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194 Dysmenorrhea
to that achieved with paracervical block. 8 Although mefenamic acid is often
mentioned in the dysmenorrhea literature, and this agent is indeed effective,
there seems little justification for selecting this drug over other NSAIDs.
Cochrane review of RCTs confirmed substantial analgesic effect of many
NSAIDs in dysmenorrhea. 9 Available data indicate, for instance, that commonly
used NSAIDs (e.g. diclofenac 12.5–25 mg PO) effectively relieve mildto-moderate
dysmenorrhea pain. 10
Because of the need for chronic use, the COX-2 selective NSAIDs are
sometimes recommended as a treatment for dysmenorrhea. 11–13 Data show
that valdecoxib, administered in a single dose of 40 mg PO, provides dysmenorrhea
pain relief within 30 min that lasts for up to 24 h. 14 A dosage regimen
of 20–40 mg valdecoxib BIDisequallyeffectiveasBIDnaprosyn sodium
(550 mg PO BID). 15 The newer COX-2 selective NSAID lumaricoxib, 400 mg
PO QD, provides equally effective dysmenorrhea relief to that achieved with
other NSAIDs. 16 Similar dysmenorrhea relief results are seen with another
COX-2 selective NSAID, etoricoxib. 17 The risks and benefits of the COX-2
selective NSAIDs must be weighed when considering this class; further
information is outlined in the Arthritis chapter (p. 94).
The novel analgesic flupirtine is suggested by some to have utility in
dysmenorrhea, but this centrally acting agent is not recommended owing
to limited evidence and frequent side effects. 18
n Summary and recommendations
First line: NSAID (e.g. ibuprofen 400–800 mg PO q4–6 h, maximum 2400
mg/day)
Reasonable: combination therapy with acetaminophen (1000 mg PO) and
caffeine (130–300 mg PO); repeat dosing q6–8 h (maximum daily caffeine
dose 1000 mg)
Pregnancy: acetaminophen (1000 mg PO q4–6 h), with caffeine (130–300 mg
q6–8 h with maximum daily caffeine dose 1000 mg) if acetaminophen
alone provides insufficient pain relief
Pediatric: ibuprofen (10 mg/kg PO q6–8h)