What are the treatment options for a female patient of reproductive age experiencing menstrual cramps?

Treatment of Menstrual Cramping

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, 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. 2

Specific dosing regimens:

• Ibuprofen 600-800 mg every 6-8 hours with food (higher doses are more effective than lower doses in clinical practice) 2, 3, 4
• Naproxen 440-550 mg every 12 hours with food 1, 2, 3
• Mefenamic acid for 5-day treatment courses 3
• Treatment duration: 5-7 days during bleeding only 1, 2, 3, 4
• Maximum daily ibuprofen dose: 3200 mg, though doses above 400 mg every 4-6 hours show no additional benefit for pain relief 4

Critical: Do not underdose NSAIDs—use the full therapeutic doses of 600-800 mg ibuprofen, not the lower 400 mg dose commonly used. 2

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 specific anatomical points: Large Intestine-4 (LI4) on the dorsum of the hand and Spleen-6 (SP6) located 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 or are contraindicated, add hormonal contraceptives. 1, 2

Approximately 18% of women are unresponsive to NSAIDs, which should prompt investigation for secondary causes. 1, 3

Hormonal contraceptive options:

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 2, 3
• COCs provide additional benefits: decreased menstrual blood loss, improvement in acne, completely reversible with no negative effect on long-term fertility 3
• Extended or continuous cycles of COCs are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 3
• Use monophasic formulations for simplicity 3

When to Investigate for Secondary Causes

Obtain transvaginal ultrasound if:

• Abnormal pelvic examination findings are present 1, 2
• Symptoms suggest secondary dysmenorrhea 1, 2
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles 1, 2
• Abrupt change in previously stable pain pattern 1

Rule out the following pathologies:

• Endometriosis, adenomyosis, fibroids, polyps, and other structural uterine pathology 1, 2
• IUD displacement in patients with worsening dysmenorrhea 1
• Sexually transmitted diseases and chronic pelvic inflammatory disease 1, 2
• Pregnancy 2, 3

Management of Suspected Endometriosis

Hormonal contraceptives are first-line for endometriosis-related dysmenorrhea. 1, 2, 3

If endometriosis is confirmed and medical management fails:

• GnRH agonists for at least 3 months with add-back therapy (prevents bone mineral loss without reducing efficacy) 1, 3
• Danazol for at least 6 months 1, 3
• Medical therapy alone may be insufficient for severe endometriosis 1

Treatment Algorithm for Refractory Cases

Escalation pathway when symptoms persist beyond 3 months despite appropriate therapy: 3

1. NSAIDs for 2-3 cycles
2. Add hormonal contraceptives if inadequate response
3. Evaluate for secondary causes with pelvic ultrasound
4. Consider medical management with progestins, danazol, oral contraceptives, or GnRH agonists if endometriosis is suspected
5. Referral to gynecologic specialist for possible laparoscopy evaluation

Critical Pitfalls to Avoid

• Do not delay NSAID treatment while waiting for diagnostic workup—start empiric therapy immediately 2
• Do not underdose NSAIDs—use full therapeutic doses of 600-800 mg ibuprofen or 440-550 mg naproxen 2
• Do not continue ineffective treatment beyond 2-3 cycles—this indicates need for investigation of secondary causes 2
• Do not forget to rule out STDs, such as chronic pelvic inflammatory disease, which can present as worsening dysmenorrhea 1, 2
• Do not use combined oral contraceptives to mask symptoms without first attempting to identify underlying pathology in treatment-refractory cases 2