What are the treatment recommendations for a female patient of reproductive age experiencing menstrual pain?

Treatment Recommendations for Menstrual Pain

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 cornerstone of dysmenorrhea management and should be initiated immediately without waiting for diagnostic workup. 2

NSAID Dosing Protocol

• Ibuprofen 600-800 mg every 6-8 hours with food (higher doses are more effective in clinical practice than the standard 400 mg) 1, 2, 3
• Naproxen 440-550 mg every 12 hours with food 1, 4
• Treatment duration: 5-7 days during bleeding only (short-term use minimizes gastrointestinal and renal risks) 1, 2
• Maximum daily ibuprofen dose should not exceed 3200 mg 3

Expected Response and Treatment Failure

• Approximately 18% of women do not respond to NSAIDs, which should prompt investigation for secondary causes 1, 2
• If no improvement after 2-3 menstrual cycles of appropriate NSAID therapy, proceed to imaging and consider secondary dysmenorrhea 2

Adjunctive Non-Pharmacological Measures

These can be used alongside NSAIDs to enhance pain relief:

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

Second-Line Treatment: Hormonal Contraceptives

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

Hormonal Options

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1
• Monophasic formulations are recommended 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
• Approximately 10% of women fail both NSAIDs and hormonal contraceptives combined, requiring further evaluation 2

Alternative Hormonal Therapies

• Progestins (oral or depot medroxyprogesterone acetate) are effective alternatives with similar efficacy to COCs 5

When to Obtain Imaging

Order transvaginal ultrasound if: 2

• Abnormal pelvic examination findings
• Symptoms suggesting secondary dysmenorrhea (pain outside of menstruation, dyspareunia, abnormal bleeding)
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles
• Abrupt change in previously stable pain pattern

What to Look For on Imaging

• Endometriosis or adenomyosis 2
• Structural abnormalities: fibroids, polyps, other uterine pathology 1, 2
• IUD displacement in patients with worsening dysmenorrhea 2
• Rule out pregnancy if indicated 1

Management of Suspected Endometriosis

If endometriosis is suspected based on imaging or clinical presentation:

• First-line: NSAIDs and hormonal contraceptives (oral contraceptives or progestins) 5
• GnRH agonists for at least 3 months provide significant pain relief and are appropriate even without surgical confirmation 5
• Add-back therapy (such as norethindrone acetate 5 mg daily) should be implemented with GnRH agonists to prevent bone mineral loss without reducing pain relief efficacy 5
• Surgery provides significant pain reduction in the first 6 months, though 44% experience recurrence within one year 5
• Medical treatment alone may be insufficient for severe endometriosis 5

Critical Pitfalls to Avoid

• Do not underdose NSAIDs: Use 600-800 mg ibuprofen, not 400 mg 2
• Do not delay NSAID treatment while waiting for diagnostic workup 2
• Do not continue ineffective treatment beyond 2-3 cycles without reassessment 2
• Rule out STDs (chronic pelvic inflammatory disease can present as worsening dysmenorrhea) 2
• Rule out pregnancy before initiating treatment 1
• Do not assume oral contraceptives correct underlying energy deficiency in athletes or those with functional hypothalamic amenorrhea—they only mask symptoms 1

Additional Considerations for Specific Populations

Adolescents

• NSAIDs remain first-line for 5-7 days during menstruation 1
• If NSAIDs fail after 2-3 cycles, COCs with 30-35 μg ethinyl estradiol are appropriate second-line therapy with added benefits of decreased menstrual blood loss and acne improvement 1
• Extended or continuous COC cycles are particularly appropriate for adolescents with severe dysmenorrhea 1

Athletes and Active Women

• Maintain adequate protein and carbohydrate intake to support hormonal regulation 1
• Continue regular exercise but reduce intensity if experiencing severe pain 1
• Avoid overtraining as low energy availability suppresses reproductive hormones and worsens menstrual problems 1
• Menstrual dysfunction lasting more than 3 months requires comprehensive evaluation 1