What is the management for a female patient with dysmenorrhea (pain before her menstrual period)?

Management of Dysmenorrhea (Pain Before/During Period)

Start with NSAIDs immediately at the onset of pain: 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. 1, 2, 3

First-Line Pharmacological Treatment

NSAIDs are the cornerstone of dysmenorrhea management because they block prostaglandin formation—the primary driver of uterine cramping and pain. 1, 4, 5

NSAID Dosing Protocol

• Ibuprofen: 600-800 mg every 6-8 hours with food 1, 2
• Naproxen: 440-550 mg every 12 hours with food 1, 3
• Mefenamic acid: 500 mg three times daily (particularly effective for reducing both pain and menstrual blood loss) 6
• Duration: Short-term treatment for 5-7 days during bleeding only 1, 2
• Timing: Begin at the earliest onset of pain for maximum effectiveness 2, 5

Key NSAID Considerations

• Approximately 18% of women do not respond to NSAIDs—these patients require escalation to hormonal therapy 1
• Always take with food to minimize gastrointestinal side effects 1, 2
• Maximum daily ibuprofen dose is 3200 mg, though doses above 400 mg per administration show no additional analgesic benefit for dysmenorrhea 2

Second-Line Treatment: Hormonal Contraceptives

If NSAIDs fail after 2-3 menstrual cycles, add combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate. 1

Hormonal Therapy Options

• Combined oral contraceptives: Monophasic formulations preferred for simplicity 1
• Extended/continuous cycles: Particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 1
• Levonorgestrel IUD: Alternative hormonal option 6
• Progestin-only pills: Use when estrogen is contraindicated 6

Benefits Beyond Pain Control

• 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

Non-Pharmacological Adjunctive Treatments

These should be used in addition to, not instead of, pharmacological therapy:

Heat Therapy

• Apply heating pad or warm towels to abdomen or back to reduce cramping 1, 6
• Creates relaxing environment with low lighting and calming music 1

Acupressure

• Large Intestine-4 (LI4) point: Located on dorsum of hand between thumb and index finger 1, 6
• Spleen-6 (SP6) point: Located approximately 4 fingers above medial malleolus 1, 6

Other Complementary Measures

• Peppermint essential oil has shown benefit in reducing dysmenorrhea symptoms 1
• Regular exercise supports hormonal regulation, but avoid overtraining 1
• Adequate protein and carbohydrate intake 1

Critical Evaluation for Secondary Causes

Before initiating treatment, rule out pregnancy and secondary causes of dysmenorrhea. 1, 6

Red Flags Requiring Further Investigation

• Abnormal uterine bleeding 7
• Dyspareunia (painful intercourse) 7
• Noncyclic pain 7
• Changes in intensity and duration of pain 7
• Abnormal pelvic examination findings 7
• Pain unresponsive to NSAIDs after adequate trial 1, 4

Secondary Causes to Exclude

• Pregnancy: Always rule out first 6, 8
• Sexually transmitted infections: Screen and treat 1, 6
• Endometriosis: Most common cause of secondary dysmenorrhea 7
• Adenomyosis: Presents with dysmenorrhea, menorrhagia, and uniformly enlarged uterus 7
• Structural abnormalities: Fibroids, polyps, other uterine pathology 1, 6

When to Perform Imaging

• Transvaginal ultrasound if secondary dysmenorrhea suspected 7
• Consider pelvic ultrasound if symptoms persist despite treatment or physical examination is abnormal 6

Treatment Algorithm for Refractory Cases

If symptoms persist beyond 3 months despite appropriate NSAID and hormonal therapy, comprehensive evaluation is mandatory. 1

Escalation Pathway

1. Initial: NSAIDs for 2-3 cycles 1, 4
2. If inadequate response: Add hormonal contraceptives 1, 4
3. If still inadequate: Evaluate for secondary causes with pelvic ultrasound 6, 7
4. If endometriosis suspected: Consider medical management with progestins, danazol, oral contraceptives, or GnRH agonists 1
5. Refractory cases: Referral to gynecologic specialist for possible laparoscopy evaluation 9, 1

Common Pitfalls to Avoid

• Don't assume oral contraceptives correct underlying energy deficiency in athletes or those with functional hypothalamic amenorrhea—they only mask symptoms 1
• Don't delay treatment initiation: NSAIDs work best when started at earliest onset of pain, not after pain is established 2, 5
• Don't use ibuprofen doses above 400 mg per administration expecting better analgesia—controlled trials show no additional benefit 2
• Don't ignore systemic symptoms: Vomiting, difficulty breathing, severe headache, or dizziness require urgent evaluation for severe anemia, dehydration, or pregnancy complications 6
• Don't continue empiric treatment indefinitely without response: Approximately 10% of women don't respond to standard therapy and require investigation for secondary causes 10, 11