Dysmenorrhea%20-%20primary Treatment

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• The 1st-line agents in most women with primary dysmenorrhea
  • Only 2-3 days/month administration gives a definite advantage over daily administration of oral contraceptives (OCs)
• Recommended in women who prefer analgesics or have contraindications to contraceptives 
• Most effective when started 1-2 days before the predicted onset of menses and continued for the usual duration of cramps
• Adolescents and young adults who cannot predict the onset of their period should be instructed to start NSAIDs as soon as menses begins or as soon as they have any menstruation-associated symptoms
• Actions: Inhibit the production and release of prostaglandin
• Effects: Approximately 70% of women experience moderate-complete relief, although individual trials show wide variations in range
  • Relief usually occurs within 30-60 minutes
  • GI side effects are reduced when taken with or after food or milk
  • No particular NSAID has been reliably shown to be more effective than others
• Pharmacologic properties and the severity of side effects determine the choice and dosage of the treatment
  • Aspirin is usually not used because of its lack of anti-inflammatory action at usual doses (it may also increase menstrual flow)
  • Indomethacin provides excellent relief of pain but its side effects often limit its use
  • NSAIDs that are associated with low risk of serious GI side effects (eg Ibuprofen or Naproxen) are usually preferred
• There is a variation in individual response; therefore, patients who have poor or partial response to one NSAID may respond well to a different agent; may also consider increasing the NSAID dose
  
  • Eg may start with a propionic acid derivative (eg Ibuprofen) then switch to a fenamate (eg Mefenamic acid) if pain relief is inadequate
• The new classes of NSAIDs and cyclooxygenase-2 (COX-2) selective inhibitors are also effective and may cause fewer GI side effects when compared to traditional NSAIDs
• Paracetamol (Acetaminophen) is an alternative treatment option for patients with mild to moderate dysmenorrhea who are intolerant of NSAIDs and who would like to avoid OC use
• If patient is unresponsive to NSAID therapy, consider switching to hormonal therapy and/or non-pharmacological therapy
• Contraindications: Peptic ulceration; hypersensitivity to Aspirin or any other NSAID which includes those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by Aspirin or any other NSAID

Hormonal Therapy

• 1st-line therapy for patients who also desire birth control
• Recommended in women in whom contraceptive use is acceptable or who are intolerant of or are unresponsive to NSAID therapy
• Counseling patients about the benefit of OCs may also help motivate compliance  
• Actions: Suppress endometrial prostaglandin production by inhibiting ovulation (no endogenous progesterone production) and by preventing normal synchronous endometrial growth and differentiation
  
  • Decrease menstrual flow and uterine contractions thus reducing dysmenorrhea 
• Effects: Effective in about 90% of patients with primary dysmenorrhea
• It may take up to 3 cycles of treatment for menstrual pain to noticeably diminish
  
  • Consider adding an NSAID for breakthrough pain
• Continuous regimen compared with cyclic dosing results in better menstrual symptom relief, though both regimens appear to be effective
• If estrogen-progestin contraceptive use did not provide adequate relief after 3 standard cycles, alternative treatment may include continuous estrogen-progestin contraceptives or a long-acting progestin-only therapy 
• Contraindications: Current pregnancy, history of venous or arterial thrombosis, cardiovascular (CV) disease, cerebrovascular disease, hepatic dysfunction, systemic lupus erythematosus (SLE), cholestatic jaundice, undiagnosed vaginal bleeding, breastfeeding (until weaning or 6 months after birth), breast carcinoma, endometrial cancer
• Various OCs are available. Please see the latest MIMS for specific formulations and prescribing information.

Other Hormonal Agents

• Levonorgestrel-releasing intrauterine system (LNG-IUS) and depot Medroxyprogesterone have a local effect in the endometrium which is to induce endometrial atrophy resulting in relief of dysmenorrhea; may also cause amenorrhea
• LNG-IUS does not suppress ovulation unlike Medroxyprogesterone which suppresses ovulation
• LNG-IUS is recommended for the treatment of idiopathic menorrhagia
  • May also be used at the time of diagnostic laparoscopy to decrease the pain of insertion
• Etonogestrel subdermal implant improves dysmenorrheal symptoms in 81% of women between 18-40 years
• Combined Ethinyl estradiol and Norelgestromin vaginal ring has been shown to reduce the incidence of dysmenorrhea from 25.9% to 5.7% after 6 treatment cycles

Combination of NSAIDs and OCs

• Combination therapy may be useful in refractory cases and may be effective in patients who remain symptomatic on either drug alone 
  
  • NSAIDs and OCs are each effective in relieving dysmenorrhea and they work via different mechanisms of actions

Topical Heat Therapy

• Applying heat to the lower abdomen with hot compress, heated pad, or hot water bottle offers some relief

Acupuncture

• May be used in patients who prefer an adjunct or an alternative to standard medical therapy 
• One small study showed up to 91% improvement in symptoms and 41% decrease in analgesic use

Ginger 

• May be given to women during the first 3-4 days of menses as an alternative therapy 
• Small randomized trials show effectivity that is comparable with NSAIDs

Magnesium Supplements

• In 1 study, up to 84% decrease in symptoms especially on days 2 and 3 of cycle was shown

Omega-3 Fatty Acids

• Small study showed the treatment group had lower scores on pain scale

Thiamine (Vitamin B₁) and Pyridoxine (Vitamin B₆)

• Effective for pain reduction compared with placebo

Tocolytics

• Eg Nitroglycerin (Glyceryl trinitrate), Nitric oxide, calcium antagonists (eg Nifedipine, Verapamil) and β-adrenergic receptor antagonists (eg Terbutaline)
• May be effective in treating primary dysmenorrhea as it blocks uterine contractility
• Have been shown to relieve intrauterine pressure but do not alleviate the accompanying symptoms (eg nausea)
• Nifedipine may be given in difficult cases of dysmenorrhea
• More studies are needed to prove efficacy and superiority over NSAID and hormonal options for symptomatic relief

Transcutaneous Electrical Nerve Stimulation (TENS) 

• High-frequency TENS may may be an option for treating women with chronic pelvic pain or women who cannot use conventional treatment
• In some studies, it has provided at least moderate relief in 42-60% of patients, reduced the requirement of NSAID and worked faster than Naproxen in 1 study 

Transdermal Nitroglycerin

• In 1 small study, it showed 90% efficacy but 20% of patients reported headache

• May be considered for patients with severe dysmenorrhea unresponsive to conventional treatment interventions

Laparoscopic Uterine Nerve Ablation

• Done either by cautery or CO₂ laser
• Indicated for patients with severe refractory dysmenorrhea or who desire fertility preservation, after prompt re-evaluation of diagnosis, investigation for secondary causes and specialist referral 

Laparoscopic Presacral Neurectomy 

• May be used in women, who desire fertility preservation, as an additional procedure to the laparoscopic treatment of endometriosis for dysmenorrhea 
• Two small studies showed it was 33-88% effective up to 12 months after treatment

Endometrial Ablation

• May decrease dysmenorrhea with menorrhagia in women who do not desire fertility preservation 

Hysterectomy

• May be considered if patient has tried all treatment options with inadequate response and has completed childbearing, and is without laparoscopic abnormalities and MRI evidence of deep infiltrating endometriosis 
• Treats primary dysmenorrhea better than non-cyclic pelvic pain