondary Causes to Rule Out

• Endometriosis 1, 3
• Adenomyosis 1, 3
• Fibroids and polyps 4, 1, 3
• IUD displacement 3
• Sexually transmitted diseases and chronic pelvic inflammatory disease 1, 3
• Pregnancy 4, 2

Management of Suspected Endometriosis

Hormonal contraceptives are first-line for endometriosis-related dysmenorrhea. 1, 3

If medical management fails:

• GnRH agonists for at least 3 months with add-back therapy to prevent bone mineral loss 1, 3
• Danazol for at least 6 months 1, 3
• GnRH agonists and danazol are equally effective for pain relief 3

Approximately 10% of women do not respond to NSAIDs and hormonal contraceptives combined, indicating need for further evaluation. 3

Critical Pitfalls to Avoid

• Do not delay NSAID treatment while waiting for diagnostic workup - start empiric therapy immediately 1, 3
• Do not underdose NSAIDs - use the full therapeutic doses of 600-800 mg ibuprofen or 440-550 mg naproxen, not the lower 400 mg dose 1, 3
• Do not continue ineffective treatment beyond 2-3 cycles - this indicates need for investigation of secondary causes 1, 3
• Do not forget to rule out STDs such as chronic pelvic inflammatory disease, which can present as worsening dysmenorrhea 1, 3
• Do not use combined oral contraceptives to mask symptoms without first attempting to identify underlying pathology in treatment-refractory cases 1

Surgical Options for Refractory Cases

For women who fail medical management: 6, 8

• Endometrial ablation
• Presacral neurectomy
• Laparoscopic uterosacral nerve ablation

Surgical treatment is only indicated in rare cases of severe dysmenorrhea refractory to all medical treatments. 8