Primary Dysmenorrhea
70. P.O., a 27-year-old woman, is seen in the primary care clinic because of severe abdominal pain secondary to her menstrual periods. She reports having pain-free menstrual periods only once or twice yearly. She has been diagnosed as having primary dysmenorrhea with no other gynecologic pathology being found. How should P.O.'s menstrual pain be treated?
Primary dysmenorrhea is a common gynecologic disorder affecting 60% to 80% of women at some time in their life.231 Pain usually occurs 2 to 12 hours before the commencement of menstrual flow, but it can occur simultaneously with, or a few hours after, the beginning of menstruation. It reaches maximal intensity at 2 to 24 hours, then decreases over the next few days.232 Primary dysmenorrhea is associated with increases in endometrial and circulatory prostaglandins. Thus, NSAIDs, which alter the production of the prostaglandins, are frequently used to manage primary dysmenorrhea. The dosages required for the treatment of primary dysmenorrhea usually are higher than those used for analgesia, but frequently a single dose is sufficient to terminate the dysmenorrhea pain. On some occasions, frequent, high doses may be required.
The best time to initiate an NSAID remains controversial. Some clinicians recommend beginning drug therapy a few days before the start of menses; others argue that the prostaglandins are not stored and, therefore, prefer to initiate drug therapy only after the start of menses. Pretreatment with an NSAID carries the risk of fetal drug exposure during early pregnancy. Studies comparing pretreatment with dosing at the onset of menses show no difference in the analgesia between either of the regimens.233,234 (Also see Chapter 47, Treatment of Menstrual and Menstrual-Related Disorders.) P.O. should be instructed to take 600 to 800 mg of ibuprofen at the onset of menses or when discomfort begins. Repeat dosages of 400 to 600 mg may be taken every 4 to 6 hours as needed. If this regimen is ineffective, she can take the first dose 1 to 2 days before the first day of menses is expected.
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