What is the diagnosis and treatment for dysmenorrhea (painful menstruation)?

From the Guidelines

Dysmenorrhea can be effectively managed with hormonal contraceptives, such as the levonorgestrel IUD, which has been shown to improve dysmenorrhea and heavy menses in adolescents 1.

Treatment Options

• Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen sodium can provide relief by reducing prostaglandin production, which causes uterine contractions and pain.
• Heat therapy using a heating pad on the lower abdomen for 15-20 minutes can also provide significant relief.
• For those seeking non-medication approaches, regular physical exercise, especially yoga, may help reduce symptoms.

Hormonal Contraceptives

• Hormonal contraceptives like birth control pills, patches, or hormonal IUDs can effectively reduce menstrual pain by thinning the uterine lining and reducing prostaglandin levels.
• The levonorgestrel IUD is a highly effective option for managing dysmenorrhea, with studies showing improvement in symptoms and heavy menses in adolescents 1.

Important Considerations

• Severe dysmenorrhea that doesn't respond to these treatments may indicate underlying conditions like endometriosis or uterine fibroids, which would require medical evaluation.
• Maintaining a healthy lifestyle with adequate sleep, stress management, and a balanced diet may also help reduce symptom severity.
• It's essential to note that while DMPA (Depo-Provera) can also improve dysmenorrhea, its use may be associated with weight gain and other side effects, and its benefits and risks should be carefully considered 1.

From the FDA Drug Label

Dysmenorrhea: For the treatment of dysmenorrhea, beginning with the earliest onset of such pain, ibuprofen tablets should be given in a dose of 400 mg every 4 hours as necessary for the relief of pain. The recommended dose of ibuprofen for dysmenorrhea is 400 mg every 4 hours as needed for pain relief 2.

• The treatment should start with the earliest onset of pain.
• The dose can be adjusted based on individual patient needs, but should not exceed 3200 mg per day.
• Key points to consider when treating dysmenorrhea with ibuprofen include:
  • Starting treatment at the earliest onset of pain
  • Using the lowest effective dose
  • Not exceeding the maximum daily dose of 3200 mg
  • Adjusting the dose as needed to achieve adequate pain relief 2

From the Research

Definition and Pathophysiology of Dysmenorrhea

• Dysmenorrhea is defined as painful uterine cramping associated with menstruation, with primary dysmenorrhea occurring in the absence of an organic cause and secondary dysmenorrhea being pelvic pain associated with an underlying pelvic pathology 3.
• The pathophysiology of dysmenorrhea involves prostaglandins, which cause myometrial contraction and vasoconstriction, leading to pain 3, 4.

Treatment Options for Dysmenorrhea

• First-line treatment for dysmenorrhea includes nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal contraception, which inhibit cyclooxygenase enzymes and block prostaglandin formation 3, 5, 4.
• Other pharmacologic treatment options include Paracetamol and Gonadotrophic Release Hormone Analogs, typically used in the treatment of endometriosis 3.
• Non-pharmacologic treatments with strong evidence include heat therapy and physical exercise 3, 6, 7.
• Other non-pharmacologic interventions, such as dietary supplements, acupuncture, and transcutaneous nerve stimulation, may be used in conjunction with first-line therapy, but have less evidence-based data supporting their effectiveness 3, 6, 7.

Efficacy of Non-Pharmacological Interventions

• A systematic review and Bayesian network meta-analysis found that exercise, acupuncture, and topical heat may be effective non-pharmacologic treatments for primary dysmenorrhea, resulting in a reduction in pain intensity 7.
• Another study found that many women use non-pharmacological methods, such as heat therapy, tea, and massage, to alleviate menstrual pain, but the literature on these methods is limited 6.

Surgical Options

• For women who fail medical management, surgical options include endometrial ablation, presacral neurectomy, and laparoscopic uterosacral nerve ablation 3.