Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 24-year-old woman is evaluated for severe cramps associated with her menstrual periods. The cramps have worsened over the past year, and the discomfort is severe enough that she has periodically missed work. She reports no abnormal vaginal discharge. Menses are unchanged from her baseline pattern. She has tried ibuprofen and naproxen for pain relief, but these medications cause stomach upset. The patient is sexually active with several male partners. She has no history of sexually transmitted infection and is up to date with her immunizations and gynecologic screening. Medical history is otherwise unremarkable, and she takes no medications.

On physical examination, vital signs are normal. On pelvic examination, there is no cervical motion tenderness, adnexal tenderness, masses, or abnormal discharge. The cervix appears normal. Bimanual examination is unremarkable, and the remainder of the physical examination is normal.

A urine pregnancy test is negative. Tests for Chlamydia trachomatis and Neisseria gonorrhoeae are negative.

Which of the following is the most appropriate treatment for this patient’s dysmenorrhea?

A. Combined estrogen-progestin contraceptive pill
B. Depot medroxyprogesterone acetate
C. Low-dose selective serotonin reuptake inhibitor
D. Progestin-only contraceptive pill
E. Tranexamic acid

MKSAP Answer and Critique

The correct answer is A. Combined estrogen-progestin contraceptive pill.

The most appropriate treatment for this patient is a combined estrogen-progestin contraceptive pill. Her history of cyclic pain and normal findings on pelvic examination are consistent with primary dysmenorrhea, which occurs in up to 50% of menstruating women and causes significant discomfort and disruption of activities. Etiology is thought to be associated with prostaglandin release that induces uterine contractions as a part of menses, resulting in increased uterine basal tone. This increase in tone may decrease uterine microvascular blood flow with relative ischemia and resulting pain. Evidence supports the efficacy of prostaglandin inhibitors (NSAIDs and cyclooxygenase-2 inhibitors) in treating dysmenorrhea; however, because this patient did not tolerate the gastrointestinal adverse effects associated with NSAID use, the next step is a trial of combined estrogen-progestin contraceptive pills, which frequently provide clinical relief.

Depot medroxyprogesterone acetate and progestin-only contraceptive pills are effective forms of contraception that can cause menstrual suppression, although bleeding patterns are very variable. Data for treatment of primary dysmenorrhea with depot medroxyprogesterone acetate or progestin-only contraceptive pills are lacking.

Selective serotonin reuptake inhibitors (SSRIs) may be considered for the treatment of premenstrual syndrome (PMS), in which disruptive physical or behavioral symptoms occur repetitively during the second half of the menstrual cycle, or premenstrual dysphoric disorder (PMDD), which is characterized by severe symptoms of irritability, mood swings, depression, anxiety, sleep disturbance, headache, fatigue, and musculoskeletal pain. Whereas PMS occurs in 30% to 80% of menstruating younger women, PMDD is less prevalent, occurring in 3% to 8% of women of reproductive age. This patient’s symptoms are related to her menstrual period and do not support a diagnosis of PMS or PMDD; therefore, initiation of an SSRI is not appropriate.

Tranexamic acid is an antifibrinolytic drug that is used to treat severe menstrual bleeding. It is not an appropriate treatment for dysmenorrhea.

Key Point

• NSAIDs and cyclooxygenase-2 inhibitors are an effective treatment for primary dysmenorrhea; however, in patients who cannot tolerate NSAIDs or have incomplete relief of symptoms, use of combined estrogen-progestin hormonal contraceptive therapy is effective.

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