What is the treatment for dysmenorrhea?

Treatment of Dysmenorrhea

Start with NSAIDs as first-line therapy: 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

First-Line Pharmacological Treatment

NSAIDs are the mainstay of treatment because they inhibit prostaglandin synthesis, which drives dysmenorrhea pain through uterine hypercontractility and ischemia. 1

Specific dosing regimens:

• Ibuprofen 600-800 mg every 6-8 hours with food (higher doses are more effective than lower doses in clinical practice) 1, 2, 4, 3
• Naproxen 440-550 mg every 12 hours with food 1, 2, 4
• Mefenamic acid 500 mg initial dose, then 250 mg every 6 hours 2, 5
• Treatment duration: 5-7 days during menstruation only 1, 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 clinical guidelines recommend higher doses of 600-800 mg for better efficacy. 3

Adjunctive Non-Pharmacological Measures

These can be used alongside NSAIDs to enhance pain relief:

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

Second-Line Treatment: When NSAIDs Fail

If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add hormonal contraceptives. 1, 4

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1, 2
• COCs provide additional benefits: decreased menstrual blood loss, improvement in acne, completely reversible with no negative effect on long-term fertility 2
• Extended or continuous cycles of COCs are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 2
• Use monophasic formulations for simplicity 2

Approximately 18% of women are unresponsive to NSAIDs, and about 10% do not respond to the combination of NSAIDs and hormonal contraceptives. 4

When to Investigate for Secondary Causes

Obtain transvaginal ultrasound if:

• Abnormal pelvic examination findings are present 4
• Symptoms suggest secondary dysmenorrhea 4
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles 1, 4
• Abrupt change in previously stable pain pattern 4

Rule out these secondary causes:

• Endometriosis, adenomyosis, fibroids, polyps, and other structural uterine pathology 1, 4
• IUD displacement 4
• Sexually transmitted diseases and chronic pelvic inflammatory disease 1, 4
• Pregnancy 2, 4

Management of Suspected Endometriosis

• Hormonal contraceptives are first-line for endometriosis-related dysmenorrhea 1, 4
• If endometriosis is confirmed and medical management fails, consider GnRH agonists for at least 3 months with add-back therapy (prevents bone mineral loss without reducing efficacy) or danazol for at least 6 months 1, 4

Critical Pitfalls to Avoid

• Do not delay NSAID treatment while waiting for diagnostic workup - start empiric therapy immediately 1, 4
• Do not underdose NSAIDs - use the full therapeutic doses of 600-800 mg ibuprofen or 440-550 mg naproxen, not the lower 400 mg dose 1, 4
• Do not continue ineffective treatment beyond 2-3 cycles - this indicates need for investigation of secondary causes 1, 4
• Do not forget to rule out STDs, such as chronic pelvic inflammatory disease, which can present as worsening dysmenorrhea 1, 4
• Do not use combined oral contraceptives to mask symptoms without first attempting to identify underlying pathology in treatment-refractory cases 1
• Do not assume oral contraceptives correct underlying energy deficiency in athletes or those with functional hypothalamic amenorrhea - they only mask symptoms 2