What are the recommended first-line treatments for managing dysmenorrh

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

First-line treatments for managing primary dysmenorrhoea in primary care include:

Offering a nonsteroidal anti-inflammatory drug (NSAID) unless contraindicated, such as ibuprofen, naproxen, or mefenamic acid, as these reduce prostaglandin production which causes menstrual pain.
If NSAIDs are contraindicated or not tolerated, offer paracetamol either alone or in addition to NSAIDs if pain relief is insufficient.
For women who do not wish to conceive, consider a 3–6 month trial of hormonal contraception as an alternative first-line treatment. Combined oral contraceptives (COCs) containing 30–35 micrograms of ethinylestradiol with norethisterone, norgestimate, or levonorgestrel are usually preferred.
Other hormonal options include oral progestogen-only contraceptives (e.g., desogestrel 75 micrograms), parenteral progestogens (e.g., depot medroxyprogesterone acetate, implants like Nexplanon®), and intrauterine progestogen-only systems (e.g., Mirena®), after discussing benefits and risks.
If response to individual treatments is insufficient, a combination of an NSAID (or paracetamol) and hormonal contraception may be considered.
Non-drug measures such as local heat application (hot water bottle or heat patch) and transcutaneous electrical nerve stimulation (TENS) set to high frequency can be recommended alongside drug treatments.

If symptoms are severe or do not respond within 3–6 months, referral to a gynaecologist is advised.

All recommendations are based on expert opinion and evidence from UK guidelines and systematic reviews.

What are the recommended first-line treatments for managing dysmenorrhoea in primary care?