What is the treatment for dysmenorrhea (painful menstruation)?

Treatment of Dysmenorrhea (Painful Menstruation)

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

NSAIDs work by inhibiting cyclooxygenase enzymes and blocking prostaglandin formation, which is the primary mechanism causing uterine cramping and pain. 3, 4

Specific NSAID Regimens:

• Ibuprofen 600-800 mg every 6-8 hours with food (FDA-approved dosing for dysmenorrhea is 400 mg every 4 hours, but guideline recommendations support higher doses) 1, 2
• Naproxen 440-550 mg every 12 hours with food 1, 5
• Mefenamic acid 500 mg three times daily is particularly effective for reducing both pain and menstrual blood loss 3, 5

Critical Timing Strategy:

For optimal effectiveness, start NSAIDs 24-48 hours before expected menstruation (perimenstrual prophylaxis) and continue for 5-7 days during bleeding. 5, 6 This prophylactic approach is especially beneficial for women with severe, predictable dysmenorrhea who have failed conventional treatment. 6

NSAID Safety Considerations:

• Use the lowest effective dose for the shortest duration 5, 2
• Always take with food to minimize gastrointestinal side effects 1, 2
• Contraindications include active peptic ulcer disease, cardiovascular disease, renal insufficiency, and history of gastrointestinal bleeding 5
• Exercise caution in patients at risk for bleeding or with renal impairment 3, 5

Second-Line Treatment: Hormonal Contraceptives

If NSAIDs fail after 2-3 menstrual cycles (approximately 18% of women are unresponsive to NSAIDs), hormonal contraceptives are the next step. 1, 5

Combined Oral Contraceptives (COCs):

• Monophasic formulations containing 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are preferred for simplicity 1
• Extended or continuous cycles (minimizing hormone-free intervals) are particularly effective for severe dysmenorrhea because they optimize ovarian suppression and reduce prostaglandin production 7, 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

Alternative Hormonal Options:

• Levonorgestrel intrauterine device (IUD) significantly improves symptoms in women with painful menses and may lead to amenorrhea 7, 3
• Contraceptive vaginal ring or transdermal patch have comparable efficacy to COCs with similar mechanisms 7
• Progestin-only pills are appropriate when estrogen is contraindicated 3

Non-Pharmacological Adjunctive Treatments

These should be used in conjunction with first-line pharmacological therapy, not as replacements:

Evidence-Based Non-Pharmacological Options:

• Heat therapy (heating pad or hot water bottle) applied to abdomen or back reduces cramping pain through local vasodilation 1, 5, 4
• Acupressure on specific points:
  • Large Intestine-4 (LI4) point on the dorsum of the hand (between thumb and index finger)
  • Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus 1, 5
• Peppermint essential oil has demonstrated symptom reduction 1, 8
• Regular aerobic exercise and stretching 8, 4

When to Suspect Secondary Dysmenorrhea

Evaluate for underlying pelvic pathology if:

• Pain does not respond to NSAIDs after 2-3 cycles 1, 5
• Symptoms worsen over time or begin after age 25 9, 10
• Physical examination reveals abnormalities 9, 10
• Associated symptoms include abnormal bleeding, dyspareunia, or infertility 8, 4

Required Evaluation for Treatment Failure:

• Rule out pregnancy immediately 3, 5
• Screen for sexually transmitted infections 3, 8
• Evaluate for structural abnormalities: fibroids, polyps, endometriosis, adenomyosis 1, 3
• Consider pelvic ultrasound if symptoms persist despite treatment 3

Common Pitfalls to Avoid

• Never prescribe opioids for dysmenorrhea - they are not more effective than NSAIDs and carry significant risks of dependence 5
• Do not prescribe NSAIDs without counseling about gastrointestinal protection in high-risk patients (older adults, those with cardiovascular or GI comorbidities) 5
• Do not exceed 3200 mg total daily dose of ibuprofen 2
• Avoid dismissing dysmenorrhea as "normal" - it is undertreated and underdiagnosed despite causing significant school and work absenteeism 9, 10

Severe Dysmenorrhea with Systemic Symptoms

If dysmenorrhea presents with vomiting, difficulty breathing, severe headache, or dizziness, urgent evaluation is required to exclude severe anemia, acute complications, severe dehydration, and pregnancy complications. 3 These are not typical symptoms of primary dysmenorrhea and warrant immediate cardiopulmonary and hematologic assessment. 3