eMedicine Specialties > Obstetrics and Gynecology > General Gynecology
Dysmenorrhea: Treatment & Medication
Updated: Jan 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Grading dysmenorrhea according to severity of pain and limitation of daily activity may help guide the treatment strategy.
- In addition to pain relief, other mainstays of treatment include reassurance and education.
Surgical Care
- Surgery is generally not indicated for patients with primary dysmenorrhea.
- In patients with secondary dysmenorrhea, treatment of the underlying pathology may necessitate surgical intervention.
- In refractory cases of dysmenorrhea, laparoscopic presacral neurectomy (PSN) or uterosacral nerve ablation (LUNA) have been efficacious in some patients for as long as 12 months after treatment.37,38,39
Consultations
In patients with refractory symptoms, a multidisciplinary approach may be indicated.
Diet
Both a low-fat vegetarian diet40 and fish-oil supplements41 have been reported to reduce menstrual pain in some women.
Medication
Treatment of primary dysmenorrhea is directed at providing relief from the cramping pelvic pain and associated symptoms (eg, headache, nausea, vomiting, flushing, diarrhea) that typically accompany or immediately precede the onset of menstrual flow. The pelvic pain can be distressing and occasionally radiates to the back and thighs, often necessitating prompt intervention. To date, pharmacotherapy has been the most reliable and effective treatment for relieving dysmenorrhea. Because the pain results from uterine vasoconstriction, anoxia, and contractions mediated by prostaglandins, symptomatic relief can often be obtained from use of agents that inhibit prostaglandin synthesis and have anti-inflammatory and analgesic properties.
NSAIDs and combination OCs are the most commonly used therapeutic modalities for the management of primary dysmenorrhea. These agents have different mechanisms of action and can be used adjunctively in refractory cases. The lack of response to NSAIDs and OCs (or the combination) may increase the likelihood of a secondary cause for dysmenorrhea.
Other therapies for dysmenorrhea have been proposed, but most are not well studied. These include thiamine, vitamin E, omega-3 fatty acids, magnesium, acupuncture, acupressure, various herbal medicines, transdermal nitroglycerin, calcium-channel blockers, beta-adrenergic agonists, antileukotrienes, and transcutaneous electrical nerve stimulation (TENS) units. Use of topical, continuous, low-level heat may be beneficial for some patients.42,43
Treatment of secondary dysmenorrhea involves correction of the underlying organic cause. Specific measures (medical or surgical) may be required to treat pelvic pathology (eg, endometriosis) and to ameliorate the associated dysmenorrhea. Periodic use of analgesic agents as adjunctive therapy may be beneficial.
Nonsteroidal anti-inflammatory drugs
NSAIDs are the most commonly used treatments for dysmenorrhea. NSAIDs decrease menstrual pain by decreasing intrauterine pressure and lowering PGF2alpha levels in menstrual fluid.44,45,46 Because they are used for short periods in otherwise healthy young women, they are generally well tolerated and free of serious toxicity. Gastrointestinal (GI) upset is the most common adverse effect associated with NSAIDs, and patients receiving these medications should be monitored for more serious adverse effects, including GI bleeding and renal dysfunction.
Patients should also be monitored for potential pharmacokinetic and pharmacodynamic drug interactions and possible effects on platelet aggregation. NSAIDs are contraindicated in patients with renal insufficiency, peptic ulcer disease, gastritis, bleeding diatheses, and aspirin hypersensitivity. These agents must be used on a regular basis (as-needed use is not adequate in most patients) for several days. To avoid inadvertent exposure to these agents during early pregnancy, NSAIDs should be started at the onset of menstrual bleeding.
While some NSAIDs have been touted as being particularly effective for dysmenorrhea (especially the fenamates), scientific data to support such claims are sparse and generally weak.47 Moreover, well-designed prospective comparative studies have not been performed. Diclofenac, ibuprofen, ketoprofen, meclofenamate, mefenamic acid, and naproxen are the NSAIDs specifically approved by the US Food and Drug Administration (FDA) for treatment of dysmenorrhea. Aspirin may not be as effective as other NSAIDs, and acetaminophen may be a useful adjunct for alleviating only mild menstrual cramping pain.48,47
NSAIDs that achieve peak serum concentrations within 30-60 minutes and have a faster onset of action (eg, ibuprofen, naproxen, meclofenamate) may be preferred. However, individual patient response varies, and patients may need a trial of several agents before finding one that works. Some NSAIDs (eg, indomethacin) should be avoided because they have a higher incidence of adverse effects.
Despite some preliminary data suggesting efficacy in patients with primary dysmenorrhea, the newer cyclooxygenase-2 (COX-2) inhibitors have not been demonstrably superior to conventional NSAIDs.49 However, these agents may be used in patients who cannot tolerate other NSAIDS or in whom these agents are contraindicated. COX-2–derived prostanoids nonetheless appear to be involved in the pathophysiology of primary dysmenorrhea.50
NSAIDs that inhibit type I prostaglandin synthetase and suppress the production of cyclic endoperoxides (eg, fenamates, COX-2–selective agents, propionic acids, indole acetic acids) alleviate dysmenorrhea symptoms by decreasing endometrial and menstrual fluid prostaglandin concentrations.
Naproxen (Naprosyn, Aleve, Anaprox)
Available in both prescription and nonprescription doses. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg PO q6-8h or 500 mg q12h; not to exceed 1.25 g/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of antihypertensives; may decrease diuretic effects of loop and thiazide diuretics; may increase PT when taking anticoagulants (instruct patients to watch for signs/symptoms of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; history of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDS; treatment of perioperative pain in setting of coronary artery bypass graft surgery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant/antiplatelet therapy; discontinue if a rash occurs
Ibuprofen (Advil, Motrin, Nuprin)
Available in both prescription and nonprescription doses. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.
Adult
400 mg PO q4-6h; not to exceed 3.2 g/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of antihypertensives; may decrease diuretic effects of loop and thiazide diuretics; may increase PT when taking anticoagulants (instruct patients to watch for signs/symptoms of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; history of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDS; treatment of perioperative pain in setting of coronary artery bypass graft surgery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant/antiplatelet therapy; discontinue if a rash occurs
Diclofenac (Cataflam, Voltaren)
Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.
Adult
100 mg PO initially then 50 mg PO tid; not to exceed 150 mg/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of antihypertensives; may decrease diuretic effects of loop and thiazide diuretics; may increase PT when taking anticoagulants (instruct patients to watch for signs/symptoms of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; history of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDS; treatment of perioperative pain in setting of coronary artery bypass graft surgery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant/antiplatelet therapy; discontinue if a rash occurs
Ketoprofen (Orudis, Actron, Oruvail)
Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in the decrease of prostaglandin synthesis. Smaller initial dosages are particularly indicated in the elderly and in those with renal or liver dysfunction. Doses greater than 75 mg do not improve therapeutic response and may be associated with a higher incidence of adverse effects.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of antihypertensives; may decrease diuretic effects of loop and thiazide diuretics; may increase PT when taking anticoagulants (instruct patients to watch for signs/symptoms of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; history of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDS; treatment of perioperative pain in setting of coronary artery bypass graft surgery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during concomitant anticoagulant/antiplatelet therapy; discontinue if a rash occurs
Meclofenamate sodium
Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis. Higher incidence of diarrhea compared with other NSAIDS.
Adult
100 mg PO tid for up to 6 d; not to exceed 300 mg/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of antihypertensives; may decrease diuretic effects of loop and thiazide diuretics; may increase PT when taking anticoagulants (instruct patients to watch for signs/symptoms of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; active GI bleeding; ulcer disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Diarrhea may occur (reduce dose or discontinue use);
caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant/antiplatelet therapy; discontinue if a rash occurs
Mefenamic acid (Ponstel)
Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis. Higher incidence of diarrhea compared to other NSAIDS.
Adult
500 mg PO initially, followed by 250 mg q6h for 2-3 d; not to exceed 1 g/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of antihypertensives; may decrease diuretic effects of loop and thiazide diuretics; may increase PT when taking anticoagulants (instruct patients to watch for signs/symptoms of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; history of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDS; treatment of perioperative pain in setting of coronary artery bypass graft surgery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Diarrhea may occur (reduce dose or discontinue use); caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during concomitant anticoagulant/antiplatelet therapy; discontinue if a rash occurs
Contraceptives
Dysmenorrhea can be prevented altogether in some patients by use of OCs, although these agents are not approved by the FDA for this indication. OCs may be an appropriate treatment choice in patients who do not wish to conceive. The combination OCs suppress the hypothalamic-pituitary-ovarian axis and thereby inhibit ovulation and prevent prostaglandin production in the late luteal phase. This generally significantly reduces the amount of menstrual flow and effectively alleviates primary dysmenorrhea in most patients. Use of OCs in a manner that reduces the number of menstrual cycles (by extending the use of active pills and avoiding the pill-free week or with extended-cycle formulations) may be beneficial for some patients.51,52
Combination OCs, the levonorgestrel intrauterine device, and depot medroxyprogesterone acetate provide effective pain relief and are associated with a reduced menstrual flow. The use of NSAIDs in combination with an OC may be necessary, especially during the first few cycles after initiation of the OC. The dose of ethinyl estradiol should generally be less than 50 mcg. A monophasic OC containing 30 mcg of ethinyl estradiol is a reasonable choice. To date, studies comparing the efficacy of various OC formulations in the management of dysmenorrhea have not been performed.
Medroxyprogesterone acetate (DMPA; DepoProvera)
Inhibits secretion of gonadotropins, thereby inhibiting ovulation and decreasing thickness of endometrium.
Adult
IM formulation: 150 mcg IM q3mo
Subcutaneous suspension (104 mg/0.65 mL): 1 injection q3mo
Pediatric
Not established
Aminoglutethimide (not currently available in the US) may significantly decrease serum concentrations
Documented hypersensitivity; undiagnosed vaginal bleeding; known or suspected malignancy of breast; active thrombophlebitis or current or past history of thromboembolic disorders or cerebral vascular disease; significant liver disease
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May cause a significant decrease in bone mineral density that may not be reversible, this risk is increased with increasing duration of use, not generally recommended for use longer than 2 years; caution in hepatic impairment, glucose intolerance, depression, or ocular disorders; may cause fluid retention; may cause menstrual irregularities and amenorrhea; weight gain observed
Levonorgestrel-releasing intrauterine device (Mirena)
Inhibits secretion of gonadotropins, thereby inhibiting ovulation and decreasing thickness of endometrium.
Adult
52 mg levonorgestrel, inserted intrauterine; removed after 5 years
Pediatric
Not established
Not established
Documented hypersensitivity; undiagnosed vaginal bleeding; known or suspected malignancy of breast; acute liver disease or liver tumor (benign or malignant); known or suspected uterine or cervical neoplasia or unresolved abnormal Pap smear; untreated acute cervicitis or vaginitis, including bacterial vaginosis or other lower genital tract infections until infection is controlled; genital actinomycosis; history of ectopic pregnancy or condition that would predispose to ectopic pregnancy; congenital or acquired uterine anomaly including fibroids if they distort the uterine cavity; acute pelvic inflammatory disease (PID) or a history of PID unless there has been a subsequent intrauterine pregnancy; postpartum endometritis or infected abortion in the past 3 months; conditions associated with increased susceptibility to infections with micro-organisms (eg, leukemia, AIDS, and IV drug abuse); woman or her partner has multiple sexual partners
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May cause menstrual irregularities and amenorrhea; may cause PID, embedment in the myometrium, perforation of uterus, or ovarian cyst
Ethinyl estradiol and gonane progestin (norgestimate, norgestrel, levonorgestrel, or desogestrel) (Ortho-Cyclen, Ovral, Lo-Ovral, Alesse, Levlen, Levlite, Nordette, Desogen, Ortho-Cept)
Reduces secretion of LH and FSH from pituitary by decreasing amount of gonadotropin-releasing hormones.
Adult
1 tab/d PO for 21 d followed by 7 d off medication (or taking inactive tab); begin new course on day 8 after taking last active tab
Schedule 1 (Sunday starter): Begin dose on first Sunday after onset of menstruation; start that Sunday if menstrual period starts on Sunday
Schedule 2 (Day 1 starter): Start dose on day 1 of menstrual cycle
Perform pregnancy test if menstrual period is missed
Pediatric
Not established
Phenobarbital, phenytoin, primidone, carbamazepine, oxcarbazepine, barbiturates, ethosuximide, felbamate, topiramate, rifampin, rifabutin, griseofulvin, modafinil, and St. John's wort induce enzymes that decrease concentrations of contraceptive steroids; broad-spectrum antibiotics may decrease effectiveness
Documented hypersensitivity; endometrial or other estrogen-dependent cancers; hepatic cancer or active liver disease; thromboembolic disorders; undiagnosed vaginal bleeding; smokers >35 y; cardiovascular or cerebrovascular disease; headaches with focal neurological symptoms; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in patients diagnosed with hepatic impairment, migraine, or seizure disorders
Ethinyl estradiol and estrane progestin (norethindrone or ethynodiol acetate) (Ortho-Novum, Ovcon 50, Ortho-Novum 7/7/7, Brevicon, LoEstrin, Modicon, Tri-Norinyl, Demulen, Zovia)
Reduces secretion of LH and FSH from pituitary by decreasing amount of gonadotropin-releasing hormones.
Adult
1 tab/d for 21 d followed by 7 d off medication (or taking inactive tab); begin new course on day 8 after taking last active tab
Schedule 1 (Sunday starter): Begin dose on first Sunday after onset of menstruation; start that Sunday if menstrual period starts on Sunday
Schedule 2 (Day 1 starter): Start dose on day 1 of menstrual cycle
Perform pregnancy test if menstrual period is missed
Pediatric
Not established
Phenobarbital, phenytoin, primidone, carbamazepine, oxcarbazepine, barbiturates, ethosuximide, felbamate, topiramate, rifampin, rifabutin, griseofulvin, modafinil, and St. John's wort induce enzymes that decrease concentrations of contraceptive steroids; broad-spectrum antibiotics may decrease effectiveness
Documented hypersensitivity; endometrial or other estrogen-dependent cancers; hepatic cancer or active liver disease; thromboembolic disorders; undiagnosed vaginal bleeding; smokers >35 y; cardiovascular or cerebrovascular disease; headaches with focal neurological symptoms; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in patients diagnosed with hepatic impairment, migraine, or seizure disorders
Ethinyl estradiol and drospirenone (Yasmin, YAZ)
Reduces secretion of LH and FSH from pituitary by decreasing amount of gonadotropin-releasing hormones.
Adult
24-tab package (YAZ): 1 tab per d for 24 d followed by 4 d off medication (or taking inactive tab); begin new course on d 5 after taking last active tab
28-tab package (Yasmin): 1 tab per d for 21 d followed by 7 d off medication (or taking inactive tab); begin new course on d 8 after taking last active tab
Schedule 1 (Sunday starter): Begin dose on first Sunday after onset of menstruation; start that Sunday if menstrual period starts on Sunday
Schedule 2 (Day 1 starter): Start dose on d 1 of menstrual cycle
Perform pregnancy test if menstrual period is missed
Pediatric
Not established
Phenobarbital, phenytoin, primidone, carbamazepine, oxcarbazepine, barbiturates, ethosuximide, felbamate, topiramate, rifampin, rifabutin, griseofulvin, modafinil, and St. John's wort induce enzymes that decrease concentrations of contraceptive steroids; broad-spectrum antibiotics may decrease effectiveness; increased risk of hyperkalemia with other hyperkalemic drugs (ACE inhibitors, angiotensin-II receptor blockers, aldosterone antagonists, potassium-sparing diuretics, NSAIDs, heparin)
Documented hypersensitivity; endometrial or other estrogen-dependent cancers; hepatic cancer or active liver disease; thromboembolic disorders; undiagnosed vaginal bleeding; smokers >35 y; cardiovascular or cerebrovascular disease; headaches with focal neurological symptoms; pregnancy; renal insufficiency, adrenal insufficiency, or any other conditions that predisposes to hyperkalemia
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in patients diagnosed with hepatic impairment, migraine, or seizure disorders
More on Dysmenorrhea |
| Overview: Dysmenorrhea |
| Differential Diagnoses & Workup: Dysmenorrhea |
 Treatment & Medication: Dysmenorrhea |
| Follow-up: Dysmenorrhea |
| References |
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Further Reading
Keywords
primary dysmenorrhea, secondary dysmenorrhea, painful menstruation, painful menses, spasmodic dysmenorrhea, congestive dysmenorrhea, endometriosis, pelvic inflammatory disease, PID, ovarian cysts, ovarian tumors, cervical stenosis, cervical occlusion, adenomyosis, fibroids, uterine polyps, intrauterine adhesions, congenital malformations, bicornuate uterus, subseptate uterus, intrauterine contraceptive devices, IUCDs, intrauterine devices, IUDs, transverse vaginal septum, pelvic congestion syndrome, Allen-Masters syndrome
