eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Dysmenorrhea: Treatment & Medication
Updated: Dec 31, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Many women never seek medical attention for dysmenorrhea. Self-medication with analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) as well as direct application of heat are common effective strategies.
Emergency Department Care
- As always, ED evaluation should begin with the ABCs and should consider serious diagnoses such as hemorrhagic shock and sepsis.
- A patient whose history and clinical presentation clearly suggest primary dysmenorrhea may be treated symptomatically and provided with appropriate follow-up.
- A patient whose presentation is less clear or whose vital signs and/or physical examination findings are abnormal deserves a more thorough workup, including full laboratory studies, pelvic ultrasonography, and potentially an OB/GYN consultation.
Consultations
Patients with pelvic pain do not routinely need consultation with a gynecologist in the emergency department, though they should be directed to follow up as an outpatient. Exceptions include certain infectious entities, such as abscesses, as well as endometriosis.
Medication
Treatment of dysmenorrhea is aimed at providing symptomatic relief as well as inhibiting the underlying processes that cause symptoms.
NSAIDs reduce prostaglandin production via cyclooxygenase inhibition and are used as first-line therapy for both primary and secondary dysmenorrhea. If taken early enough and in sufficient quantity, they are extremely successful in alleviating menstrual pain. In the ED setting, patients who do not respond to NSAIDs may require treatment with narcotics for pain control. Patients whose symptoms are not relieved by NSAIDs are very likely to have underlying pelvic pathology such as endometriosis.
COX-2 specific inhibitors have also proven effective in relieving menstrual pain. Their selectivity reduces the GI symptoms caused by inhibition of the COX-1 receptor. However, recent clinical trials have raised their cardiovascular safety profiles into question. As a result, some of these agents are no longer available.
Simple analgesics, such as aspirin and acetaminophen, may also be useful, especially when NSAIDs are contraindicated.
Oral contraceptives, which block monthly ovulation and may decrease menstrual flow, may also relieve symptoms. One recent update of a Cochrane Database of Systematic Reviews article showed some evidence of symptomatic benefit in patients with primary dysmenorrhea, though no specific preparation showed superiority over another.12
Certain dietary supplements may be effective, though their effectiveness has only been demonstrated in small clinical trials. Thiamine, fish oil, pyridoxine, magnesium, and vitamin E are examples.3,13
Nonsteroidal anti-inflammatory agents
These drugs are highly effective in treating dysmenorrhea, especially when they are started before the onset of menses and continued through day 2. They are readily available, relatively inexpensive, and have a low side effect profile when used cautiously and in those who have no contraindications.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for treatment of mild to moderate pain, if not contraindicated. Inhibits inflammatory reactions and pain, probably by decreasing activity of the enzyme cyclooxygenase, which results in inhibition 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 hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs 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
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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 anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn, Aleve)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis. Cost is approximately $3.00/d compared with $0.14/d for generic ibuprofen.
Adult
500 mg PO followed by 250 mg q6-8h; 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 effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs 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
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
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Diclofenac (Cataflam, Voltaren)
Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzene acetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA. One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. Believed to inhibit the enzyme cyclooxygenase, which is essential in prostaglandin biosynthesis. Can cause hepatotoxicity; hence, liver enzymes should be monitored in first 8 weeks of treatment. Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Delayed-release, enteric-coated form is diclofenac sodium, and immediate-release form is diclofenac potassium. Has relatively low risk for bleeding GI ulcers.
Adult
25 mg PO bid/tid
If well tolerated, increase by 25 or 50 mg at weekly intervals until satisfactory response is obtained or total daily dose of 150-200 mg PO reached
Higher doses generally do not increase effectiveness
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding) may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into CNS or give to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding
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
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if leukopenia, granulocytopenia, or thrombocytopenia persists
Hydrocodone and acetaminophen (Vicodin, Lorcet-HD, Lortab)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: Not established
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
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
Tab contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
More on Dysmenorrhea |
| Overview: Dysmenorrhea |
| Differential Diagnoses & Workup: Dysmenorrhea |
 Treatment & Medication: Dysmenorrhea |
| Follow-up: Dysmenorrhea |
| References |
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References
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Proctor ML, Murphy PA, Pattison HM, Suckling J, Farquhar CM. Behavioural interventions for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. Jul 18 2007;CD002248. [Medline].
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Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P. Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. Fertil Steril. Sep 2006;86(3):711-5. [Medline].
Wong CL, Farquhar C, Roberts H, Proctor M. Oral contraceptive pill as treatment for primary dysmenorrhoea. Cochrane Database Syst Rev. Apr 15 2009;CD002120. [Medline].
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[Best Evidence] Witt CM, Reinhold T, Brinkhaus B, Roll S, Jena S, Willich SN. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol. Feb 2008;198(2):166.e1-8. [Medline].
Andersch B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol. Nov 15 1982;144(6):655-60. [Medline].
Harel Z, Biro FM, Kottenhahn RK, Rosenthal SL. Supplementation with omega-3 polyunsaturated fatty acids in the management of dysmenorrhea in adolescents. Am J Obstet Gynecol. Apr 1996;174(4):1335-8. [Medline].
Further Reading
Keywords
dysmenorrhea, dysmenorrhea symptoms, dysmenorrhea causes, dysmenorrhea treatment, primary dysmenorrhea, secondary dysmenorrhea, menstrual pain, painful periods, menorrhalgia, pelvic pain, menstrual cramps, endometriosis, uterine fibroids, uterine adenomyosis, chronic pelvic inflammatory disease, leiomyomata, adenomyosis, endometrial polyps
