APPROACH CONSIDERATIONS

The goal of treatment is to provide adequate relief of pain. At a minimum, pain relief should be sufficient to allow women to perform most, if not all, of their usual activities and to reduce the productivity loss commonly associated with dysmenorrhea.

Treatment of primary dysmenorrhea can be initiated empirically. Laboratory tests, imaging studies, and/or laparoscopy are not required to definitively exclude causes of secondary dysmenorrhea when a detailed history and physical examination strongly support the diagnosis, particularly in adolescents.

Relief of symptoms with standard treatment should start initially. If symptoms do not sufficiently respond to standard treatments, physicians should begin an evaluation for causes of secondary dysmenorrhea.

Baseline interventions –

General measures for management include patient education and reassurance. Treatment is supportive and should be guided by individual needs, as the severity of pain and degree of limitation of activity vary widely among women with dysmenorrhea.

The initial approach includes a discussion of nonpharmacologic interventions that can be helpful, such as exercise and the application of a heat pack to the lower abdomen.

First-tier treatment –

For women who do not have adequate relief with baseline interventions or who desire immediate pharmacologic therapy, first-line treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and/or hormonal contraception.

NSAIDs (eg: mefenamic acid, tolfenamic acid, bromfenac, ibuprofen, naproxen, aspirin) or Paracetamol are a logical first choice for women who prefer not to use hormonal treatment or prefer/need to avoid hormonal therapy. Paracetamol is an alternative treatment for patients who cannot tolerate NSAIDs or have medical contraindications.

Treatment typically begins just prior to or with the onset of menses and continues for two to three days. Treatment duration depends on the duration of the patient's menses and symptom pattern. Some women may need combinations of treatment. Patient-specific factors, such as personal treatment goals and the cost and convenience of various treatments, help guide treatment selection.

Hormonal contraception includes combined estrogen-progestin products (oral pills, transdermal patch, and vaginal ring) and progestin-only options (implant, injection, intrauterine device, and oral pills).

Choice of treatment order depends on the clinical needs and preferences of the patient. For women with primary dysmenorrhea desiring contraception, hormonal contraception is a logical initial choice. Initiating hormonal contraception may also be appropriate for women who do not need contraception (eg, they are not sexually active with a male partner) and do not currently wish to conceive.

For patients whose symptoms improve somewhat but still have pain, physicians may offer Combination treatment (NSAIDs plus Hormonal contraception). Treatment with both hormonal contraception and NSAIDs may be effective in women who remain symptomatic on either therapy alone.

Reevaluate for underlying causes of dysmenorrhea –

Women who do not achieve adequate pain relief after three to six months of treatment with NSAIDs and/or hormonal contraceptives, either alone or in combination, may have secondary dysmenorrhea (ie, dysmenorrhea related to underlying pathology including endometriosis and adenomyosis).

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