Am Fam Physician. 2021 Aug ;104(2):164-170.

  Patient information: See related handout on painful menstrual periods, written by authors of this article.

Author disclosure: No relevant financial affiliations.

Dysmenorrhea is common and usually independent of, rather than secondary to, pelvic pathology. Dysmenorrhea occurs in 50% to 90% of adolescent girls and women of reproductive age and is a leading cause of absenteeism. Secondary dysmenorrhea as a result of endometriosis, pelvic anatomic abnormalities, or infection may present with progressive worsening of pain, abnormal uterine bleeding, vaginal discharge, or dyspareunia. Initial workup should include a menstrual history and pregnancy test for patients who are sexually active. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives are first-line medical options that may be used independently or in combination. Because most progestin or estrogen-progestin combinations are effective, secondary indications, such as contraception, should be considered. Good evidence supports the effectiveness of some nonpharmacologic options, including exercise, transcutaneous electrical nerve stimulation, heat therapy, and self-acupressure. If secondary dysmenorrhea is suspected, nonsteroidal anti-inflammatory drugs or hormonal therapies may be effective, but further workup should include pelvic examination and ultrasonography. Referral to an obstetrician-gynecologist may be warranted for further evaluation and treatment.

Dysmenorrhea, which is defined as painful menstruation, affects up to 50% to 90% of adolescent girls and women of reproductive age.1,2 Nearly one-half of patients (45%) with symptoms of dysmenorrhea will present first to their primary care physician.3 Dysmenorrhea leads to decreased quality of life, absenteeism, and increased risk of depression and anxiety.4,5 Up to one-half of patients with dysmenorrhea miss school or work at least once, and 10% to 15% have regular absences during menses.68 A prospective longitudinal study of 400 patients with dysmenorrhea revealed that most have persistent symptoms throughout their years of menstruation, although some improvement in severity may occur, for example, after childbirth.9

 Enlarge     Print


Clinical recommendationEvidence ratingComments

Empiric therapy should be initiated if the history is consistent with primary dysmenorrhea.1,19


Recommendation from consensus guidelines

Nonsteroidal anti-inflammatory drugs should be used as first-line treatment for primary dysmenorrhea.22


Systematic review of 80 randomized controlled trials

Combined estrogen-progestin oral contraceptives are an alternative first-line treatment or an adjunct to nonsteroidal anti-inflammatory drugs for primary dysmenorrhea.2628,30


Consistent findings from randomized controlled trials

The levonorgestrel-releasing intrauterine system (Mirena) is effective for the treatment of primary dysmenorrhea and secondary dysmenorrhea caused by endometriosis.31


Systematic review with consistent findings

Consider exercise, high-frequency transcutaneous electrical nerve stimulation, heat therapy, or self-acupressure as an alternative or adjunct to first-line therapies for dysmenorrhea.3237


Limited-quality evidence from randomized controlled trial and systematic review

Pelvic examination and ultrasonography should be completed if first-line therapy is ineffective or if symptoms of secondary dysmenorrhea are present.1,19


Recommendation from consensus guidelines

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

KATHRYN A. MCKENNA, MD, MPH, is associate director of the Penn Medicine Lancaster (Pa.) General Health Family and Community Medicine Residency Program....

COREY D. FOGLEMAN, MD, FAAFP, is deputy director of the Penn Medicine Lancaster General Health Family and Community Medicine Residency Program.

Address correspondence to Kathryn A. McKenna, MD, MPH, Penn Medicine Lancaster General Health Family and Community Medicine Residency Program, 540 N Duke St., 3rd Floor, Lancaster, PA 17604 (email: Kathryn.McKenna@pennmedicine.upenn.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. ACOG committee opinion no. 760: dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol. 2018;132(6):e249–e258....

2. Al-Jefout M, Nawaiseh N. Continuous norethisterone acetate versus cyclical drospirenone 3 mg/ethinyl estradiol 20 mg for the management of primary dysmenorrhea in young adult women. J Pediatr Adolesc Gynecol. 2016;29(2):143–147.

3. Greene R, Stratton P, Cleary SD, et al. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril. 2009;91(1):32–39.

4. Balık G, Ustüner I, Kağıtcı M, et al. Is there a relationship between mood disorders and dysmenorrhea? J Pediatr Adolesc Gynecol. 2014;27(6):371–374.

5. Nur Azurah AG, Sanci L, Moore E, et al. The quality of life of adolescents with menstrual problems. J Pediatr Adolesc Gynecol. 2013;26(2):102–108.

6. Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134–1138.

7. Zannoni L, Giorgi M, Spagnolo E, et al. Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents. J Pediatr Adolesc Gynecol. 2014;27(5):258–265.

8. O'Connell K, Davis AR, Westhoff C. Self-treatment patterns among adolescent girls with dysmenorrhea. J Pediatr Adolesc Gynecol. 2006;19(4):285–289.

9. Weissman AM, Hartz AJ, Hansen MD, et al. The natural history of primary dysmenorrhoea: a longitudinal study. BJOG. 2004;111(4):345–352.

10. Oladosu FA, Tu FF, Hellman KM. Nonsteroidal antiinflammatory drug resistance in dysmenorrhea: epidemiology, causes, and treatment. Am J Obstet Gynecol. 2018;218(4):390–400.

11. Heitmann RJ, Langan KL, Huang RR, et al. Premenstrual spotting of ≥2 days is strongly associated with histologically confirmed endometriosis in women with infertility. Am J Obstet Gynecol. 2014;211(4):358.e1–358.e6.

12. Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006;332(7544):749–755.

13. Yu H, Li B, Li T, et al. Combination of noninvasive methods in diagnosis of infertile women with minimal or mild endometriosis, a retrospective study in China. Medicine (Baltimore). 2019;98(31):e16695.

14. Peterson CM, Johnstone EB, Hammoud AO, et al.; ENDO Study Working Group. Risk factors associated with endometriosis: importance of study population for characterizing disease in the ENDO Study. Am J Obstet Gynecol. 2013;208(6):451.e1–451.e11.

15. Latthe PM, Champaneria R, Khan KS. Dysmenorrhea. BMJ Clin Evid. . 2011:0813.

16. Grandi G, Ferrari S, Xholli A, et al. Prevalence of menstrual pain in young women: what is dysmenorrhea? J Pain Res. 2012;5:169–174.

17. Subasinghe AK, Happo L, Jayasinghe YL, et al. Prevalence and severity of dysmenorrhoea, and management options reported by young Australian women. Aust Fam Physician. 2016;45(11):829–834.

18. Agarwal SK, Chapron C, Giudice LC, et al. Clinical diagnosis of endometriosis: a call to action. Am J Obstet Gynecol. 2019;220(4):354.e1–354.e12.

19. Burnett M, Lemyre M. No. 345—primary dysmenorrhea consensus guideline. J Obstet Gynaecol Can. 2017;39(7):585–595.

20. Bofill Rodriguez M, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;(9):CD000400.

21. Harel Z. Dysmenorrhea in adolescents and young adults: an update on pharmacological treatments and management strategies. Expert Opin Pharmacother. 2012;13(15):2157–2170.

22. Marjoribanks J, Ayeleke RO, Farquhar C, et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015;(7):CD001751.

23. Matteson KA, Rahn DD, Wheeler TL II, et al.; Society of Gynecologic Surgeons Systematic Review Group. Non-surgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol. 2013;121(3):632–643.

24. Joffe H, Cohen LS, Harlow BL. Impact of oral contraceptive pill use on premenstrual mood: predictors of improvement and deterioration. Am J Obstet Gynecol. 2003;189(6):1523–1530.

25. ACOG practice bulletin no. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206–218.

26. Davis AR, Westhoff C, O'Connell K, et al. Oral contraceptives for dysmenorrhea in adolescent girls: a randomized trial. Obstet Gynecol. 2005;106(1):97–104.

27. Wong CL, Farquhar C, Roberts H, et al. Oral contraceptive pill for primary dysmenorrhoea. Cochrane Database Syst Rev. 2009;(4):CD002120.

28. Edelman A, Micks E, Gallo MF, et al. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst Rev. 2014;(7):CD004695.

29. Muzii L, Di Tucci C, Achilli C, et al. Continuous versus cyclic oral contraceptives after laparoscopic excision of ovarian endometriomas: a systematic review and meta-analysis. Am J Obstet Gynecol. 2016;214(2):203–211.

30. Dmitrovic R, Kunselman AR, Legro RS. Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea: a randomized controlled trial. Obstet Gynecol. 2012;119(6):1143–1150.

31. Imai A, Matsunami K, Takagi H, et al. Levonorgestrel-releasing intrauterine device used for dysmenorrhea: five-year literature review. Clin Exp Obstet Gynecol. 2014;41(5):495–498.

32. Matthewman G, Lee A, Kaur JG, et al. Physical activity for primary dysmenorrhea: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2018;219(3):255.e1–255.e20.

33. Armour M, Ee CC, Naidoo D, et al. Exercise for dysmenorrhoea. Cochrane Database Syst Rev. 2019;(9):CD004142.

34. Bai H-Y, Bai H-Y, Yang Z-Q. Effect of transcutaneous electrical nerve stimulation therapy for the treatment of primary dysmenorrheal. Medicine (Baltimore). 2017;96(36):e7959.

35. Proctor ML, Smith CA, Farquhar CM, et al. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database Syst Rev. 2002;(1):CD002123.

36. Chaudhuri A, Singh A, Dhaliwal L. A randomised controlled trial of exercise and hot water bottle in the management of dysmenorrhoea in school girls of Chandigarh, India. Indian J Physiol Pharmacol. 2013;57(2):114–122.

37. Blödt S, Pach D, von Eisenhart-Rothe S, et al. Effectiveness of app-based self-acupressure for women with menstrual pain compared to usual care: a randomized pragmatic trial. Am J Obstet Gynecol. 2018;218(2):227.e1–227.e9.

38. Smith CA, Armour M, Zhu X, et al. Acupuncture for dysmenorrhoea. Cochrane Database Syst Rev. 2016;(4):CD007854.

39. Woo HL, Ji HR, Pak YK, et al. The efficacy and safety of acupuncture in women with primary dysmenorrhea: a systematic review and meta-analysis. Medicine (Baltimore). 2018;97(23):e11007.

40. Cho S-H, Hwang E-W. Acupuncture for primary dysmenorrhoea: a systematic review. BJOG. 2010;117(5):509–521.

41. Proctor ML, Hing W, Johnson TC, et al. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2006;(3):CD002119.

42. Proctor ML, Murphy PA, Pattison HM, et al. Behavioural interventions for dysmenorrhoea. Cochrane Database Syst Rev. 2007;(3):CD002248.

43. Pattanittum P, Kunyanone N, Brown J, et al. Dietary supplements for dysmenorrhoea. Cochrane Database Syst Rev. 2016;(3):CD002124.

44. Santanam N, Kavtaradze N, Murphy A, et al. Antioxidant supplementation reduces endometriosis-related pelvic pain in humans. Transl Res. 2013;161(3):189–195.

45. Lee HW, Ang L, Lee MS, et al. Fennel for reducing pain in primary dysmenorrhea: a systematic review and meta-analysis of randomized controlled trials. Nutrients. 2020;12(11):3438.

46. Zhu X, Proctor M, Bensoussan A, et al. Chinese herbal medicine for primary dysmenorrhoea. Cochrane Database Syst Rev. 2008;(2):CD005288.

47. Leem J, Jo J, Kwon C-Y, et al. Herbal medicine (Hyeolbuchukeo-tang or Xuefu Zhuyu decoction) for treating primary dysmenorrhea: a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2019;98(5):e14170.

48. Surrey E, Taylor HS, Giudice L, et al. Long-term outcomes of elagolix in women with endometriosis: results from two extension studies [published correction appears in Obstet Gynecol. 2018;132(6):1507–1508]. Obstet Gynecol. 2018;132(1):147–160.

49. Fedorowicz Z, Nasser M, Jagannath VA, et al. Beta2-adrenoceptor agonists for dysmenorrhoea. Cochrane Database Syst Rev. 2012;(5):CD008585.

50. Proctor ML, Latthe PM, Farquhar CM, et al. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2005;(4):CD001896.

51. Daniels J, Gray R, Hills RK, et al.; LUNA Trial Collaboration. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial. JAMA. 2009;302(9):955–961.

52. Berner E, Qvigstad E, Myrvold AK, et al. Pain reduction after total laparoscopic hysterectomy and laparoscopic supracervical hysterectomy among women with dysmenorrhoea: a randomised controlled trial. BJOG. 2015;122(8):1102–1111.

53. Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014;89(5):341–346. Accessed December 10, 2020. https://www.aafp.org/afp/2014/0301/p341.html

54. French L. Dysmenorrhea. Am Fam Physician. 2005;71(2):285–291. Accessed December 10, 2020. https://www.aafp.org/afp/2005/0115/p285.html

55. Coco AS. Primary dysmenorrhea. Am Fam Physician. 1999;60(2):489–496. Accessed December 10, 2020. https://www.aafp.org/afp/1999/0801/p489.html



Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

More in Pubmed


Jan 2022

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article