Sections

Dysmenorrhea

Medication

Medication Summary

Treatment of primary dysmenorrhea is directed at providing relief from the cramping pelvic pain and associated symptoms that typically accompany or immediately precede the onset of menstrual flow. To date, pharmacotherapy has been the most reliable and effective treatment for relieving dysmenorrhea. Nonsteroidal anti-inflammatory drugs (NSAIDs) and combination oral contraceptives (OCs) are the most commonly used therapeutic modalities for the management of primary dysmenorrhea.

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.

Class Summary

NSAIDs 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. 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.

Naproxen (Naprosyn, Aleve, Anaprox)

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Naproxen is available in both prescription and nonprescription doses. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. The daily cost is approximately $3.00, compared with $0.14 for generic ibuprofen.

Ibuprofen (Advil, Motrin, NeoProfen)

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Ibuprofen is available in both prescription and nonprescription doses. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. If not contraindicated, it is the drug of choice for treatment of mild to moderate pain.

Diclofenac (Cataflam, Voltaren XR, Cambia, Zipsor)

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Diclofenac is one of a series of phenylacetic acids that have demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis.

Because diclofenac can cause hepatotoxicity, liver enzymes should be monitored in the first 8 weeks of treatment. Diclofenac is rapidly absorbed; metabolism occurs in the liver via demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium. Diclofenac carries a relatively low risk of bleeding gastrointestinal (GI) ulcers.

Ketoprofen

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Ketoprofen inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Smaller initial dosages are particularly indicated in the elderly and in those with renal or liver dysfunction. Doses higher than 75 mg do not improve therapeutic response and may be associated with a higher incidence of adverse effects.

Meclofenamate

Meclofenamate inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Compared with other NSAIDs, it is associated with a higher incidence of diarrhea.

Mefenamic acid (Ponstel)

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Mefenamic acid inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Compared with other NSAIDs, it is associated with a higher incidence of diarrhea.

Class Summary

These medications provide control of moderate to severe pain.

Hydrocodone and acetaminophen (Vicodin, Lorcet Plus, Lortab)

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Hydrocodone plus acetaminophen is a drug combination indicated for moderate to severe pain.

Class Summary

In some patients, OCs can prevent dysmenorrhea altogether, though 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. Use of OCs in a manner that reduces the number of menstrual cycles may be beneficial for some patients. Combination OCs, the levonorgestrel intrauterine device, and depot medroxyprogesterone acetate provide effective pain relief and are associated with a reduced menstrual flow.

Medroxyprogesterone (Provera, Depo Provera)

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Medroxyprogesterone inhibits secretion of gonadotropins, thereby inhibiting ovulation and decreasing the thickness of the endometrium.

Levonorgestrel-releasing intrauterine device (Mirena)

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The levonorgestrel-releasing intrauterine device inhibits secretion of gonadotropins, thereby inhibiting ovulation and decreasing the thickness of the endometrium.

Ethinyl estradiol and norgestimate (Ortho Tri-Cyclen, MonoNessa, Previfem, TriNessa)

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This drug combination reduces secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing the amount of gonadotropin-releasing hormones.

Ethinyl estradiol and norgestrel (Lo/Ovral 28, Ogestrel, Low-Ogestrel)

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This drug combination reduces secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing the amount of gonadotropin-releasing hormones.

Ethinyl estradiol and levonorgestrel (Levora, Lybrel, Altavera)

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This drug combination reduces secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing the amount of gonadotropin-releasing hormones.

Ethinyl estradiol and Norethindrone (Cyclofem, Nortrel 1/35, Ortho-Novum)

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This drug combination reduces secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing the amount of gonadotropin-releasing hormones.

Ethinyl estradiol and Ethynodiol diacetate (Kelnor, Zovia)

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This drug combination reduces secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing the amount of gonadotropin-releasing hormones.

Drosperinone/ethinyl estradiol (Yasmin, Yaz)

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Reduces secretion of LH and FSH from pituitary by decreasing amount of gonadotropin-releasing hormones.

Questions

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Author

Karim Anton Calis, PharmD, MPH, FASHP, FCCP Clinical Professor, Medical College of Virginia, Virginia Commonwealth University School of Pharmacy; Clinical Professor, University of Maryland School of Pharmacy; Director of Clinical Research and Compliance, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health

Karim Anton Calis, PharmD, MPH, FASHP, FCCP is a member of the following medical societies: American College of Clinical Pharmacy, American Society of Health-System Pharmacists, Endocrine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Devra K Dang, PharmD, BCPS (AQ-ID), CDE Associate Clinical Professor, University of Connecticut School of Pharmacy

Disclosure: Nothing to disclose.

Sophia N Kalantaridou, MD Professor, Department of Obstetrics and Gynecology, University of Ioannina Medical School, Greece

Disclosure: Nothing to disclose.

Mert Erogul, MD Assistant Professor of Emergency Medicine, University Hospital of Brooklyn; Consulting Staff, Department of Emergency Medicine, Kings County Hospital

Mert Erogul, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Frances E Casey, MD, MPH Assistant Professor, Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center

Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, National Abortion Federation, Physicians for Reproductive Health, Society of Family Planning

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Vaishali Popat, MD, MPH Clinical Investigator, Intramural Research Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health

Vaishali Popat, MD, MPH is a member of the following medical societies: American College of Physicians, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Nahrain Alzubaidi, MD Georgetown University Hospital