Clinical recommendation	Evidence rating	Comments
Empiric therapy should be initiated if the history is consistent with primary dysmenorrhea.1,19	C	Recommendation from consensus guidelines
Nonsteroidal anti-inflammatory drugs should be used as first-line treatment for primary dysmenorrhea.22	A	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.26–28,30	B	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	A	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.32–37	B	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	C	Recommendation from consensus guidelines