What is the best treatment approach for a 14-year-old female patient experiencing menstrual pain?

Treatment of Menstrual Pain in a 14-Year-Old

NSAIDs are the first-line treatment for menstrual pain in adolescents, with ibuprofen 600-800 mg every 6-8 hours or naproxen sodium 440-550 mg every 12 hours taken with food for 5-7 days during menstruation being the most effective options. 1, 2, 3

First-Line Pharmacological Treatment

Start with NSAIDs immediately at the onset of menstrual bleeding:

• Ibuprofen 600-800 mg every 6-8 hours (maximum 2,400 mg daily) taken with food 3, 4
• Alternative: Naproxen sodium 440-550 mg every 12 hours (maximum 1,500 mg daily), which has superior efficacy data and longer duration of action 2, 3, 5
• Treatment duration should be 5-7 days during menstruation only 1, 2
• For severe cases, consider starting NSAIDs 24 hours before expected menstruation for perimenstrual prophylaxis 2

The FDA label confirms ibuprofen 400 mg every 4-6 hours for dysmenorrhea, though higher doses (600-800 mg) are recommended by ACOG for better efficacy 4, 3. Research demonstrates that naproxen provides superior pain relief compared to ibuprofen 200 mg and acetaminophen, with effects lasting up to 6 hours 5.

Adjunctive Non-Pharmacological Measures

These should be used alongside NSAIDs, not as replacements:

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

Second-Line Treatment if NSAIDs Fail

If no improvement after 2-3 menstrual cycles of adequate NSAID therapy:

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1
• Use monophasic formulation 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 and are safe throughout reproductive years 1

Approximately 18% of women with dysmenorrhea do not respond to NSAIDs, making hormonal contraceptives an important second-line option 2, 3.

Critical Safety Considerations

Contraindications to NSAID use (must screen for these):

• Active peptic ulcer disease 2, 3
• Cardiovascular disease 2, 3
• Renal insufficiency 2, 3
• History of gastrointestinal bleeding 2, 3

Use lowest effective dose for shortest duration and exercise caution in patients at risk for bleeding or renal impairment 2.

When to Escalate Care

Refer for gynecologic evaluation if:

• No response to NSAIDs after 2-3 cycles of adequate treatment 2
• Menstrual dysfunction lasting more than 3 months 1
• Suspicion of secondary dysmenorrhea (underlying pelvic pathology such as endometriosis, fibroids, polyps) 1, 2

Rule out before treating:

• Pregnancy 1
• Sexually transmitted infections 1
• Structural abnormalities 1

Common Pitfalls to Avoid

• Do not prescribe opioids for dysmenorrhea—they are not more effective than NSAIDs and carry significant risks of dependence 2
• Do not use subtherapeutic NSAID doses (e.g., ibuprofen 200-400 mg)—higher doses (600-800 mg) are more effective 3, 4
• Do not assume oral contraceptives correct underlying energy deficiency in athletes—they only mask symptoms 1
• In high-risk patients (older adults, GI comorbidities), provide counseling about gastrointestinal protection when prescribing NSAIDs 2