Oral contraceptives are the second line of therapy for most patients, unless birth control is also desired. The necessity of daily medication to prevent symptoms for one or two days a month makes them too cumbersome as a first-line choice compared with the highly effective NSAIDs.

Oral contraceptives prevent menstrual pain through a different mechanism than NSAIDs. The action of oral contraceptives is twofold: reduction of menstrual fluid volume and suppression of ovulation. They are up to 90 percent effective. Any oral contraceptive will work and no particular group is superior to the other in this respect. In general, it may take up to three cycles for menstrual pain to noticeably diminish, so it is important to stress this point to patients at the time of the initial prescription and consider adding an NSAID for breakthrough pain during the interim. It is important to inquire about contraindications: cardiovascular disease, cerebro-vascular disease, hepatic disease, history of venous throm

Because NSAIDs and oral contraceptives are so effective and work through different mechanisms, a combination of the two is a very attractive option in refractory cases. No consistent data demonstrate effectiveness rates for this combination, but it is probably at least 90 percent, given the previously stated rates of effectiveness for the individual treatments. Consequently, about 10 percent of patients may remain nonresponders to combination treatment.

OCPs useful in patients not responding to NSAIDs

Combinations may be tried

Suspect secondary causes in non responders

Therapies for Refractory Dysmenorrhea Alternative Therapies Trials of transcutaneous electrical nerve stimulation (TENS) units, laparoscopic presacral neuronectomy, acupuncture, omega-3 fatty acids, transdermal nitroglycerin, thiamine and magnesium all demonstrated some relief of dysmenorrhea symptoms, although the numbers in the studies were small and only short-term follow-up was noted. Women should be encouraged to try any safe option and to feel comfortable discussing these options with their physician.

Patients Who Do Not Respond Women who do not respond to therapy with NSAIDs and/or oral contraceptives present a dilemma. Nonresponse is also an indication to consider some secondary cause of dysmenorrhea, such as endometriosis. One study indicated that most women with endometriosis endure pain for many years before the condition is detected—the mean delay in diagnosis after onset of pain symptoms was almost 12 years.

Further Reading

2. Smith RP. Cyclic pelvic pain and dysmenorrhea. Ob Gyn Clin North Am . 1993;20:753-64.