Managing Menstrual Cramps (Dysmenorrhea): Evidence-Based Strategies

Primary dysmenorrhea (pain without pelvic pathology) affects 50–90% of menstruating women. Secondary dysmenorrhea (endometriosis, adenomyosis, fibroids) requires targeted treatment.

First-Line (Primary Dysmenorrhea)

• NSAIDs: Ibuprofen 400–600 mg q6h or naproxen 220–440 mg q8–12h. Start 1–2 days before expected menses; continue 2–3 days. Inhibit prostaglandin synthesis.
• Hormonal contraception: Combined OCP, patch, ring, DMPA, hormonal IUD, implant. Suppress ovulation, thin endometrium → ↓prostaglandins. 80–90% effective.

Adjunctive Non-Pharmacologic

• Heat: Continuous low-level heat (heat wrap, hot water bottle) = ibuprofen for pain relief.
• Exercise: Regular aerobic activity reduces severity (endorphins, prostaglandin modulation).
• Diet: Low-fat vegetarian, omega-3, magnesium, vitamin B1, vitamin E — modest evidence.
• TENS: Transcutaneous electrical nerve stimulation; some RCTs show benefit.
• Acupuncture/acupressure: SP6 (Sanyinjiao) point; mixed evidence.

Second-Line / Refractory

• Higher-dose NSAIDs, COX-2 selective (celecoxib).
• GnRH agonists (with add-back) for endometriosis.
• Laparoscopic excision for confirmed endometriosis.

Red Flags for Secondary Causes

• Onset >25 years old
• Progressive worsening
• Pain outside menses
• Dyspareunia, heavy bleeding, infertility
• Palpable mass, abnormal exam

If red flags present, evaluate for endometriosis, adenomyosis, fibroids, PID, cervical stenosis.