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Managing dysmenorrhoea

Oral analgesics are the only OTC pharmacological options available for dysmenorrhoea management, according to NICE guidance1. There are several oral analgesics available:1,20

  • NSAIDs such as naproxen, ibuprofen and aspirin are NICE’s first-line recommended dysmenorrhoea treatment
  • Paracetamol is a second-line treatment and should be used where NSAIDs are contraindicated or not tolerated. Paracetamol can be used in combination with an NSAID if there is insufficient pain relief.

Where a patient’s pain is unable to be managed with OTC analgesics, they should be referred to their doctor for prescription options with a hormonal contraception, an alternative first-line treatment1.

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Differences between oral analgesics

  NSAIDs Paracetamol
Mode of Action

Reversibly inhibit the enzymes cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) involved in prostaglandin production21.

COX-2 prostaglandins mediate pain, inflammation and fever20. COX-1 prostaglandins have  protective roles on gastric mucosal integrity, platelet-initiated blood clotting and renal blood flow20,21

The mode of action is not fully known but is believed to inhibit COX enzymes in the central nervous system (CNS)20.

 

 

 
Tolerability

NSAIDs contraindications include:

  • Active gastrointestinal (GI) bleeding or
  • Previous NSAID associated GI bleeding
  • Active GI ulcer or 
  • History of recurrent GI haemorrhage or ulceration
  • Severe heart failure
  • Renal/hepatic impairment
  • Varicella infection
  • History of hypersensitvity reactions to NSAIDs
  • Pregnant women in the third trimester6.

Although there are no contraindications for paracetamol, and adverse effects are rare, there is risk of hepatotoxicity and accidental overdose20.

Patients at risk include those with:

  • Chronic alcohol consumption
  • Malnutrition and dehydration
  • A body weight <50kg
  • Severe hepatic disease
  • Older age or frailty
  • Use of liver enzyme-inducing drugs20.

When should you refer the patient to a doctor?

Patients presenting with the following symptoms that suggest secondary dysmenorrhoea should be referred to their doctor for further investigation1,19

  • Chronic pelvic pain occurring before menstruation
  • Deep pain during intercourse
  • Rectal pain or bleeding
  • Heavy menstrual bleeding (may or may not be accompanied by lower abdominal pain), bleeding or spotting between periods, or after intercourse, abnormal or postmenopausal bleeding
  • Longer, heavier periods and more irregular periods
  • Abnormal vaginal bleeding or discharge – mucoid, blood-stained, or purulent
  • Pelvic mass
  • Pelvic/lower abdominal pain and tenderness or abdominal distension
  • Loss of appetite/early satiety
  • Increased urinary urgency and frequency or pain when urinating or passing stools
  • Dyspepsia and nausea
  • Fever (if there is an acute infection)
  • Pain after intra-uterine device (IUD) insertion 3–6 months earlier.

Patients who complain of dysmenorrhoea or pelvic pain that is more severe than usual, which is not eased by analgesics, should be referred to a doctor urgently19.