What pain management options are available for a reproductive‑age woman with primary dysmenorrhea who cannot take non‑steroidal anti‑inflammatory drugs because of ulcer disease, renal impairment, or allergy?

Pain Control Options for Dysmenorrhea When NSAIDs Are Contraindicated

For women who cannot take NSAIDs due to ulcer disease, renal impairment, or allergy, hormonal contraceptives—particularly combined oral contraceptives or the levonorgestrel IUD—are the most effective first-line alternatives for dysmenorrhea pain control, with tranexamic acid serving as a non-hormonal option if hormonal methods are declined. 1, 2, 3

Primary Hormonal Options

Combined Oral Contraceptives (COCs)

• COCs provide moderate to significant pain reduction (standardized mean difference -0.58), with 37-60% of women experiencing improvement compared to 28% with placebo. 4
• For women desiring contraception, COCs are preferable to NSAIDs as first-line therapy because they provide pain relief without the gastrointestinal and renal risks associated with NSAIDs, making them particularly suitable for your patient population. 3
• Continuous-use regimens (skipping the hormone-free interval) may provide superior pain relief compared to standard 21/7 cycling, though this increases irregular bleeding risk. 4
• Common side effects include irregular bleeding (39-60% vs 18% with placebo), headaches, and nausea, but these are generally manageable. 4

Levonorgestrel Intrauterine Device (Mirena)

• The levonorgestrel IUD is highly effective for dysmenorrhea, providing therapeutic reduction in both bleeding and pain with continuation rates of 75% or greater at one year. 1
• Mirena releases 20 micrograms of levonorgestrel per 24 hours and is FDA-approved for 5 years but effective for up to 7 years. 1
• This option is particularly valuable for women who need long-term menstrual suppression when estrogen is contraindicated or for those with concurrent heavy menstrual bleeding. 1
• The American Academy of Pediatrics specifically recommends levonorgestrel IUDs for adolescents with medical conditions requiring menstrual suppression, especially when estrogen should be avoided. 1

Injectable Progestin

• Depot medroxyprogesterone acetate (DMPA) can be considered if the patient is willing to use injectable contraception, though breakthrough bleeding may occur. 2
• If heavy or prolonged bleeding develops with DMPA, alternative pain management becomes necessary since NSAIDs would typically be first-line. 2

Non-Hormonal Pharmacologic Option

Tranexamic Acid

• Tranexamic acid used for 5 days during menstruation reduces menstrual blood loss by 20-60% and can provide pain relief, particularly when dysmenorrhea is associated with heavy bleeding. 2
• This is the most effective non-hormonal option when both NSAIDs and hormones are contraindicated or declined. 2

Non-Pharmacologic Adjunctive Therapies

Heat Therapy

• Topical heat applied to the abdomen or back may reduce cramping pain and can be used alongside any pharmacologic option. 5, 6
• This is safe, inexpensive, and has no contraindications. 5

Acupressure

• Bilateral stimulation of acupressure point Large Intestine-4 (LI4) on the dorsum of the hand between the thumb and index finger has evidence for pain relief during procedures and can be applied to dysmenorrhea. 5, 6
• Spleen-6 (SP6) acupressure point located three finger-widths above the medial malleolus is specifically effective for primary dysmenorrhea relief. 5, 6
• Patients can perform self-stimulation at home during menstrual cramping. 5

Clinical Decision Algorithm

Step 1: Assess contraceptive needs

• If contraception desired → Combined oral contraceptives (consider continuous regimen for severe pain) 3, 4
• If long-acting contraception preferred → Levonorgestrel IUD (Mirena) 1
• If injectable acceptable → DMPA 2

Step 2: If hormonal methods contraindicated or declined

• Tranexamic acid 5 days during menstruation 2

Step 3: Add non-pharmacologic adjuncts to any regimen

• Heat therapy 5, 6
• Acupressure at LI4 and SP6 points 5, 6

Important Caveats

• Before initiating any hormonal therapy, rule out pregnancy and screen for sexually transmitted infections as clinically indicated. 2
• COCs increase risk of venous thromboembolism, so screen for cardiovascular risk factors and avoid in women with history of VTE, stroke, or multiple cardiovascular risk factors. 1
• The levonorgestrel IUD should not be used in women with current or recent (past 3 months) pelvic inflammatory disease. 1
• Tranexamic acid is contraindicated in women with active thromboembolic disease or history of thrombosis. 2
• For women with renal impairment severe enough to contraindicate NSAIDs, avoid tranexamic acid and use reduced doses of hormonal contraceptives with caution, as these are also renally cleared. 6

When to Reassess

• If pain remains uncontrolled after 3 months of appropriate hormonal therapy, perform pelvic ultrasonography and consider referral for laparoscopy to rule out secondary causes of dysmenorrhea such as endometriosis. 7
• Persistent unacceptable bleeding that does not improve with standard management is an indication to reconsider the treatment approach. 1