How should abdominal pain during menses be treated in a healthy reproductive‑age woman with presumed primary dysmenorrhea?

Treatment of Abdominal Pain During Menses (Primary Dysmenorrhea)

Start with NSAIDs as first-line therapy: 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

First-Line Pharmacological Treatment

NSAIDs are the mainstay of therapy because they inhibit cyclooxygenase enzymes and block prostaglandin formation, which is the primary cause of uterine cramping in dysmenorrhea. 1, 3

• Ibuprofen 600-800 mg every 6-8 hours with food is the preferred first-line agent 1, 2
• Naproxen 440-550 mg every 12 hours with food is an equally effective alternative 1, 2
• Mefenamic acid 500 mg three times daily is particularly effective for reducing both pain and menstrual blood loss 1, 4
• Treatment duration should be 5-7 days during bleeding only, not continuous 1, 2
• Maximum daily ibuprofen dose is 3200 mg, though doses above 400 mg per administration were no more effective in controlled trials 2

Approximately 18% of women do not respond to NSAIDs, which should prompt investigation for secondary causes after 2-3 menstrual cycles of adequate treatment. 1, 5

Adjunctive Non-Pharmacological Treatments

These can be used alongside NSAIDs to enhance pain relief:

• Heat therapy applied to abdomen or back reduces cramping pain through local vasodilation 1, 4
• Acupressure at Large Intestine-4 (LI4) point on the dorsum of the hand between thumb and index finger 1, 4
• Acupressure at Spleen-6 (SP6) point located approximately 4 fingers above the medial malleolus 1, 4
• Peppermint essential oil has demonstrated symptom reduction 1, 4

Second-Line Treatment: Hormonal Contraceptives

If NSAIDs fail after 2-3 menstrual cycles or are contraindicated, add hormonal contraceptives. 1, 5

• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are the preferred second-line option 1
• Monophasic formulations are recommended for simplicity 1
• Extended or continuous cycles are particularly appropriate for severe dysmenorrhea as they minimize hormone-free intervals and optimize ovarian suppression 1
• COCs are completely reversible with no negative effect on long-term fertility 1
• Approximately 10% of women fail both NSAIDs and hormonal contraceptives combined, requiring further evaluation 5

When to Investigate for Secondary Causes

Obtain transvaginal ultrasound if any of the following are present: 5

• Abnormal pelvic examination findings 5
• Failure to respond to appropriate NSAID therapy after 2-3 menstrual cycles 5
• Abrupt change in previously stable pain pattern 5
• Age >25 years at symptom onset (primary dysmenorrhea typically begins in adolescence) 6

Rule out these conditions before assuming primary dysmenorrhea: 1, 4

• Pregnancy (always rule out first with urine or serum β-hCG) 4, 5
• Sexually transmitted infections (chronic PID can present as worsening dysmenorrhea) 1, 5
• Structural abnormalities: fibroids, polyps, endometriosis, adenomyosis 4, 5
• IUD displacement in patients with worsening dysmenorrhea 5

Management of Refractory Cases

If symptoms persist beyond 3 months despite appropriate NSAID and hormonal therapy, escalate as follows: 1

1. Confirm medication compliance and adequate dosing 5
2. Obtain pelvic ultrasound to evaluate for secondary causes 5
3. If endometriosis is suspected: Consider GnRH agonists for at least 3 months or danazol for at least 6 months, with add-back therapy to prevent bone mineral loss 5
4. Refer to gynecologic specialist for possible laparoscopy evaluation 1

Critical Red Flags Requiring Urgent Evaluation

These symptoms are NOT typical of primary dysmenorrhea and require immediate assessment: 4

• Difficulty breathing (requires urgent cardiopulmonary assessment) 4
• Severe headache with dizziness (could indicate severe anemia, hypertension, or other serious conditions) 4
• Persistent vomiting (risks dehydration and electrolyte abnormalities; rule out pregnancy) 4
• Severe anemia symptoms 4

Common Pitfalls to Avoid

• Do not underdose NSAIDs: Higher doses (ibuprofen 600-800 mg) are more effective than lower doses (400 mg) in clinical practice 1, 5
• Do not delay NSAID treatment while waiting for diagnostic workup 5
• Do not continue ineffective treatment beyond 2-3 cycles without reassessment 5
• Do not assume oral contraceptives correct underlying pathology: They may mask symptoms of endometriosis or other conditions 1
• Do not forget to take NSAIDs with food to minimize gastrointestinal side effects 1, 2