Patient handout

Dysmenorrhoea (primary vs secondary — endometriosis-aware)

PRODUCTION

1. Your condition

This handout is for dysmenorrhoea (primary vs secondary — endometriosis-aware). Your care team identified this based on: recurrent crampy lower-abdominal/pelvic pain temporally locked to menses (acog co 760; eshre 2022).

Other reasons your team may use this plan: dysmenorrhoea + deep dyspareunia / dyschezia / cyclical dysuria / subfertility (endometriosis-suggestive cluster) (eshre 2022 becker); adolescent with menses-locked pain (primary if onset 6–12 mo post-menarche; endometriosis leading secondary cause) (acog co 760); adolescent cyclical pain + pelvic mass ± primary amenorrhoea — obstructive müllerian/outflow anomaly (acog co 760; eshre 2022).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
naproxen	500 mg PO then 250 mg q8h (or 500 mg BID)	PO	start with/just before flow ×3–5 d	Cochrane Marjoribanks 2015 PMID 26224322 — NSAID vs placebo pain relief OR 4.37 (95% CI 3.76–5.09); NSAID > paracetamol OR 1.89; in-repo validated rxcui 7646
ibuprofen	400–600 mg PO q6h with food	PO	q6h with flow ×3–5 d	Alternative first-line NSAID; no individual NSAID proven superior (Cochrane Marjoribanks 2015 PMID 26224322); in-repo validated rxcui 5640
mefenamic acid	500 mg PO then 250 mg q6h	PO	q6h with flow ×2–3 d	Fenamate NSAID with antiprostaglandin + anti-PG-receptor action; classic dysmenorrhoea agent (Cochrane Marjoribanks 2015 PMID 26224322). rxcui OMITTED — no in-repo precedent (allowed at INTEGRATED)
celecoxib	400 mg PO then 200 mg q12h	PO	with flow ×3–5 d	COX-2 selective when GI risk dominant + CV risk acceptable; no clear COX-2-vs-nonselective efficacy difference (Cochrane Marjoribanks 2015 PMID 26224322); in-repo validated rxcui 140587
topical heat + regular aerobic exercise	—	—	—	Heat ≈ NSAID-equivalent analgesia; exercise vs no-treatment menstrual-pain SMD −1.86 (95% CI −2.06 to −1.66), 45–60 min ≥3×/wk (Cochrane Armour 2019 PMID 31538328)

Plan: Dysmenorrhoea ladder: NSAID → hormonal (COC/LNG-IUS/progestin) → empiric-fail imaging → refractory-endometriosis GnRH ± add-back → fertility-sparing/chronic-pain (ESHRE 2022; ACOG CO 760; SOGC 437 2023)

3. When to call your provider

Contact your care team if any of the following happen:

Adolescent cyclical pain + pelvic mass ± primary amenorrhoea → urgent paediatric/adolescent gynae (obstructive Müllerian/outflow anomaly) (ACOG CO 760)
Acute severe unilateral pain → exclude ovarian torsion / ruptured endometrioma (route to gyn.ovarian-torsion.v1)
Fever + pelvic pain → PID pathway (gyn.pelvic-inflammatory-disease.core.v1; CDC STI 2021)
3–6-mo empiric-trial failure → imaging + gynae referral (ACOG CO 760 PMID 30461694)
Subfertility + endometriosis-suggestive → reproductive-medicine referral, plan around fertility window (ESHRE 2022)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Adolescent (special pop: adolescent) with never-pain-free cyclical pelvic pain + pelvic mass ± primary amenorrhoea — obstructive Müllerian/outflow anomaly (imperforate hymen, obstructed hemivagina, non-communicating horn) (ACOG CO 760; ESHRE 2022)
Refractory endometriosis-associated dysmenorrhoea (special pop: refractory-endometriosis-GnRH) after NSAID + first-line hormonal failure (ESHRE 2022; SPIRIT; Elaris)
Acute severe unilateral pelvic pain superimposed on dysmenorrhoea — exclude ovarian torsion / ruptured endometrioma / ectopic(life-threatening)
Pregnancy confirmed, actively conceiving, or breastfeeding (special pop: pregnancy/lactation) — hormonal suppression is contraceptive and must be held; NSAIDs contraindicated (3rd-trimester ductal closure) and avoided peri-conception (ESHRE 2022; ACOG CO 760)

5. Follow-up

Long-term hormonal suppression to menopause or until a fertility window (endometriosis is chronic + potentially progressive — ACOG CO 760); preconception/fertility-sparing planning; chronic-pelvic-pain biopsychosocial multimodal pathway for central-sensitisation overlap (Horne BMJ 2022 PMID 36375827; Mardon BJOG 2022 PMID 34919325); return precautions (new acute severe pain, fever, pregnancy, neurologic/vascular hormonal AE)

6. Sources

Guideline: ESHRE Endometriosis Guideline 2022 (Becker, Hum Reprod Open) + ACOG Committee Opinion 760 (Dysmenorrhea & Endometriosis in the Adolescent) + ACOG endometriosis guidance + SOGC Adenomyosis Guideline 437 (2023) + NICE NG73 + RCOG + WES; reconciled 2026-05-17