Treatment of Dysmenorrhea in a 16-Year-Old
Start with NSAIDs as first-line therapy: ibuprofen 600-800 mg every 6-8 hours with food for 5-7 days during menstruation only. 1, 2, 3, 4
First-Line Pharmacological Treatment
NSAIDs are the mainstay of treatment because they inhibit prostaglandin synthesis, which drives dysmenorrhea pain through uterine hypercontractility and ischemia. 3
Specific NSAID dosing options:
- Ibuprofen 600-800 mg every 6-8 hours with food (higher doses are more effective than lower doses in clinical practice) 1, 2, 3, 4
- Naproxen 440-550 mg every 12 hours with food 1, 2, 3
- Mefenamic acid for 5-day treatment courses 1
Treatment duration: 5-7 days during days of bleeding only 1, 2, 3, 4
Critical dosing point: Do not underdose NSAIDs—use the full therapeutic doses of 600-800 mg ibuprofen, not lower doses. 3 The FDA label confirms that doses greater than 400 mg were no more effective than 400 mg for general pain, but clinical guidelines specifically recommend 600-800 mg for dysmenorrhea based on superior efficacy. 4, 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, 2, 3
- Peppermint essential oil has demonstrated symptom reduction 1, 2, 3
Second-Line Treatment: When NSAIDs Fail
If NSAIDs fail after 2-3 menstrual cycles, add combined oral contraceptives (COCs). 1, 2, 3, 5
Specific COC recommendations for adolescents:
- Use COCs with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1
- Monophasic formulation is recommended for simplicity 1
- Extended or continuous cycles are particularly appropriate for adolescents with severe dysmenorrhea, as they minimize hormone-free intervals and optimize ovarian suppression 1
Additional benefits of COCs in adolescents:
- Decreased menstrual blood loss 1
- Improvement in acne 1
- Completely reversible with no negative effect on long-term fertility 1
- Safe throughout reproductive years 1
Approximately 18% of women are unresponsive to NSAIDs, and about 10% do not respond to NSAIDs and hormonal contraceptives combined. 1, 2, 6
When to Investigate for Secondary Causes
Obtain transvaginal ultrasound if:
- Abnormal pelvic examination findings are present 2
- Symptoms suggest secondary dysmenorrhea 2
- Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles 2, 3, 5
- Abrupt change in previously stable pain pattern 2
Rule out:
- Endometriosis, adenomyosis, fibroids, polyps, and other structural uterine pathology 2, 3
- Sexually transmitted diseases (chronic pelvic inflammatory disease can present as worsening dysmenorrhea) 2, 3
- Pregnancy 1
- IUD displacement (if applicable) 2
Critical Pitfalls to Avoid
- Do not delay NSAID treatment while waiting for diagnostic workup—start empiric therapy immediately 3
- Do not underdose NSAIDs—use full therapeutic doses of 600-800 mg ibuprofen or 440-550 mg naproxen 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, which can present as worsening dysmenorrhea 2, 3
Special Considerations for Adolescents
In this age group, primary dysmenorrhea typically presents 2-3 years after menarche and is associated with normal ovulatory cycles. 7, 5 The diagnosis is clinical, based on typical cramping pain in the lower abdomen occurring just before or during menstruation, with normal physical examination. 6, 8 No diagnostic evaluation is necessary in patients with typical symptoms and no risk factors for secondary causes. 6