What are the treatment options for dysmenorrhea (menstrual cramps)?

Treatment of Dysmenorrhea (Period Pain)

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, and if NSAIDs fail after 2-3 cycles, combined oral contraceptives should be added as second-line therapy. 1, 2

First-Line Pharmacologic Treatment: NSAIDs

NSAIDs work by inhibiting cyclooxygenase enzymes, which blocks prostaglandin formation—the primary mediator causing uterine cramping, hypercontractility, and ischemia in dysmenorrhea 1, 2, 3. The evidence strongly supports NSAIDs as initial therapy:

• Ibuprofen 600-800 mg every 6-8 hours with food is the preferred first-line option 1, 2
• Naproxen 440-550 mg every 12 hours with food is an equally effective alternative 1
• Mefenamic acid 500 mg three times daily is particularly effective for reducing both pain and menstrual blood loss 1
• Treatment duration should be short-term (5-7 days) during days of bleeding only 1
• Start NSAIDs at the earliest onset of pain or even 1-2 days before expected menses for maximum effectiveness 2, 4

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," though clinical guidelines recommend higher doses (600-800 mg) for better efficacy 2, 1.

Important consideration: Approximately 18% of women with dysmenorrhea do not respond to NSAIDs, necessitating escalation to hormonal therapy 1.

Second-Line Treatment: Hormonal Contraceptives

When NSAIDs fail after 2-3 menstrual cycles, hormonal contraceptives should be initiated 1:

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are the preferred second-line option 1
• COCs reduce dysmenorrhea by inhibiting endometrial growth, decreasing prostaglandin production, and suppressing ovulation 5, 3
• Monophasic formulations are recommended for simplicity 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

Extended or Continuous Cycle Regimens

For severe dysmenorrhea, extended or continuous cycle COCs (eliminating or minimizing the hormone-free interval) are particularly effective 5, 1:

• This approach minimizes hormone-free intervals and optimizes ovarian suppression 1
• Extended cycles are especially useful for severe dysmenorrhea, endometriosis, heavy menstrual bleeding, and conditions exacerbated cyclically (migraine without aura, epilepsy) 5
• The most common adverse effect is unscheduled bleeding, which typically improves over time 5

Alternative Hormonal Options

• Contraceptive vaginal ring (NuvaRing) releases combined estrogen and progestin, has comparable efficacy to COCs, and can be used continuously (replaced monthly rather than every 3 weeks) 5
• Transdermal contraceptive patch is another combined hormonal option with similar efficacy 5
• Levonorgestrel intrauterine device is effective for women who cannot tolerate or have contraindications to estrogen 1

Non-Pharmacologic Adjunctive Treatments

These should be used in conjunction with pharmacologic therapy, not as replacements 1:

• Heat therapy applied to the abdomen or back reduces cramping pain 1
• 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
• Peppermint essential oil has been shown to decrease dysmenorrhea symptoms 1
• Regular aerobic exercise and stretching may provide benefit 6

When to Suspect Secondary Dysmenorrhea

Evaluate for underlying pathology if 1, 4:

• No response to NSAIDs and hormonal contraceptives after adequate trial
• Pain that worsens over time or begins after age 25
• Abnormal pelvic examination findings
• Associated symptoms: heavy menstrual bleeding, intermenstrual bleeding, dyspareunia, infertility

Evaluation for Secondary Causes

• Rule out pregnancy immediately with urine or serum hCG 1
• Screen for sexually transmitted infections 1
• Evaluate for structural abnormalities: fibroids, polyps, endometriosis, adenomyosis via pelvic ultrasound 1
• Consider referral to gynecology for suspected endometriosis, which may require laparoscopy for definitive diagnosis 6

Treatment Algorithm Summary

1. Start with NSAIDs (ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours) for 5-7 days during menstruation 1, 2
2. Add heat therapy and acupressure as adjunctive measures 1
3. If inadequate response after 2-3 cycles, add combined oral contraceptives (30-35 μg ethinyl estradiol with levonorgestrel or norgestimate) 1
4. For severe dysmenorrhea, use extended or continuous cycle COCs to eliminate hormone-free intervals 5, 1
5. If still inadequate response, evaluate for secondary causes (pregnancy, STIs, structural abnormalities, endometriosis) 1
6. Consider alternative hormonal methods (vaginal ring, patch, LNG-IUD) if COCs are not tolerated 5, 1

Common Pitfalls to Avoid

• Starting NSAIDs too late: Begin at the earliest onset of pain or even 1-2 days before expected menses for maximum prostaglandin inhibition 2, 4
• Inadequate NSAID dosing: Use 600-800 mg ibuprofen, not the lower 400 mg dose, for dysmenorrhea 1, 2
• Premature discontinuation of NSAIDs: Give an adequate trial of 2-3 menstrual cycles before declaring treatment failure 1
• Failing to consider extended cycle COCs: Standard cyclic COCs may be less effective than continuous regimens for severe dysmenorrhea 5, 1
• Delaying evaluation for secondary causes: If no response to first and second-line therapy, investigate for underlying pathology rather than continuing ineffective treatment 1, 4