Nonsteroidal Anti Inflammatory Drugs

® Given their impact on inhibiting prostaglandins as well as their ability to provide direct analgesia, NSAIDs are the treatment of choice for dysmenorrhea. There does not appear to be a difference between agents in efficacy. Choice of one agent over an-

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other may be based on cost, convenience, and patient preference. ' The most commonly used agents are naproxen and ibuprofen.

It has been suggested that a loading dose (twice the usual single dose) of the NSAID be taken, followed by the usually recommended dose until symptoms resolve.14 An alternate recommendation is to begin the NSAID at the onset of menses or perhaps even the day prior and to continue treatment around the clock instead of waiting until the onset of symptoms. For patients in whom NSAID use is contraindic-ated, the agents discussed below should be considered. The use of acetaminophen has been proven inferior to the use of NSAIDs for the treatment of this disorder. 1

Oral Contraceptives

OCs help to improve dysmenorrhea by inhibiting the proliferation of endometrial tissue. This reduction in tissue translates into a reduction in endometrial-derived prostaglandins that are thought to contribute to the pelvic pain experienced.14,25 A trial of 2 to 3 months of OC dosing is required to establish whether the patient is a responder or a nonresponder. Significant improvements in mild, moderate, and severe dysmenorrhea have been noted with the use of OCs. These agents have other benefits, such as the prevention of pregnancy, improving acne, and reducing ovarian cancer risk. While monophasic formulations may be more efficacious for this indication, the supporting evidence for this is limited.11

Progesterone

The benefit of depo MPA in dysmenorrhea is related to its ability to render most patients amenorrheic within 1 year of use.11 This is an expected side effect. Since the pelvic pain of dysmenorrhea is related to the prostaglandins released during menses, in the setting of amenorrhea, the underlying cause of dysmenorrhea is removed.

Observational data illustrate a reduction in dysmenorrhea from 60% to 29% with the levonorgestrel-releasing IUD after 3 years.11 As observed with depo MPA, this reduction is likely secondary to the increasing incidence of amenorrhea in users of this contraceptive device.

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