MKSAP Quiz: worsening dysmenorrhea with pain
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A 22-year-old woman is evaluated for dysmenorrhea, which has worsened over the past 3 years. Although the frequency of her periods is regular, her menstrual period lasts for 5 to 7 days. When menstruating, she sometimes misses work because of pain. Ibuprofen and naproxen do not resolve her symptoms and upset her stomach. She is not currently sexually active. Her medical history is unremarkable. Pelvic examination is normal.
Which of the following is the most appropriate treatment for this patient?
A. Oral contraceptives
B. Depot-medroxyprogesterone acetate (DMPA)
C. Meclofenamate
D. Magnesium
E. Tramadol
MKSAP Answer and Critique
The correct answer is A) Oral contraceptives. This item is available online to MKSAP 14 subscribers in the General Internal Medicine section, Item 93.
This patient is likely experiencing primary dysmenorrhea, a term that describes menstrual cramping without a pathologic cause. The mainstay treatments are oral contraceptives, which generally reduce symptoms of primary dysmenorrhea, or NSAIDs. Meclofenamate would not necessarily be the next best choice for a patient who has experienced no relief using other NSAIDs. An individual patient may respond to one NSAID when others have not been effective. However, no evidence demonstrates the superiority of one NSAID over another.
Treatment of primary dysmenorrhea with depot-medroxyprogesterone acetate (DMPA) is an off-label use that can induce hypomenorrhea or amenorrhea, resulting in decreased dysmenorrhea. However, only about 50% of patients will become completely amenorrheic during the first year of use of this agent, with the remainder continuing to experience dysmenorrhea. Other alternative therapies, including magnesium, vitamin B6 (pyridoxine), vitamin E, and omega-3 fatty acids, have shown some benefit but have not been studied thoroughly enough to make a recommendation for use in this patient. Although tramadol may effectively reduce pain, it is not a good long-term solution.
Key Point
- The mainstay of treatment for primary dysmenorrhea is oral contraceptives or NSAIDs.