Management of Dysmenorrhea (Painful Periods)
NSAIDs are the first-line medication for dysmenorrhea, with naproxen sodium 440-550 mg every 12 hours being the preferred agent recommended by ACOG. 1
First-Line Pharmacologic Treatment
NSAIDs as Primary Therapy
- NSAIDs should be initiated as the first-line treatment for primary dysmenorrhea because they directly inhibit prostaglandin synthesis, which is the underlying cause of menstrual pain—women with dysmenorrhea have elevated prostaglandin levels in menstrual fluid that cause uterine hyperactivity and ischemia 2, 3, 4
- NSAIDs are highly effective, providing moderate to excellent pain relief in 45-53% of women compared to only 18% with placebo (OR 4.37,95% CI 3.76-5.09) 5
- Naproxen sodium 440-550 mg every 12 hours is the specifically recommended regimen 1
- Alternative NSAIDs include ibuprofen 400 mg every 4-6 hours (maximum 2400 mg/day) 6 or other agents like mefenamic acid, though there is insufficient evidence that any individual NSAID is superior to another 5
Optimal Timing Strategy
- Start NSAIDs 2 days before expected menstruation and continue for 5 days for perimenstrual prophylaxis, rather than waiting for pain to begin 1
- This preemptive approach prevents prostaglandin accumulation rather than simply treating established pain 3
Diagnostic Considerations Before Treatment
Distinguishing Primary from Secondary Dysmenorrhea
- Primary dysmenorrhea typically presents 2-3 years after menarche, with pain beginning when bleeding starts and lasting 48-72 hours 2
- If NSAIDs fail to provide adequate relief, verify the diagnosis and consider secondary dysmenorrhea from underlying pelvic pathology (endometriosis, fibroids, pelvic inflammatory disease) 1
- Secondary causes require cause-specific treatment rather than symptomatic management alone 2
Safety Considerations and Contraindications
NSAID Risk Profile
- NSAIDs increase adverse effects compared to placebo (OR 1.29,95% CI 1.11-1.51), including gastrointestinal effects (OR 1.58) and neurological effects (OR 2.74) 5
- Use the lowest effective dose for the shortest duration, and exercise caution in patients at risk for bleeding or with renal impairment 1
- Contraindications include active peptic ulcer disease, cardiovascular disease, renal insufficiency, and history of gastrointestinal bleeding 7
Second-Line and Adjunctive Options
When NSAIDs Are Insufficient or Contraindicated
- Refer for hormonal contraceptive options (combined oral contraceptives reduce endometrial prostaglandin production and provide good relief) 1, 3
- Consider further gynecologic evaluation to rule out secondary causes if first-line therapy fails 1
Complementary Non-Pharmacologic Measures
- Heat therapy (heating pad or hot water bottle to abdomen/back) provides additional symptomatic relief 1
- Acupressure at specific points (Large Intestine-4 and Spleen-6) may offer benefit for primary dysmenorrhea 1
What NOT to Order
Avoid Inappropriate Medications
- Do not prescribe opioids for dysmenorrhea—they are not more effective than NSAIDs for this condition and carry significant risks of dependence, adverse effects, and long-term use (up to 13% of patients develop chronic opioid use after short-term exposure) 7
- Acetaminophen alone is less effective than NSAIDs for dysmenorrhea (OR 1.89 favoring NSAIDs) and does not address the prostaglandin-mediated pathophysiology 5
Common Pitfalls to Avoid
- Starting with inadequate NSAID dosing may lead to perceived treatment failure and inappropriate escalation—ensure maximum recommended doses are reached before declaring failure 8
- Waiting until pain is severe to initiate treatment rather than using prophylactic dosing starting before menses 1
- Failing to reassess the diagnosis when NSAIDs don't work—approximately 10% of women don't respond to NSAIDs, and this should prompt evaluation for secondary causes 9
- Prescribing NSAIDs without counseling about gastrointestinal protection in high-risk patients (older adults, those with cardiovascular or GI comorbidities) 7