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Dysmenorrhea
BENJAMIN A. WHITE AND STEPHEN H. THOMAS
n Agents
n Acetaminophen
n Caffeine
n NSAIDs
n Evidence
This chapter addresses relief of abdominal cramping and related symptoms
(e.g. pelvic pain, backache) associated with the menstrual cycle. Other painful
conditions that can be associated with menstruation (e.g. cyclic mastalgia)
are addressed elsewhere in this text or tend to be treated in similar fashion as
nonmenstrual occurrences (e.g. triptans for menstrual migraines). 1 This
chapter focuses on analgesic control of dysmenorrhea symptoms, rather
than hormonal regulation of the ovulatory cycle (e.g. with oral contraceptives).
Hormonal therapy may be needed to control dysmenorrhea in the
10–20% of patients unable to be managed by the analgesics discussed here.
Placebo-controlled trial evidence demonstrates some utility of acetaminophen
(paracetamal) for relieving dysmenorrhea, but the optimal
approach when using this agent is to combine it with caffeine. A large RCT
with crossover design comparing monotherapy with either acetaminophen
(1 g PO) or caffeine (130 mg PO) or combination therapy with both agents
showed significantly better relief of dysmenorrhea-associated abdominal
cramping and backache with the combination. 2
Prostaglandin inhibition by NSAIDs is responsible for their decades of
successful use as the mainstay of dysmenorrhea treatment. 3–7 An RCT in
patients undergoing fractional curettage demonstrated the potent analgesic
effects of NSAIDs on uterine pain. When administered a few hours before the
procedure, a dose of mefenamic acid (500 mg PO) provided equal pain relief
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