Recommended Treatment for Menstrual Pain
NSAIDs are the first-line treatment for menstrual pain (dysmenorrhea), with naproxen sodium 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours taken with food for 5-7 days during menstruation being the most effective options. 1, 2, 3
First-Line Pharmacologic Treatment: NSAIDs
Preferred NSAID Regimens
Naproxen sodium is the preferred agent based on superior efficacy data, dosed at 440-550 mg every 12 hours during menstruation, with a maximum daily dose not exceeding 1,500 mg 2, 3
Naproxen can be started prophylactically 2 days before expected menstruation and continued for 5 days for perimenstrual prophylaxis 2
Ibuprofen is an effective alternative at 600-800 mg every 6-8 hours (not to exceed 2,400 mg daily), taken with food 1, 3, 4
Treatment duration should be short-term (5-7 days) during days of bleeding only 1, 2
Naproxen 400 mg provides greater pain relief than acetaminophen and ibuprofen at 6 hours post-administration 5
Critical Safety Considerations
Absolute contraindications to NSAIDs include: active peptic ulcer disease, cardiovascular disease, renal insufficiency, and history of gastrointestinal bleeding 2, 3
Use the lowest effective dose for the shortest duration, exercising caution in patients at risk for bleeding or with renal impairment 2, 3
Patients with gastrointestinal risk factors (age ≥60 years, history of peptic ulcer disease, significant alcohol use) require close monitoring for gastrointestinal side effects 3
Never prescribe opioids for dysmenorrhea - they are not more effective than NSAIDs and carry significant risks of dependence and adverse effects 2
Second-Line Treatment: Hormonal Contraceptives
When to Escalate to Hormonal Therapy
If NSAIDs fail after 2-3 menstrual cycles (approximately 18% of women are unresponsive to NSAIDs), consider hormonal contraceptives 1, 3
Verify the diagnosis and rule out secondary dysmenorrhea from underlying pelvic pathology before escalating treatment 2
Hormonal Contraceptive Protocol
Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are recommended as second-line therapy 1, 3
Monophasic formulations are preferred 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 are completely reversible with no negative effect on long-term fertility 1
Adjunctive Non-Pharmacologic Measures
Evidence-Based Complementary Therapies
Heat therapy applied to the abdomen or back may reduce cramping pain 1, 2, 3
Acupressure on specific points: Large Intestine-4 (LI4) point on the dorsum of the hand and Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus 1, 2, 3
Peppermint essential oil has been shown to decrease dysmenorrhea symptoms 1, 3
Vitamin B1 at 100 mg daily is effective for dysmenorrhea, though based on limited evidence 6
Magnesium supplementation shows promise for pain relief and reduces the need for additional medication, though optimal dosing remains unclear 6
Critical Evaluation Steps Before Treatment
Rule Out Secondary Causes
Pregnancy must be ruled out 1
Sexually transmitted diseases should be ruled out and treated 1
Structural abnormalities (fibroids, polyps, other pathologic uterine conditions) should be evaluated and treated 1
If bleeding irregularities persist despite treatment, consider alternative contraceptive methods or refer for gynecologic evaluation 1, 2
Common Pitfalls to Avoid
Prescribing NSAIDs without counseling about gastrointestinal protection in high-risk patients (older adults, those with cardiovascular or GI comorbidities) 2
Using inadequate NSAID doses - therapeutic doses are 600-800 mg ibuprofen or 440-550 mg naproxen sodium, not lower OTC doses 3, 4
Failing to take NSAIDs with food, which increases gastrointestinal side effects 1, 3
Prescribing opioids for dysmenorrhea when NSAIDs are equally or more effective without addiction risk 2