Primary dysmenorrhea refers to the presence of recurrent, crampy, lower abdominal pain occurring during menses and in the absence of demonstrable disease. The management of women with primary dysmenorrhea will be reviewed here. The pathogenesis, clinical manifestations, and diagnosis of primary dysmenorrhea are discussed separately. (See "Primary dysmenorrhea in adult women: Clinical features and diagnosis".)
Goal — The goal of treatment is to provide adequate relief of pain. At a minimum, pain relief should be sufficient to allow the woman to perform most, if not all, of her usual activities.
General approach — Treatment of primary dysmenorrhea can be initiated empirically. Laboratory tests, imaging studies, and/or laparoscopy are not required to definitively exclude causes of secondary dysmenorrhea when a detailed history and physical examination strongly support the diagnosis. (See "Primary dysmenorrhea in adult women: Clinical features and diagnosis", section on 'Diagnosis' and "Primary dysmenorrhea in adult women: Clinical features and diagnosis", section on 'Diagnostic evaluation'.)
General measures for management include patient education and reassurance. Treatment is supportive and should be guided by individual needs, as the severity of pain and degree of limitation of activity vary widely among women with dysmenorrhea (table 1). The initial approach includes a discussion of nonpharmacologic interventions that can be helpful, such as application of a heat pack to the lower abdomen, exercise, and relaxation techniques. First-line pharmacologic therapy includes nonsteroidal anti-inflammatory drugs (NSAIDs) and/or estrogen-progestin contraceptives (cyclic, long-cycle, or continuous), depending on the clinical needs of the patient. For women with primary dysmenorrhea desiring contraception, estrogen-progestin contraceptives are a logical choice. For women who prefer not to use hormonal treatment, NSAIDs are a logical choice. However, some women may need both types of treatment. (See 'Drug therapy' below.)
Women who do not achieve adequate pain relief after three months of treatment with NSAIDs and hormonal contraceptives may have secondary dysmenorrhea due to endometriosis or other conditions. Options for these women include diagnostic laparoscopy or empiric GnRH agonist therapy. Intrauterine progestin delivery systems (levonorgestrel intrauterine system) have demonstrated some efficacy in women with dysmenorrhea secondary to either proven or suspected endometriosis. (See 'Management of treatment failure' below.)