How to help patients manage menstrual pain

In this article:

• How to help patients manage their menstrual pain
• When to refer patients to a healthcare provider

In this article

• How to help patients manage their menstrual pain
• When to refer patients to a healthcare provider

About 80% of women experience menstrual pain—also known as dysmenorrhea—at some point in their lives. It can affect women in a wide age range, from adolescence to late adulthood. In most cases, the pain is mild. But for some, the pain can be so severe that it negatively affects their quality of life. On average, pain can last for 1 to 2 days, but many people may experience discomfort for even longer.

There are two types of dysmenorrhea: primary and secondary dysmenorrhea. Primary dysmenorrhea is period pain that occurs in the absence of another pelvic disease. It’s caused by high levels of prostaglandins, which are natural chemicals that make the uterus contract and cause painful cramping and discomfort. Secondary dysmenorrhea is painful periods caused by an identifiable disorder, such as endometriosis or pelvic infections. Secondary dysmenorrhea is typically more intense, and the pain often gets worse over time.

Many women will turn to over-the-counter (OTC) pain relievers for dysmenorrhea. However, medications are not the only option for pain relief. As a pharmacist, you have the opportunity to counsel patients on proper menstrual pain management, including medications and lifestyle changes. You can also identify situations where a patient should seek treatment from a medical provider. Read on to refresh your knowledge on how to help patients manage their menstrual pain.

How to help patients manage their menstrual pain

Dysmenorrhea is incredibly common, and many women seek relief from OTC medications. Pharmacists can play a crucial role in helping patients manage their pain by providing lifestyle and medication recommendations. Just as importantly, pharmacists can also help recognize if a patient is having severe symptoms that a healthcare provider should further evaluate.

Non-pharmacological treatments

In addition to recommending medications, you can help patients by discussing non-medicinal methods for menstrual pain relief. By identifying potential factors that contribute to period discomfort, patients may adjust their day-to-day routine to minimize pain. The following lifestyle modifications may help your patients manage period pain.

• Making time for regular exercise: Exercise, specifically aerobic exercise, may help reduce period pain by improving blood flow in the pelvis and stimulating the release of endorphins that block pain. Examples of aerobic exercise include walking, jogging, biking, and swimming.
• Getting enough sleep: Feeling rested before and during a period can make it easier to deal with menstrual pain.
• Making dietary changes: Increasing fiber intake, eating lean meats, and limiting sugary and salty food can also help ease period pain.
• Quitting smoking: There is some evidence that dysmenorrhea is more common in women who smoke. Smoking may contribute to menstrual pain by reducing the oxygen supply to the pelvis.
• Reducing stress: Stress and anxiety can worsen dysmenorrhea. Meditation or yoga may help patients relax and be better suited to cope with pain.
• Applying heat: Applying a heat source to the abdomen can help relieve pain by improving blood circulation and muscle relaxation. This can be done with heating pads, hot water bottles, or taking a warm bath.
• Consuming ginger: Ginger is known to have anti-inflammatory and antioxidant properties. There is also evidence that ginger can relieve the intensity and duration of menstrual pain. Ginger is available in many forms, including teas, capsules, and extracts.

Pharmacological treatments

While non-medicinal methods can help, medications are typically the first choice for dysmenorrhea. These include nonsteroidal anti-inflammatory drugs (NSAIDs), Tylenol (acetaminophen), and hormonal therapy.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are typically regarded as the first-line treatment for dysmenorrhea because they target prostaglandins and lessen their effects. This makes menstrual cramping less severe.

Many NSAIDs are available over the counter. They work best if taken one to two days before the onset of menses and continued for two to three days afterward. No particular NSAID has been shown to be more effective than others. You may recommend an NSAID based on its effectiveness and tolerability for the patient. In many cases, choosing the right NSAID may be a case of trial and error.

Examples of NSAIDs that are used for dysmenorrhea include:

• Celebrex (celecoxib)
• Motrin (ibuprofen)
• Naprosyn (naproxen)
• Mefenamic acid

NSAIDs are often included in combination menstrual relief products as well. These combination products contain multiple active drugs that target various symptoms of menstruation, including cramps, backache, bloating, and headache. They may contain caffeine, a diuretic, or an antihistamine in addition to a pain reliever. While combination products are convenient options for patients with multiple symptoms, they aren’t the right choice for everyone. It’s important to consider potential drug interactions, overdose, and drug-condition interactions before recommending them.

As with all medications, before suggesting any OTC NSAIDs, be sure to review the patient’s medication and medical history list, including allergies. Then, discuss the proper use, dosage, and side effects of the new drug with the patient. Remind them that NSAIDs are only for short-term use, and if they aren’t finding relief with these drugs, they should contact their healthcare provider.

Tylenol (acetaminophen)

Another OTC option for menstrual pain is Tylenol (acetaminophen). While Tylenol doesn’t target prostaglandins specifically, it is a reasonable option for patients who cannot tolerate NSAIDs. Remind patients to be wary of their alcohol consumption while taking Tylenol (acetaminophen) and not to take more than 4,000 mg of acetaminophen per day.

Similar to NSAIDs, Tylenol is another common ingredient included in combination menstrual relief products. Although Tylenol tends to be better tolerated and has fewer interactions than NSAIDs, it’s still important to be mindful of all ingredients in the product and ensure they are safe for the patient.

Hormonal therapy

Hormonal birth control is another treatment option for dysmenorrhea. These include oral, intravaginal, and intrauterine contraceptives.

Contraceptives are thought to relieve menstrual pain by lowering prostaglandin release during menstruation. In theory, this can decrease uterine contractions and ultimately reduce pain. However, the evidence supporting their effectiveness is limited. You should consider each drug’s side effect profile before recommending their use. For example, while birth control pills may be effective for reducing period pain, they can cause irregular bleeding, headache, or nausea.

Here are some examples of hormonal contraceptives used for the treatment of dysmenorrhea:

• Ortho-Cyclen (norgestimate/ethinyl estradiol)
• Seasonique (levonorgestrel/ethinyl estradiol)
• Nexplanon (etonogestrel implant)
• Nuvaring (etonogestrel/ethinyl estradiol vaginal ring)
• Mirena (levonorgestrel-releasing IUD)
• Depo-Provera (medroxyprogesterone)

When to refer patients to a healthcare provider

Mild dysmenorrhea can typically be managed with OTC medications and non-pharmacologic treatments. However, some cases of menstrual pain may indicate an underlying condition, such as a pelvic infection, endometriosis, or fibroids. In these cases, you may need to refer patients to their healthcare provider for further evaluation or treatment.

The following are examples of situations that should warrant a referral:

• Menstrual pain lasts longer than the duration of a period
• Pain that occurs in the absence of a period
• Severe pain that results in missed school or work days
• Menstrual pain accompanied by pelvic pain, pain during urination, pain with sex, or fever
• Heavy menstrual bleeding with or without blood clots

As one of the most accessible healthcare providers, you have a crucial role in educating patients about their over-the-counter medications and lifestyle changes for dysmenorrhea. Additionally, you are in a unique position to recognize when a patient may need further evaluation.