What are the treatment options for a female of reproductive age experiencing pelvic pain during menses (dysmenorrhea)?

Treatment of Dysmenorrhea (Pelvic Pain During Menses)

Start with NSAIDs as first-line therapy, specifically ibuprofen 400 mg every 4-6 hours or mefenamic acid 500 mg initial dose followed by 250 mg every 6 hours, beginning at the earliest onset of menstrual pain. 1, 2

First-Line Pharmacological Treatment

NSAIDs (Preferred Initial Therapy)

• Ibuprofen 400 mg every 4-6 hours is the standard first-line treatment, with doses above 400 mg showing no additional benefit in controlled trials 1, 3, 4
• Mefenamic acid is equally effective: 500 mg loading dose, then 250 mg every 6 hours, proven superior to placebo across all pain parameters 2
• NSAIDs work by inhibiting prostaglandin synthesis, directly addressing the pathophysiology of primary dysmenorrhea (excessive endometrial prostaglandin production causing uterine hypercontractility and ischemia) 3, 4, 5
• Begin treatment at the earliest onset of pain or bleeding, whichever comes first, for maximum efficacy 1, 2
• Take with food or milk to minimize gastrointestinal side effects 1

Hormonal Contraceptives (Second-Line or Combined Therapy)

• Add oral contraceptive pills when NSAIDs alone provide insufficient relief or when contraception is desired 3, 4
• Combined hormonal contraceptives reduce dysmenorrhea severity and are associated with less severe menstrual pain in multiple studies 6, 4
• The combination of NSAIDs plus hormonal contraceptives addresses both prostaglandin overproduction and endometrial proliferation 3, 4

Treatment Algorithm

Step 1: Start NSAID therapy (ibuprofen 400 mg every 4-6 hours) at pain onset 1, 3

Step 2: If inadequate response after 2-3 menstrual cycles, add oral contraceptive pills 3, 4

Step 3: If symptoms persist despite combined therapy, this indicates possible secondary dysmenorrhea requiring gynecologic evaluation for endometriosis or other pelvic pathology 6, 4

Alternative and Adjunctive Treatments

When conventional treatments are contraindicated or patient preference dictates:

• Topical heat application to lower abdomen 3
• Transcutaneous electrical nerve stimulation (TENS) 3
• Acupuncture and acupressure 3, 5
• Dietary supplements 3
• Lifestyle modifications 3

These alternatives have supporting evidence but are generally less robust than NSAIDs and hormonal therapy 3, 5

Critical Clinical Pitfalls

• 10-25% of patients fail to respond to NSAIDs and oral contraceptives—this mandates evaluation for secondary causes, particularly endometriosis 6, 7
• Only 6% of adolescents receive medical advice for dysmenorrhea, while 70% practice self-management, sometimes with non-therapeutic high doses 6
• Dysmenorrhea is significantly underdiagnosed and undertreated despite causing major quality-of-life impairment and being a leading cause of school/work absenteeism (one-third to one-half of affected women miss school or work at least once per cycle) 3, 6, 5
• Do not delay evaluation for secondary causes if empiric treatment fails after 2-3 compliant cycles 4

When to Suspect Secondary Dysmenorrhea

Refer for gynecologic evaluation with possible laparoscopy if:

• Pain persists despite compliant use of NSAIDs plus hormonal contraceptives 6, 4
• Pain begins years after menarche rather than in adolescence 5
• Associated symptoms suggest endometriosis or other pelvic pathology 7

Efficacy Expectations

• NSAIDs and oral contraceptives have high efficacy rates (75-80% response) when used appropriately 6, 4
• Failure to respond to first-line therapy is a strong indicator of organic pelvic disease requiring specialist referral 6, 7
• Surgical treatment is reserved only for severe dysmenorrhea refractory to all medical management 3