What medication is recommended for a female experiencing abdominal cramping during her menstrual period?

Medication for Menstrual Cramping (Primary Dysmenorrhea)

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

First-Line Treatment: NSAIDs

NSAIDs provide superior pain relief compared to placebo (OR 7.91) and are more effective than acetaminophen for menstrual cramping. 3, 4, 5

Recommended NSAID Regimens:

• Naproxen sodium 440-550 mg every 12 hours (preferred option) 1, 2

  • Can be started 2 days before expected menstruation for perimenstrual prophylaxis and continued for 5 days 2
  • Provides significant, long-lasting pain relief over 12 hours 5

• Ibuprofen 600-800 mg every 6-8 hours (alternative) 1

  • Take with food to minimize gastrointestinal side effects 6

• Mefenamic acid 500 mg three times daily for 5 days (alternative) 6, 1

• Diclofenac potassium 50 mg three times daily (alternative) 7

Treatment Duration:

• Short-term use only: 5-7 days during days of bleeding 6, 1, 8

Important Safety Considerations

Contraindications for NSAIDs:

• Active peptic ulcer disease 2
• Cardiovascular disease 8, 2
• Renal insufficiency 2
• History of gastrointestinal bleeding 2

Common Adverse Effects:

NSAIDs increase risk of side effects compared to placebo (OR 1.29), including gastrointestinal effects (OR 1.58) and neurological effects (OR 2.74) 4. If 10% of women taking placebo experience side effects, 11-14% taking NSAIDs will do so. 4

Critical Pitfall to Avoid:

Never prescribe opioids for dysmenorrhea—they are not more effective than NSAIDs and carry significant risks of dependence and adverse effects. 2

Adjunctive Non-Pharmacological Measures

These can be used alongside NSAIDs for additional relief:

• Heat therapy applied to abdomen or back reduces cramping pain 1, 2
• Acupressure on specific points:
  • Large Intestine-4 (LI4) point on dorsum of hand 1, 2
  • Spleen-6 (SP6) point approximately 4 fingers above medial malleolus 1, 2
• Peppermint essential oil has shown benefit for dysmenorrhea symptoms 1

Second-Line Treatment: Hormonal Options

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

Hormonal Treatment Approach:

• COCs reduce menstrual blood loss and improve symptoms through ovarian suppression 1
• Extended or continuous cycle COCs are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals 1
• Monophasic formulations are recommended for simplicity 1
• COCs are completely reversible with no negative effect on long-term fertility 1

Alternative Hormonal Options:

If bleeding irregularities persist despite NSAIDs, consider:

• Low-dose COCs for short-term treatment (10-20 days) 6, 8
• Estrogen for short-term treatment (10-20 days) 6

When to Escalate Care

Approximately 18% of women with dysmenorrhea are unresponsive to NSAIDs. 1

Evaluation for Treatment Failure:

If symptoms persist beyond 3 months despite appropriate NSAID and hormonal therapy, evaluate for secondary causes: 1

• Structural abnormalities (fibroids, polyps, pathologic uterine conditions) 1
• Sexually transmitted diseases 1
• Pregnancy 1
• Endometriosis 1

Referral Pathway:

Refer to gynecologic specialist for possible laparoscopy evaluation if refractory to first and second-line treatments. 1 Consider medical management with progestins, danazol, or GnRH agonists if endometriosis is suspected. 1