What is the first line of treatment for dysmenorrhea?

First-Line Treatment for Dysmenorrhea

NSAIDs are the first-line treatment for dysmenorrhea, specifically 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 only. 1, 2, 3

Why NSAIDs Work as First-Line Therapy

NSAIDs are the mainstay of treatment because they inhibit prostaglandin synthesis, which is the primary driver of dysmenorrhea pain through uterine hypercontractility and ischemia. 3 This mechanism directly addresses the pathophysiology of primary dysmenorrhea. 4

Specific NSAID Dosing Protocols

The recommended regimens are:

• Ibuprofen 600-800 mg every 6-8 hours with food 1, 2, 3
• Naproxen 440-550 mg every 12 hours with food 1, 2, 3
• Mefenamic acid 500 mg initial dose, then 250 mg every 6 hours 1, 5

Higher doses of ibuprofen (600-800 mg) are more effective in clinical practice than lower doses. 2, 3 The FDA label for ibuprofen specifically states that for dysmenorrhea, treatment should begin with the earliest onset of pain at 400 mg every 4 hours as necessary, though guideline recommendations favor the higher 600-800 mg dosing. 6

Treatment duration should be short-term (5-7 days) during days of bleeding only. 1, 2, 3

Adjunctive Non-Pharmacological Measures

These can be used alongside NSAIDs from the start:

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

When to Escalate to Second-Line Treatment

If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add combined oral contraceptives (COCs) as second-line therapy. 2, 3 Approximately 18% of women with dysmenorrhea are unresponsive to NSAIDs. 1, 2

The recommended COC formulation is 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate, using a monophasic formulation for simplicity. 1, 3 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, 3

Extended or continuous cycles of COCs are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression. 1

When to Investigate for Secondary Causes

Obtain transvaginal ultrasound if:

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

Rule out these conditions:

• Endometriosis, adenomyosis, fibroids, polyps, and other structural uterine pathology 1, 2, 3
• IUD displacement in patients with worsening dysmenorrhea 2, 3
• Sexually transmitted diseases and chronic pelvic inflammatory disease 1, 2, 3
• Pregnancy 1, 3

Critical Pitfalls to Avoid

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