What is the first line of treatment for a patient with dysmenorrhea?

First-Line Treatment for Dysmenorrhea

Start with NSAIDs immediately as first-line therapy, specifically 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

NSAID Dosing Protocol

• Use higher therapeutic doses from the start - ibuprofen 600-800 mg every 6-8 hours with food is more effective than lower doses in clinical practice 1, 3
• Naproxen 440-550 mg every 12 hours with food is an equally effective alternative 1, 2, 3
• Mefenamic acid can be used for 5-day treatment courses 2
• Treatment duration should be short-term (5-7 days) during days of bleeding only 1, 2, 3
• Maximum daily dose of ibuprofen should not exceed 3200 mg 4

The mechanism behind NSAID effectiveness is inhibition of prostaglandin synthesis, which drives dysmenorrhea pain through uterine hypercontractility and ischemia. 3

Adjunctive Non-Pharmacological Measures (Can Be Started Simultaneously)

• Apply heat therapy to the abdomen or back to reduce cramping pain 1, 2, 3
• Use acupressure at Large Intestine-4 (LI4) on the dorsum of the hand and Spleen-6 (SP6) approximately 4 fingers above the medial malleolus 1, 2, 3
• Peppermint essential oil has demonstrated symptom reduction 1, 2, 3

When NSAIDs Fail: Second-Line Treatment

• If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add hormonal contraceptives as second-line treatment 1, 3
• Combined oral contraceptives with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are recommended 2, 3
• COCs provide additional benefits including decreased menstrual blood loss, improvement in acne, and are completely reversible with no negative effect on long-term fertility 2, 3
• Extended or continuous cycles of COCs are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 2
• Use monophasic formulations for simplicity 2

Critical Timing for Investigation of Secondary Causes

Obtain transvaginal ultrasound if any of the following are present: 1, 3

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

Look specifically for: 1, 3

• Endometriosis and adenomyosis 1, 3
• Structural abnormalities including fibroids and polyps 1, 3
• IUD displacement 1, 3
• Rule out pregnancy 2
• Rule out sexually transmitted diseases and chronic pelvic inflammatory disease 1, 3

Common Pitfalls to Avoid

• Do not delay NSAID treatment while waiting for diagnostic workup - start empiric therapy immediately 1, 3
• Do not underdose NSAIDs - use full therapeutic doses of 600-800 mg ibuprofen or 440-550 mg naproxen, not the lower OTC doses 1, 3
• Do not continue ineffective treatment beyond 2-3 cycles - this indicates need for investigation of secondary causes 1, 3
• Do not forget to rule out STDs, as chronic pelvic inflammatory disease can present as worsening dysmenorrhea 1, 3

Expected Response Rates

• Approximately 18% of women are unresponsive to NSAIDs, which should prompt investigation for secondary causes 1, 2
• Approximately 10% of women do not respond to the combination of NSAIDs and hormonal contraceptives 1