What is the first‑line treatment for dysmenorrhea in adolescent girls?

Treatment of Menstrual Cramps (Dysmenorrhea) in Girls

NSAIDs, specifically ibuprofen 400 mg every 4–6 hours starting at the earliest onset of pain, are the first-line treatment for menstrual cramps in adolescent girls. 1

First-Line Treatment: NSAIDs

Ibuprofen is the preferred initial medication for dysmenorrhea, with the following dosing:

• Start with 400 mg every 4–6 hours as soon as menstrual pain begins 1
• Take with food or milk to minimize gastrointestinal side effects 1
• Maximum daily dose should not exceed 3200 mg 1
• NSAIDs are significantly more effective than placebo, with 45–53% of women achieving moderate to excellent pain relief compared to only 18% with placebo 2

The mechanism of action involves blocking prostaglandin production, which is the primary cause of menstrual cramping pain 3, 2

Important Timing Consideration

• Begin treatment at the earliest onset of pain, not after pain becomes severe 1
• Starting NSAIDs early provides better pain control than waiting 1

Second-Line Treatment: Hormonal Contraceptives

If NSAIDs alone provide insufficient relief (which occurs in approximately 18% of women), add extended or continuous-cycle combined oral contraceptives (COCs) 4, 5

The recommended hormonal regimen is:

• Monophasic COC containing 30–35 µg ethinyl estradiol plus levonorgestrel or norgestimate 4
• Use continuous dosing (skip placebo pills) or allow only a 3–4 day hormone-free interval every three months 4
• Continuous hormonal exposure provides superior symptom control by maintaining consistent ovarian suppression 4

Alternative Hormonal Options (If COCs Not Tolerated)

If oral contraceptives cause side effects, consider:

1. Levonorgestrel intrauterine device (IUD) - particularly effective for reducing dysmenorrhea and menstrual bleeding 6, 7

   • Provides 71–95% reduction in menstrual blood loss 7
   • Continuation rates exceed 75% at one year 6, 7
   • Especially useful when estrogen is contraindicated 6, 7

2. Contraceptive vaginal ring (NuvaRing) used continuously 4

3. Depot medroxyprogesterone acetate (DMPA) 150 mg intramuscularly every 11–13 weeks 4

   • Highly effective for suppressing dysmenorrhea 4
   • Requires counseling about initial menstrual irregularities 4

Non-Pharmacological Adjuncts

Heat therapy applied to the abdomen or back may reduce cramping pain 6

Acupressure at specific points may provide additional relief 6:

• Large Intestine-4 (LI4) point on the hand 6
• Spleen-6 (SP6) point above the ankle 6

Peppermint essential oil has been shown to decrease dysmenorrhea symptoms 6

Common Pitfalls to Avoid

• Do not wait for severe pain to develop before starting NSAIDs - early initiation is more effective 1
• Do not use acetaminophen (paracetamol) as first-line - NSAIDs are significantly more effective for menstrual pain 2, 8
• Do not assume all NSAIDs are equally effective - while evidence is limited, ibuprofen and naproxen have the strongest supporting data 2, 8
• Do not overlook the 10% of women who fail to respond to NSAIDs and hormonal therapy - these patients require evaluation for secondary causes of dysmenorrhea 9, 5

When to Escalate Care

Consider secondary causes of dysmenorrhea (such as endometriosis) if:

• Pain does not respond to NSAIDs plus hormonal contraceptives 9
• Symptoms worsen over time 9
• Pain occurs outside of menstruation 9

Safety Considerations

NSAIDs carry a risk of adverse effects 2:

• Overall adverse effects occur in 11–14% of users (versus 10% with placebo) 2
• Gastrointestinal side effects are most common 2
• Taking with food reduces GI symptoms 1

Contraindications to COCs include severe hypertension (≥160/100 mmHg), active liver disease, migraine with aura, history of thromboembolism, or thrombophilia 4