Approach Considerations
Many women never seek medical attention for dysmenorrhea. Self-medication with analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) and direct application of heat are common effective strategies.
When a patient is seen in the emergency department (ED), evaluation should begin with the ABCs (A irway, B reathing, C irculation) 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 or physical findings are abnormal deserves a more thorough workup, including full laboratory studies, pelvic ultrasonography, and potentially an obstetrics/gynecology consultation.
Treatment of dysmenorrhea is aimed at providing symptomatic relief as well as inhibiting the underlying processes that cause symptoms. Grading dysmenorrhea according to the severity of pain and the degree of limitation of daily activity may help guide the treatment strategy. Medications used may include NSAIDs and opioid analgesics, as well as hormonal contraceptives. In addition to pain relief, mainstays of treatment include reassurance and education. Other therapies have been proposed, but most are not well studied.
In patients with refractory symptoms, a multidisciplinary approach may be indicated. Patients with pelvic pain do not routinely need consultation with a gynecologist in the ED, though they should be directed to follow up on an outpatient basis. Exceptions include certain infectious entities (eg, abscesses) or surgical emergencies, such as ovarian torsion.
Patients with both primary and secondary dysmenorrhea should be provided with appropriate gynecologic follow-up. If they do not have regular medical care, an appointment with a primary medical doctor is also indicated.
Pharmacologic Therapy
Treatment of primary dysmenorrhea is directed at providing relief from the cramping pelvic pain and associated symptoms (eg, headache, nausea, vomiting, flushing, and 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 by using agents that inhibit prostaglandin synthesis and possess anti-inflammatory and analgesic properties.
NSAIDs and hormonal contraceptives 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. Lack of response to NSAIDs and hormonal contraceptives (or a combination thereof) may increase the likelihood of a secondary cause for dysmenorrhea.
Treatment of secondary dysmenorrhea involves correction of the underlying organic cause. Specific measures (medical or surgical) may be required to treat pelvic pathologic conditions (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 common treatment for both primary and secondary dysmenorrhea. They decrease menstrual pain by decreasing intrauterine pressure and lowering prostaglandin F2α (PGF2α) levels in menstrual fluid. [60, 61, 62] NSAIDs that inhibit type I prostaglandin synthetase and suppress production of cyclic endoperoxides (eg, fenamates, cyclooxygenase [COX]-2–selective agents, propionic acids, and indole acetic acids) alleviate symptoms by decreasing endometrial and menstrual fluid prostaglandin concentrations.
If taken early enough and in sufficient quantity, NSAIDs are extremely successful in alleviating menstrual pain. 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, or 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, or just prior to the start, of menstrual bleeding.
Whereas some NSAIDs (especially the fenamates) have been touted as being particularly effective for dysmenorrhea, scientific data to support such claims are sparse and generally weak. [63] Moreover, well-designed prospective comparative studies have not been performed [64] . The NSAIDs specifically approved by the US Food and Drug Administration (FDA) for treatment of dysmenorrhea are as follows:
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Diclofenac
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Ibuprofen
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Ketoprofen
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Meclofenamate
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Mefenamic acid
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Naproxen
Aspirin may not be as effective as these NSAIDs, and acetaminophen may be a useful adjunct for alleviating only mild menstrual cramping pain. [63, 65]
NSAIDs that achieve peak serum concentrations within 30-60 minutes and have a faster onset of action (eg, ibuprofen, naproxen, and meclofenamate) may be preferred. However, individual patient response varies, and patients may need to try several agents before finding one that works. Some NSAIDs (eg, indomethacin) should be avoided, because they have a higher incidence of adverse effects.
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. Despite some preliminary data suggesting efficacy in patients with primary dysmenorrhea, COX-2 inhibitors have not been demonstrably superior to conventional NSAIDs. [66]
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. [67]
Other analgesic agents
In an emergency 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 an underlying pelvic condition (eg, endometriosis).
In a study comparing montelukast, a leukotriene-receptor antagonist, with placebo in patients with dysmenorrhea, montelukast was effective in reducing pain. [68] Clinicians may consider this agent as an alternative to hormonal therapy or in lieu of NSAIDs.
Simple analgesics, such as aspirin and acetaminophen, may also be useful, especially when NSAIDs are contraindicated.
Hormonal contraceptives
Hormonal contraceptives, which block monthly ovulation and may decrease menstrual flow, may also relieve symptoms. An update of a Cochrane review showed some evidence of symptomatic benefit in patients with primary dysmenorrhea, though no specific preparation showed superiority over any other. [69] In some patients, hormonal contraceptives can prevent dysmenorrhea altogether, even though these agents are not approved by the FDA for this indication.
Hormonal contraceptives may be an appropriate choice for patients who do not wish to conceive. Hormonal contraceptives suppress the hypothalamic-pituitary-ovarian axis, thereby inhibiting ovulation and preventing prostaglandin production in the late luteal phase. This generally reduces the amount of menstrual flow and alleviates primary dysmenorrhea in most patients. Use of hormonal contraceptives in a manner that reduces the number of menstrual cycles may be beneficial for some patients. [70, 71]
Combination oral contraceptives, the levonorgestrel intrauterine device, and depot medroxyprogesterone acetate [72] provide effective pain relief and are associated with reduced menstrual flow. It may be necessary to add an NSAID to the these oral contraceptives, especially during the first few cycles after initiation. The ethinyl estradiol dose should generally be less than 50 µg; a monophasic oral contraceptive containing 30 µg is a reasonable choice. To date, studies comparing the efficacy of various formulations in the management of dysmenorrhea have not been performed.
In a study of women with primary dysmenorrhea, Petraglia et al found that estradiol valerate plus dienogest and ethinyl estradiol plus levonorgestrel were comparably effective in relieving dysmenorrheic pain. Each of the treatments was taken orally by over 200 women daily for three 28-day cycles, with the number of days of pain and the degree of pain being evaluated. Based on the patients’ self-assessments, the investigators determined that pain was reduced by both treatments by approximately the same number of days (by 4.6 days for estradiol valerate plus dienogest, by 4.2 days for ethinyl estradiol plus levonorgestrel). [73]
Dietary and Other Therapies
Other therapies for dysmenorrhea have been proposed, but most are not well studied. A low-fat vegetarian diet, [74, 30] [75] pyridoxine, magnesium, and vitamin E are examples. [27, 76]
In addition, acupuncture, [77, 78, 79, 80, 81] acupressure, [82, 80] , auriculotherapy [83] , aromatherapy, [84] various herbal medicines and dietary supplements, [85, 86] transdermal nitroglycerin, calcium-channel blockers, beta-adrenergic agonists, antileukotrienes, transcutaneous electrical nerve stimulation (TENS) units, and physiotherapy have been suggested for therapeutic use in this setting. [87] A systematic review and meta-analysis of 9 randomized controlled trials examining various methods of physiotherapy as a treatment for primary dysmenorrhea reported a significant reduction in menstrual pain intensity; however, the available evidence remains of low quality. [88] Topical application of continuous low-level heat may be beneficial for some patients. [89, 90] Interruption of nerve pathways has been performed, but data are limited. [91, 92, 93]
Prevention
Various measures have been used to manage dysmenorrhea in the outpatient setting, including the following:
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Lifestyle modification seems to be helpful
A Cochrane review of 5 randomized controlled trials showed that certain behavioral interventions, including relaxation techniques, may be effective at treating primary and secondary dysmenorrhea. [16]
