Holistic approach to dysmenorrhea management: Integrating pharmacological and non-pharmacological interventions for improved women's health in the Middle East and Africa.

The current body of research provides valuable insights into various health interventions, yet several areas warrant further exploration to enhance their effectiveness and applicability, particularly in the context of the MEA region. Additionally, there is a need for stronger emphasis on policy-level interventions to support long-term improvements in dysmenorrhea care. Policy Development and Advocacy : Encourage government support and international health partnerships to develop policies that prioritize women’s health, specifically targeting dysmenorrhea management. Advocacy efforts should focus on integrating menstrual health into national health agendas and securing funding for research and healthcare initiatives. Multicenter Empirical Studies: Conducting multicenter empirical studies across various locations in the MEA region is essential to gather comprehensive data on the effectiveness and applicability of pharmaceutical innovations. These studies will help account for regional variations and provide robust evidence to guide healthcare practices. Field Studies on NSAID Stability : While digital health solutions offer promising avenues for healthcare delivery, there is a need for field studies conducted under real-world environmental conditions in the MEA region to assess the stability and effectiveness of these interventions, particularly for non-steroidal anti-inflammatory drugs (NSAIDs). Effectiveness of Mobile Health (mHealth) Applications: Aboye et al. (2023) provided a comprehensive review of mHealth approaches in Sub-Saharan Africa, highlighting their potential to improve healthcare access and outcomes [ 173 ]. Despite these advancements, effectiveness studies of mHealth applications in the MEA region are limited. Future research should focus on evaluating user engagement, health outcomes, and the integration of these technologies into existing healthcare systems to fully realize their potential. Impact of Training Programs on Behavior Change: While the existing literature highlights the benefits of health education and digital interventions, the contribution of training programs to behavior change remains underexplored. Measuring the impact of these programs on healthcare providers and patients in the MEA region could provide valuable insights into designing interventions that promote best practices and improve health outcomes. Policy Development and Advocacy : Encourage government support and international health partnerships to develop policies that prioritize women’s health, specifically targeting dysmenorrhea management. Advocacy efforts should focus on integrating menstrual health into national health agendas and securing funding for research and healthcare initiatives. Multicenter Empirical Studies: Conducting multicenter empirical studies across various locations in the MEA region is essential to gather comprehensive data on the effectiveness and applicability of pharmaceutical innovations. These studies will help account for regional variations and provide robust evidence to guide healthcare practices. Field Studies on NSAID Stability : While digital health solutions offer promising avenues for healthcare delivery, there is a need for field studies conducted under real-world environmental conditions in the MEA region to assess the stability and effectiveness of these interventions, particularly for non-steroidal anti-inflammatory drugs (NSAIDs). Effectiveness of Mobile Health (mHealth) Applications: Aboye et al. (2023) provided a comprehensive review of mHealth approaches in Sub-Saharan Africa, highlighting their potential to improve healthcare access and outcomes [ 173 ]. Despite these advancements, effectiveness studies of mHealth applications in the MEA region are limited. Future research should focus on evaluating user engagement, health outcomes, and the integration of these technologies into existing healthcare systems to fully realize their potential. Impact of Training Programs on Behavior Change: While the existing literature highlights the benefits of health education and digital interventions, the contribution of training programs to behavior change remains underexplored. Measuring the impact of these programs on healthcare providers and patients in the MEA region could provide valuable insights into designing interventions that promote best practices and improve health outcomes. By addressing these research areas and emphasizing policy-level interventions, the MEA region can enhance its healthcare infrastructure and ensure the successful implementation of innovative pharmaceutical strategies tailored to its specific needs.

This narrative review aims to explore a holistic approach to dysmenorrhea management, focusing on pharmacological and non-pharmacological interventions for improved women’s health in MEA. The literature search was conducted using major databases like PubMed, Google Scholar, and Embase, supplemented by manual searches of key journals, reference lists from papers, and online searches to identify relevant literature. Studies were chosen for their relevance to the manuscript’s topics, emphasizing recent publications without restricting to a specific time period. As a narrative review, this manuscript aims to synthesize existing literature to provide a broad understanding of the topic, rather than conducting a formal quality assessment of each study. Key studies included in this review were selected based on their methodological rigor, such as randomized controlled trials and large cohort studies, which provide robust evidence. The evidence is generally consistent across studies, with direct applicability to the target population, enhancing the reliability of the conclusions. While the review highlights significant findings, it also identifies gaps in the literature, particularly in long-term outcomes and diverse populations. Overall, the evidence suggests promising trends, though further high-quality research is needed to confirm these findings and address existing gaps.

Dysmenorrhea management in the Middle East and Africa (MEA) is hindered by cultural stigmas, limited healthcare access, and environmental challenges. Societal norms often discourage open discussions about menstruation, leading to underreporting and misdiagnosis. Access to affordable healthcare and medications is limited, especially in rural areas, and misconceptions about the safety of treatments persist. Extreme weather conditions further complicate treatment by degrading medication efficacy. These barriers will be detailed in the following sections, along with innovative approaches and the need for increased public awareness [ 136 ]. Across various cultures in MEA, menstruation is often stigmatized, perceived as ‘dirty’ or ‘impure,’ and shrouded in silence. Such menstrual stigma exerts a pervasive influence on women and girls, creating an environment where menstrual topics are seldom discussed openly. This silence fosters a lack of accurate information and discourages women from seeking the support they need. The stigma not only hinders access to necessary medical care and education about menstrual health but also perpetuates misconceptions regarding treatment options, such as the fear that medications may harm fertility [ 137 – 139 ]. Internalized negative attitudes lead many to impose self-expectations to keep their menstrual status hidden, resulting in feelings of shame and distress, particularly at the prospect of having their menses exposed [ 137 – 139 ]. Despite dysmenorrhea being the leading cause of pelvic pain and a significant morbidity among gynecological disorders, many young women in MEA experience this condition in silence [ 137 ]. Research indicates that a significant number of women and girls experience menstrual disorders but only a small percentage seek medical care. Specifically, studies show that only about 9% to 16% of women and girls pursue treatment for these conditions, often choosing to endure pain instead of seeking help [ 139 , 140 ]. Social and cultural factors often inhibit research on gynecological issues; between 2012 and 2016, only six articles on dysmenorrhea were published in Arab countries [ 138 , 139 ]. This lack of discourse contributes to the under-treatment of dysmenorrhea, as many young females perceive it as a taboo topic and often believe that its painful symptoms are an unavoidable part of menstruation, something they must simply tolerate [ 55 ]. The impact of dysmenorrhea on daily life is profound. A study conducted among students at the University of Gondar in Northwestern Ethiopia revealed that over half of the respondents (63%) experienced social withdrawal, and nearly 51.4% reported a reduction in academic performance due to menstrual pain. Interestingly, the majority (63.8%) resorted to home remedies for relief rather than seeking professional medical help. This choice underscores the limited access to supportive healthcare, where many women feel embarrassed to seek assistance from healthcare providers [ 141 ]. A critical barrier to managing dysmenorrhea is the pervasive lack of knowledge about menstrual biology. Many studies have indicated that most women lack comprehensive information regarding menstruation, with only healthcare providers and biology teachers possessing adequate understanding. This knowledge gap means that even when women are aware of their menstrual cycles, they often struggle to grasp the relationship between menstruation and reproductive health. Consequently, many girls express a strong desire for practical information on managing their menses and alleviating pain [ 139 , 141 , 142 ]. According to a cross-sectional study by Elseifi et al. (2020) [ 139 ], the healthcare-seeking rate among women suffering from primary dysmenorrhea is alarmingly low, ranging from 14.2% to 16.3%. Factors influencing this reluctance include the belief that menstrual pain is a normal part of menstruation and various barriers such as embarrassment about visiting a physician, seeking advice from informal sources, fears of ineffective treatment, and concerns over potential side effects. Additionally, logistical issues like transportation difficulties further complicate access to care [ 139 , 142 ]. In the challenging landscape of dysmenorrhea management, particularly in the MEA region, the stability of medications poses a significant barrier to effective treatment. NSAIDs and analgesics, such as paracetamol, are widely recognized as primary pharmacological interventions for alleviating menstrual pain [ 55 , 143 ]. However, their therapeutic efficacy is heavily reliant on the stability of their APIs, which can be adversely affected by various environmental factors, including temperature, humidity, and light exposure [ 144 ]. This instability can lead to treatment failure, where medications do not provide the expected relief, or poor pain management, resulting in prolonged discomfort for patients. The climatic conditions in the MEA region exacerbate this challenge, as many countries experience high temperatures and humidity levels that can exceed the ideal storage conditions for these medications. In particular, temperatures can reach above 40 °C, leading to the accelerated degradation of active compounds [ 145 ]. This is especially prevalent in African countries where medications are often sold outdoors, exposing them to direct sunlight, heat, and precipitation. Such exposure can significantly compromise the integrity of solid oral dosage forms, diminishing their effectiveness [ 146 ]. Empirical evidence indicates that even within household settings in hot and humid regions, ambient temperatures can exceed recommended storage level temperatures. This not only threatens the shelf life of medications but also reduces their potency. Studies have shown that while the total amount of drug absorbed may remain unchanged, high temperatures and humidity can markedly reduce the rate of drug absorption, making it crucial for patients to receive medications that maintain their therapeutic value [ 147 – 150 ]. In addition to external environmental factors, improper storage practices further contribute to the instability of these medications. Despite the widespread use of OTC products for managing dysmenorrhea, the reality remains that their efficacy can be severely compromised by suboptimal storage conditions [ 151 ]. Research has illustrated that improper storage practices, combined with a lack of public knowledge about appropriate medication storage, can lead to the deterioration of these critical treatments. Therefore, it is imperative that healthcare stakeholders prioritize the design of medicinal products that can withstand various environmental challenges while ensuring that patients have access to effective treatments for dysmenorrhea. This situation calls for innovative approaches to improve the stability and efficacy of NSAIDs and analgesics in the MEA region. The development of novel formulations that are more resistant to high temperatures and humidity, utilizing different excipients and advanced packaging solutions, could provide viable alternatives [ 56 ]. Moreover, increasing public awareness regarding the proper storage of medicinal products is essential. By educating women and girls about the importance of medication storage and menstrual health, it is possible to mitigate some of the challenges associated with dysmenorrhea management [ 152 – 157 ]. OTC dysmenorrhea treatments typically come with a two-year expiration date, and maintaining their potency is contingent upon stringent adherence to established storage standards [ 158 ]. However, in the MEA region, where heat and humidity can be relentless, many therapeutic products suffer from degradation. A comprehensive study conducted over six months assessed various brands of paracetamol tablets under different temperatures (25 °C, 37 °C, and 45 °C) and humidity conditions (75% and 100% RH). The results were telling: while certain packaging materials like PVC/PVDC/Al foil and polycoated paper demonstrated superior protective qualities, many brands showed a significant decline in stability when subjected to increased temperatures and humidity levels [ 158 ]. Similarly, earlier research highlighted that exposure to elevated temperatures resulted in prolonged disintegration times, thus affecting the tablets’ efficacy [ 158 ]. The conclusions drawn from various studies across the region consistently emphasize the detrimental impact of improper storage practices and inadequate public awareness on the stability of these essential drugs [ 147 , 148 , 159 , 160 ].

Public awareness plays an essential role in the preservation of therapeutic products. Increasing educational initiatives surrounding menstrual health and dysmenorrhea treatment is vital for empowering women in the MEA region [ 36 – 38 , 46 , 51 , 53 – 55 ]. Culturally and socially tailored educational initiatives in the MEA region are essential for empowering women and enhancing dysmenorrhea management. By partnering with local health organizations and educational institutions, programs can be developed that align with community values and address specific misconceptions and practices. There is an urgent need for health education programs at both school and university levels. Such initiatives can empower young women to navigate the challenges associated with dysmenorrhea and mitigate its interference with their daily lives. Awareness of individual menstrual factors, such as physical symptoms like cramping, fatigue, headaches, nausea, and other associated symptoms, can greatly enhance coping strategies. For instance, a study by Yang and Chen (2023) demonstrated that a menstrual health education program significantly improved psychological well-being and promoted positive behavioral changes among adolescent girls in rural Uganda [ 161 ]. Similarly, Ayieko et al. (2025) found that a multifaceted menstrual health intervention in Northwest Tanzania led to improved psychosocial outcomes and menstrual practices among secondary schoolgirls [ 162 ]. These findings underscore the importance of culturally adapted health education programs in raising menstrual health awareness. Such initiatives should additionally emphasize menstrual health and the correct storage of OTC medications, thereby improving women’s ability to effectively manage dysmenorrhea. Despite the limited focus on dysmenorrhea in research, it is essential to recognize that knowledge, social support, and individual experiences all intertwine to influence how women manage menstrual pain. The barriers and challenges faced by women in the MEA region highlight a critical need for open discussions, improved access to care, and comprehensive education on menstrual health [ 101 ]. To effectively advance menstrual health education and implementation strategies, integrating it into national health and education policies is essential to secure ongoing funding and support for programs at both school and community levels. Forming public-private partnerships among government agencies, NGOs, and private sector stakeholders can harness resources and expertise to expand the scope and influence of these initiatives. Furthermore, involving community leaders and influencers in promoting open discussions about menstrual health can help remove stigma and cultivate widespread community support for educational endeavors. Digital apps have become increasingly important in addressing women’s health, providing tools for managing various conditions, including menstrual health. These platforms offer women convenient, stigma-free access to track symptoms and manage conditions like dysmenorrhea (menstrual pain). Mobile apps play a significant role in addressing women’s health, particularly in managing dysmenorrhea (menstrual pain). A scoping review of menstruation-related apps revealed that 64% of the apps included pain and symptom tracking, with most using simple checkboxes to report symptoms. Despite the abundance of apps, only 10% offered pain management interventions, and many lacked evidence-based strategies. Apps provide accessible and potentially stigma-free platforms, but their content, especially for pain and symptom management, is generally of low quality, underscoring the need for more evidence-based and user-centered designs [ 163 ]. Furthermore, encouraging the development of apps with local language support and culturally relevant content can enhance accessibility and engagement among women in the MEA region. Naderbagi et al.. (2024) emphasize the importance of cultural and contextual adaptation in digital health interventions, highlighting that tailoring these applications to fit local needs significantly improves their effectiveness and user acceptance [ 164 ]. Similarly, El-Jardali et al. (2023) discuss the potential of digital health in fragile states within the Middle East and North Africa (MENA) region, noting that while digital solutions can bridge healthcare gaps, they must be carefully adapted to address the unique challenges and infrastructure limitations present in these areas [ 165 ]. Innovative approaches in formulation and packaging have become essential to counteract the effects of heat, humidity, and light on pharmaceutical products. The use of advanced excipients and packaging materials helps protect active pharmaceutical ingredients (APIs) from degradation, ensuring prolonged shelf life and effectiveness. Alongside these scientific innovations, digital applications and public awareness campaigns also play a pivotal role, especially in women’s health management, by providing tools for tracking symptoms and educating the public on proper medication storage practices. To protect medicines from harmful environmental conditions like heat and humidity, new formulation strategies are being developed. These strategies use special ingredients called excipients and carriers to keep drugs stable and effective [ 56 , 152 – 154 ]. New excipients are especially important in extreme climates, as they help manage moisture and protect sensitive drug components. For example, Soluplus ® is a polymer that helps drugs dissolve better, making them easier for the body to absorb. Captisol ® is another excipient that improves drug stability by increasing solubility. Prosolv ® ODT is a combination of ingredients that work together to protect drugs from heat and light. Kollicoat ® IR is a coating material that shields drugs from moisture, while Eudracap™ is used to protect drugs from acidic conditions. These coatings help medicines last longer and maintain their effectiveness. These advancements are essential for ensuring medicines remain potent and safe, even in challenging environments [ 166 ]. Advanced packaging solutions that provide optimal heat and humidity protection offer a feasible alternative [ 155 – 157 , 167 – 169 ]. Advanced packaging materials play a critical role in maintaining drug stability under extreme climatic conditions by providing specialized barriers against environmental factors. For instance, glass is an inert and impermeable material widely used in pharmaceutical packaging for moisture-sensitive drugs, offering excellent protection from humidity and oxygen. However, due to its fragility and weight, aluminum and tin are often used as alternatives, particularly for moisture and light-sensitive drugs, providing lightweight, corrosion-resistant, and effective barriers. Polyethylene (PE) and polypropylene (PP) coatings are applied to paperboard and plastic packaging to enhance moisture resistance, ensuring that moisture-sensitive drugs remain stable. Additionally, biodegradable polymers like polylactic acid (PLA) and polyhydroxyalkanoates (PHA), along with nanocomposites, can be incorporated to enhance mechanical strength, thermal stability, and environmental resistance. These advanced materials are particularly beneficial in hot and humid climates, where conventional packaging might fail to preserve drug integrity [ 167 ]. Although innovative formulation strategies, including the development of novel excipients and advanced packaging solutions, are crucial for maintaining drug stability in extreme climatic conditions, their successful implementation in the Middle East and North Africa (MENA) region requires a nuanced understanding of the region’s healthcare infrastructure. As highlighted by Katoue et al. (2022), aligning these innovations with local manufacturing capabilities and regulatory frameworks is essential [ 170 ]. By fostering public-private partnerships and leveraging regional opportunities, the MENA healthcare systems can effectively integrate these technologies, ensuring the delivery of stable and effective pharmaceuticals even in challenging environmental conditions. This approach not only enhances drug efficacy and safety but also strengthens the overall healthcare infrastructure in the region, paving the way for sustainable pharmaceutical advancements. Healthcare professionals play a crucial role in educating patients about dysmenorrhea, particularly in Middle Eastern countries where awareness and management options are limited. Social initiatives aimed at increasing awareness include community workshops and school-based programs that focus on menstrual health education, which can help destigmatize discussions around dysmenorrhea and empower women to seek help. For instance, studies have shown that effective health education significantly enhances knowledge and self-care practices among young women, leading to better management of symptoms and improved quality of life [ 168 , 169 ]. Incorporating training and capacity-building for healthcare providers is essential to improve menstrual health management in underserved areas. As highlighted by Alkhaibari et al. (2023), patient-centered care in the Middle East and North African region can be significantly enhanced through targeted provider education and training [ 171 ]. By equipping healthcare professionals with the necessary skills and knowledge, they can better address the unique challenges faced by women in these regions, ensuring more effective communication and management strategies [ 171 ]. In terms of pharmacological approaches, healthcare providers typically recommend NSAIDs as first-line treatments for pain relief. However, there is a notable reliance on self-medication, with many women opting for over-the-counter analgesics without professional guidance [ 93 , 172 ]. This highlights the need for healthcare professionals to provide clear information on appropriate medication use, potential side effects, and when to seek further medical advice. Non-pharmacological approaches are also important, especially in resource-constrained settings. These may include lifestyle modifications such as exercise, dietary changes, and the use of heat therapy. Research indicates that many women in the region prefer these methods due to their perceived safety and effectiveness [ 26 ]. Integrating these approaches into patient education can enhance overall management strategies for dysmenorrhea. Overall, the combined efforts of healthcare professionals through education, social initiatives, and a balanced approach to pharmacological and non-pharmacological treatments are essential for improving the management of dysmenorrhea among women in the MEA region. By focusing on training and capacity-building, healthcare providers can play a pivotal role in advancing menstrual health management in underserved areas. In summary, addressing the multifaceted barriers and challenges in dysmenorrhea management in the Middle East and Africa requires a streamlined and interconnected approach. Key solutions include fostering public education to dismantle sociocultural stigma and enhance women’s knowledge of menstrual health. This can lead to better diagnosis and treatment outcomes. Additionally, developing stable formulations and ensuring proper storage and handling of medications like NSAIDs and paracetamol are crucial to maintaining their efficacy in challenging environmental conditions. By increasing accessibility to healthcare resources and promoting open dialogue around menstruation, we can empower women and improve their quality of life. These interconnected strategies pave the way for healthier menstrual experiences and enhanced overall well-being for women in the region.

This review highlights the urgent need to address the barriers to effective dysmenorrhea management in the MEA region. Key actionable takeaways include dismantling sociocultural stigmas through public health initiatives and educational programs, ensuring the stability and efficacy of medications despite environmental challenges, and fostering collaboration among healthcare providers, educators, and regulatory bodies. By empowering women with education and promoting open dialogue, we can improve access to effective treatments and accurate information. These efforts, complemented by ongoing research and community engagement, are essential for enhancing the quality of life for women dealing with dysmenorrhea in the region.

Dysmenorrhea affects the quality of life of affected individuals, as it can result in school or work absences, decreased productivity among adolescent school learners and economically active women, and increased healthcare costs [ 36 – 38 , 46 , 53 – 55 ]. The primary goal of treating dysmenorrhea is to reduce the associated pain and discomfort that usually inhibit patient’s daily activities and impairs their QoL [ 14 , 22 , 56 ]. Effective management begins with patient education, reassurance, and supportive therapy [ 56 ]. For optimal treatment and compliance, patient preference shall be taken into consideration. Treating physician should counsel the patient on the types of therapeutic options available, potential adverse effects and best suited therapeutic regimen. Indeed, it must be considered that primary dysmenorrhea may appear in adolescence but often persists into adulthood, so different treatment options may be appropriate for a given patient over time depending on the stage of life [ 22 ]. Physicians typically use a combination of non-pharmacological and pharmacological approaches tailored to the individual’s needs as summarized in Fig. 2 . Both the treatment modalities may be used either alone or in combination. Due to the diverse etiology of dysmenorrhea, different pharmacological modes of action are targeted for analgesic effect and restoring patient’s normal daily routine. While some drugs inhibit prostaglandin production, others reduce uterine contraction or pain through direct analgesic effect. Treatment may be individualized based on the patient characteristics or may be tailored as per patient and physician preference [ 22 ]. Fig. 2 Combined approach in the management of dysmenorrhea Combined approach in the management of dysmenorrhea Non-pharmacological treatments for dysmenorrhea are increasingly recognized for their effectiveness and safety [ 57 ]. These approaches are generally safe, have minimal side effects, and can be easily incorporated into a woman’s daily routine [ 58 ]. Healthcare providers should consider incorporating these approaches into the management of primary dysmenorrhea, either alone or in combination with pharmacological treatments, to provide comprehensive and personalized care for women suffering from this condition. Heat is a common method to ease menstrual pain, as it reduces muscle tension and relaxes abdominal muscles, alleviating pain caused by muscle spasms [ 59 – 62 ]. Heat increases pelvic blood circulation, reducing congestion and swelling, which diminishes pain from nerve compression. Some studies have reported heat therapy to be as effective as nonsteroidal anti-inflammatory drugs (NSAIDs) and more effective than acetaminophen, with no adverse effects [ 57 , 61 , 63 , 64 ]. Physical activity can also reduce pain intensity [ 65 ]. Abdominal cramp is usually caused by increased production of PGs, causing uterine hypoxia and ischemia. Exercise improves uterine blood flow and cyclic metabolism, relieving pain associated with increased PG production, which often leads to uterine hypoxia and ischemia [ 66 , 67 ]. Systemic review and meta-analysis by Li et al., 2024 [ 57 ] regards exercise specifically as a potentially effective non-pharmacological short-term treatment for management of dysmenorrhea. Regular exercise—such as isometric, aerobic, Zumba, strengthening, stretching, yoga, mixed and jogging—positively affects dysmenorrhea symptoms by reductions in pain intensity [ 62 , 65 , 68 – 70 ]. Dietary choices can significantly influence dysmenorrhea, with evidence suggesting that a low-fat vegetarian diet may alleviate menstrual pain. Studies, such as one by Barnard et al., have shown that adopting such a diet can reduce both the severity and duration of dysmenorrhea [ 71 ]. Similarly, increased intake of fruits, vegetables, fish, and dairy products has been associated with reduced menstrual discomfort [ 72 ]. Herbal medicine is widely embraced globally for managing dysmenorrhea, especially in regions with limited access to modern medicine or where individuals seek alternatives to conventional treatments [ 62 , 73 – 77 ]. Notable remedies include Native American use of Artemisia californica and Rhus glabra , and traditional Chinese medicine formulations like Danggui Shaoyao Powder, which is popular in Taiwan [ 78 – 83 ]. In India, herbs from the Asteraceae family are commonly used, with Vitex negundo L. being particularly prevalent [ 84 – 87 ]. Artemisia vulgaris is recognized for its widespread application in treating dysmenorrhea across multiple countries, including India, Italy, and Vietnam [ 84 – 87 ]. This herb is valued for its effectiveness in managing menstrual pain, with various parts of the plant being utilized in traditional remedies. Its prominence in different cultural practices underscores its significance as a natural treatment option for dysmenorrhea. Similarly, Italy utilizes a variety of herbs, including chamomile and yarrow, prepared mainly as decoctions and infusions [ 88 ]. South Africa employs 30 plant species, with roots often used medicinally, and the Middle East frequently uses cinnamon, ginger, and fennel for their anti-inflammatory and analgesic properties [ 39 , 89 – 95 ]. Overall, while herbal remedies vary across cultures, common patterns include the use of plants with anti-inflammatory and pain-relieving properties, highlighting their potential effectiveness in managing dysmenorrhea. The effectiveness of acupuncture is backed by several studies; however, these studies often lack active comparisons and robust methodological approaches [ 96 – 98 ]. However, a recent systemic review and meta-analysis by Li et al., 2024 regards acupuncture specifically as a potentially effective non-pharmacological short-term treatment for management of dysmenorrhea [ 57 ]. Transcutaneous electrical nerve stimulation (TENS) and behavioral counseling are two non-pharmacological options that may be considered as secondary treatments for dysmenorrhea management, after first-line therapies have been exhausted [ 19 , 62 ]. Pharmacological treatments for dysmenorrhea are often necessary for managing severe symptoms. Menstrual cramps and the severity of pain are linked to increased levels of prostaglandins PGF2α and PGE2 in the endometrium [ 23 ]. NSAIDs are the primary pharmacological treatment for dysmenorrhea because they inhibit cyclooxygenase (COX) enzymes, reducing prostaglandin production and alleviating pain. Scheduled use of NSAIDs, starting one to two days before the onset of pain, is more effective than taking them only as needed [ 99 – 101 ]. Although NSAIDs are generally well tolerated, they can cause gastrointestinal issues like nausea, vomiting, and heartburn [ 102 ]. Less common side effects include nephrotoxicity, hepatotoxicity, blood disorders, bronchospasm, fluid retention, and edema [ 102 ]. While there is limited evidence on which NSAID is the most effective or safest, commonly used options include ibuprofen, naproxen, mefenamic acid, and ketoprofen [ 6 , 20 ]. Over-the-counter availability of NSAIDs like ibuprofen and ketoprofen increases the risk of overuse or misuse, which can lead to adverse effects such as gastrointestinal issues, allergic reactions, and serious effects on the central nervous system, kidneys, and cardiovascular system [ 101 , 102 ]. A review by Marjoribanks et al., which included 80 randomized controlled trials with 5,820 women, found that NSAIDs are 4.5 times more effective than a placebo in relieving pain, with an odds ratio (OR) of 4.37 and a 95% confidence interval (CI) of 3.76–5.09 [ 102 ]. NSAIDs were also found to be twice as effective as paracetamol, with an OR of 1.89 (95% CI = 1.05–3.43) [ 102 ]. However, NSAIDs are associated with potential adverse effects, indicated by an OR of 1.29 (95% CI = 1.11–1.51), including gastrointestinal complications (OR = 1.58, 95% CI = 1.12–2.23) and neurological side effects (OR = 1.58, 95% CI = 1.12–2.23) [ 55 ]. These statistics highlight the effectiveness of NSAIDs compared to placebo and paracetamol, while also acknowledging the risk of side effects. In a systematic review comparing different NSAIDs to placebo for dysmenorrhea treatment, Marjoribanks et al. concluded that no NSAID is universally safer or more effective than others [ 102 ]. However, a meta-analysis of 70 studies showed that flurbiprofen and tiaprofenic acid have superior efficacy [ 101 , 102 ]. Approximately 20% of patients may not respond to NSAIDs, a condition known as NSAID-resistant dysmenorrhea. Fenamates, such as mefenamic acid, may offer slightly superior efficacy compared to phenyl propionic acid derivatives like ibuprofen and naproxen [ 103 , 104 ]. This is due to their dual mechanism of action, which involves inhibiting both the synthesis and action of prostaglandins [ 103 , 104 ]. Mefenamic acid can be started at a dosage of 500 mg at the onset of menses or pain, followed by 250 mg every six hours for up to three days, providing effective relief. A study suggests that ibuprofen and fenamates are preferred for safety and efficacy compared to other NSAIDs [ 105 ]. While NSAIDs are generally more effective than paracetamol for pain relief in dysmenorrhea, paracetamol remains a suitable alternative, especially when NSAIDs are contraindicated. Selective COX-2 NSAIDs like celecoxib were previously recommended but are no longer used due to the risk of serious adverse events, such as cardiovascular issues and delayed ovulation [ 106 – 108 ]. Prostaglandins play a crucial role in ovulation, and inhibiting them with celecoxib can disrupt normal ovulatory function [ 106 – 108 ]. In summary, while NSAIDs remain the cornerstone of pharmacological treatment for dysmenorrhea due to their effectiveness in reducing pain, it is crucial to balance their use with awareness of potential side effects and the risk of overuse, ensuring that treatment is both safe and effective for everyone. Hormonal contraception that combines estrogen and progesterone, available in the forms of pills, patches, or vaginal rings, has been shown to effectively alleviate dysmenorrhea pain compared to a placebo [ 109 – 112 ]. Any available combination pill offered comparable pain relief, showing no difference in efficacy. However, other studies have challenged the effectiveness of combined hormonal contraceptives for treating dysmenorrhea, citing small sample sizes and a lack of extensive comparative data [ 113 , 114 ]. A contraceptive that combines estrogen and progesterone serves to restrict the growth of the endometrium while also preventing ovulation. Over time, this leads to a thinning of the endometrial lining, resulting in lighter menstrual periods and fewer uterine contractions during menstruation. Consequently, this can alleviate menstrual pain. Additionally, combination oral contraceptives (COCs) function by reducing the production of PGs and leukotrienes, which are involved in inflammatory processes and pain during menstruation [ 99 ]. Low concentrations of PGs are observed in the menstrual fluid of women using COCs. Users of contraceptive pills tend to experience significantly reduced rates of dysmenorrhea and require fewer additional analgesics for pain management [ 115 ]. Continuous regimens of hormonal contraception, where no placebo pills are taken, offer greater benefits in alleviating dysmenorrhea compared to traditional cyclic therapy, however they still have limitations of adverse effects and long-term effects are yet to be explored [ 19 , 116 ]. The progestin only contraceptives which include pills, implants, intrauterine devices (IUDs), and intramuscular injections, are especially effective for individuals experiencing secondary dysmenorrhea due to endometriosis. Progesterone functions by promoting atrophy of the endometrial lining and by inhibiting ovulation. This hormonal treatment works primarily through its ability to thin the uterine lining, which can reduce menstrual bleeding and alleviate pain associated with dysmenorrhea. Their use in treating primary dysmenorrhea is still being investigated [ 117 – 119 ]. GnRH agonists and antagonists are utilized as second-line pharmacologic treatments for dysmenorrhea associated with endometriosis. GnRH agonists include medications such as nafarelin, leuprolide acetate, and goserelin, while the GnRH antagonist is elagolix. These treatments are effective in alleviating pelvic pain caused by endometriosis; however, their use may be constrained by high cost and potential adverse effects, particularly when not combined with add-back therapy using estrogen and progesterone to mitigate side effects such as bone density loss and menopausal symptoms [ 120 , 121 ]. The American Society of Reproductive Medicine endorses the use of GnRH agonists for treating dysmenorrhea following a laparoscopic diagnosis of endometriosis. Nevertheless, these medications are not recommended for long-term use due to their side effects and the risk of significant bone density loss over time [ 122 , 123 ]. They have limited use in primary dysmenorrhea. Aromatase inhibitors can be a valuable option for treating secondary dysmenorrhea, particularly in cases where initial medical management has failed to show positive results. However, their use requires careful consideration of potential adverse effects and the need for concomitant estrogen and progesterone therapy, especially in premenopausal women. Larger randomized clinical trials are still needed to further establish the efficacy and safety in managing endometriosis-related pain [ 19 ]. There is limited data on use of Aromatase inhibitor in primary dysmenorrhea. Calcium channel blockers including nifedipine, diminish the influx of calcium into muscle cells, thereby inhibiting their contraction. Consequently, it is proposed that administering nifedipine may alleviate menstrual pain by reducing uterine contractions [ 25 ]. Vasopressin and oxytocin receptor agonists have been investigated for the treatment of dysmenorrhea; however, their effectiveness is still uncertain due to various limitations in the studies conducted [ 19 ]. It possesses both muscle-relaxing effects and vasodilatory properties, which have been demonstrated to alleviate pain associated with dysmenorrhea. However, the absence of specific formulation and dosage guidelines has led to the recommendation that magnesium should be used alongside other therapies rather than as a standalone treatment for dysmenorrhea [ 101 ]. Paracetamol, commonly referred to as acetaminophen, is a well-known analgesic that effectively relieves menstrual pain. When combined with diuretics such as pamabrom or caffeine, its effectiveness in alleviating menstrual discomfort is significantly enhanced [ 124 – 126 ]. Paracetamol has been demonstrated to influence the COX pathway as well. Nevertheless, its primary action occurs within the central nervous system, and it exerts only a mild effect on peripheral anti-inflammatory pathways [ 127 ]. Clinical studies have consistently demonstrated paracetamol’s efficacy in providing relief from dysmenorrhea. A single-dose, placebo-controlled, double-blind, crossover study by Ali et al. 2007, found that paracetamol had significantly greater pain relief from placebo [in achieving total pain relief within three hours post-dose (TOTPAR 0–3 h) ( p < 0.05) and even more so at four (TOTPAR 0–4 h) ( p < 0.01) and six hours (TOTPAR 0–6 h) ( p < 0.01)] [ 125 ]. A pooled analysis of randomized, double-blind, placebo- or active-controlled studies of 443 women by Milsom et al. in 2002, examined the effectiveness of paracetamol compared to naproxen sodium, ibuprofen, and placebo in patients experiencing moderate to severe primary dysmenorrhea. The results indicated that maximal pain relief from paracetamol was observed two hours post-dose, providing statistically significant pain relief at two, three, and four hours after administration compared to placebo ( p < 0.01) [ 104 ]. Pain relief was measured using a 4-point categorical scale (0 = no relief, 1 = slight relief, 2 = moderate relief, and 3 = considerable or complete relief) [ 104 ]. Notably, paracetamol also offered superior relief at two hours compared to naproxen (400 mg), naproxen (200 mg), and ibuprofen (200 mg), and at three and four hours compared to ibuprofen (200 mg) [ 128 ]. Since muscle spasms are a significant factor in dysmenorrhea, antispasmodic medications have been investigated for their ability to reduce menstrual pain. Hyoscine butylbromide, an anticholinergic agent known for its smooth muscle relaxation properties, has gained worldwide recognition as an effective treatment for dysmenorrhea. Randomized controlled trials have shown that combining an antispasmodic with an NSAID produces better outcomes than using an NSAID alone. A review by Tytgat 2007, analyzed from 10 placebo-controlled studies that confirmed the efficacy of hyoscine butylbromide in alleviating abdominal cramping, supporting its use in managing dysmenorrhea [ 129 ]. Recently, to report real world effects of hyoscine butyl bromide and paracetamol combination, a pharmacy-based patient survey (PBPS) comprising of 1686 patients was conducted by Stewen et al. 2024 [ 130 ]. The survey reported tolerability as “great safety profile” and patient satisfaction was reflected by 97.5% willing to use combination of hyoscine butyl bromide and paracetamol for dysmenorrhea and 97.1% patients willing to recommend it to friends or family. One of the advantages of hyoscine butylbromide is its low absorption and minimal systemic impact, as it does not penetrate the blood-brain barrier. This leads to fewer side effects, with clinical data showing a negligible increase in anticholinergic-related adverse effects. A longitudinal study assessing the safety and efficacy of a combination of lysine clonixinate (125 mg) and hyoscine butylbromide (10 mg) in 30 women with uterine dysfunction reported significant reductions in menstrual pain with minimal adverse effects [ 131 ]. Paracetamol functions as an analgesic and antipyretic, primarily inhibiting prostaglandin synthesis within the central nervous system [ 132 ]. In contrast, hyoscine butylbromide operates as a peripheral anticholinergic that does not cross the blood-brain barrier, exerting a spasmolytic action on the smooth muscles of the gastrointestinal, biliary, and genitourinary tracts, without crossing the blood-brain barrier [ 129 ]. With clinical evidence supporting its efficacy in relieving both pain and cramping, the combination approach addresses the multifaceted nature of menstrual discomfort. As women continue to seek effective relief from dysmenorrhea, the paracetamol-hyoscine butylbromide combination stands out as a well-tolerated and efficacious option, helping to restore comfort and improve quality of life during menstruation [ 130 ]. This combination is designed to provide dual analgesic and antispasmodic relief from menstrual cramps and pain associated with conditions like irritable bowel syndrome. This medication addresses symptoms such as muscle aches and headaches, offering a reliable option for many women managing dysmenorrhea. Three randomized, double-blind, placebo-controlled clinical trials support the efficacy of this combination in primary dysmenorrhea patients: In a prospective randomized double-blind crossover study conducted by de los Santos AR et al. in 2001, 125 patients with primary dysmenorrhea were given either a placebo, lysine clonixinate (125 mg) plus propinox (10 mg), or paracetamol (500 mg) plus hyoscine butylbromide (10 mg). The average intensity of menstrual pain was significantly lower in the combination group compared to the placebo group, indicating that both active treatments offered greater pain relief. The intensity of pain at day 5 was 1.45 ± 0.87, 1.36 ± 0.81, and 1.85 ± 0.87 for hyoscine butylbromide plus paracetamol, lysine clonixinate plus propinox, and placebo, respectively. Both active preparations provided significantly greater pain relief compared to placebo and the baseline intensity of 2.72 ± 0.61 [ 133 ]. Another four-arm double-blind study by Mueller in 2006 involved 1,637 patients with recurrent crampy abdominal pain, randomized to receive either placebo, hyoscine butylbromide (10 mg), paracetamol (500 mg), or a combination of both for three weeks. The results highlighted that the combination therapy led to nearly 50% improvement in pain intensity after one week, with both treatment arms scoring significantly better than placebo throughout the study duration. The primary endpoint was the mean change in Visual Analogue Scale (VAS) between day 0 and 21. Pain frequency was self-assessed daily using a four-stage Verbal Rating Scale (VRS) of 0 (not at all), 1 (1–2 times), 2 (3–5 times) and 3 (>five times). Separation between the active treatment and placebo became noticeable after 2 days of treatment. The mean improvement from baseline on active treatment was almost 50% after 1 week of treatment. Similar effects were found for abdominal pain frequency. After 1, 2 and 3 weeks, all three treatment arms scored significantly better than placebo ( P < 0.001). Pain intensity decreased in all treatment groups; the adjusted mean changes from baseline were 2.3, 2.4 and 2.4 cm for the hyoscine, paracetamol and combination groups, respectively, compared with 1.9 cm for the placebo group (all P < 0.0001). The VRS also showed a statistically significant decrease in frequency of pain of 0.7, 0.7 and 0.7 in the hyoscine, paracetamol and combination groups compared with 0.5 in placebo (all P < 0.0001) [ 134 ]. In a double-blind, randomized parallel group trial involving patients with irritable bowel syndrome, 712 participants received either hyoscine butylbromide (30 mg/day) plus paracetamol (1500 mg/day), hyoscine butylbromide alone, paracetamol alone, or placebo. The differences between the combined preparation and placebo, as well as hyoscine and placebo were statistically significant. Moreover, patients given hyoscine and paracetamol had greater reductions in the severity of pain (VAS) than those receiving paracetamol after 4 weeks. After four weeks, those on the combined therapy reported marked or some improvement in symptoms at a rate of 81%, compared to 64% in the placebo group, highlighting the superior effectiveness of the dual-action approach [ 135 ]. In a prospective randomized double-blind crossover study conducted by de los Santos AR et al. in 2001, 125 patients with primary dysmenorrhea were given either a placebo, lysine clonixinate (125 mg) plus propinox (10 mg), or paracetamol (500 mg) plus hyoscine butylbromide (10 mg). The average intensity of menstrual pain was significantly lower in the combination group compared to the placebo group, indicating that both active treatments offered greater pain relief. The intensity of pain at day 5 was 1.45 ± 0.87, 1.36 ± 0.81, and 1.85 ± 0.87 for hyoscine butylbromide plus paracetamol, lysine clonixinate plus propinox, and placebo, respectively. Both active preparations provided significantly greater pain relief compared to placebo and the baseline intensity of 2.72 ± 0.61 [ 133 ]. Another four-arm double-blind study by Mueller in 2006 involved 1,637 patients with recurrent crampy abdominal pain, randomized to receive either placebo, hyoscine butylbromide (10 mg), paracetamol (500 mg), or a combination of both for three weeks. The results highlighted that the combination therapy led to nearly 50% improvement in pain intensity after one week, with both treatment arms scoring significantly better than placebo throughout the study duration. The primary endpoint was the mean change in Visual Analogue Scale (VAS) between day 0 and 21. Pain frequency was self-assessed daily using a four-stage Verbal Rating Scale (VRS) of 0 (not at all), 1 (1–2 times), 2 (3–5 times) and 3 (>five times). Separation between the active treatment and placebo became noticeable after 2 days of treatment. The mean improvement from baseline on active treatment was almost 50% after 1 week of treatment. Similar effects were found for abdominal pain frequency. After 1, 2 and 3 weeks, all three treatment arms scored significantly better than placebo ( P < 0.001). Pain intensity decreased in all treatment groups; the adjusted mean changes from baseline were 2.3, 2.4 and 2.4 cm for the hyoscine, paracetamol and combination groups, respectively, compared with 1.9 cm for the placebo group (all P < 0.0001). The VRS also showed a statistically significant decrease in frequency of pain of 0.7, 0.7 and 0.7 in the hyoscine, paracetamol and combination groups compared with 0.5 in placebo (all P < 0.0001) [ 134 ]. In a double-blind, randomized parallel group trial involving patients with irritable bowel syndrome, 712 participants received either hyoscine butylbromide (30 mg/day) plus paracetamol (1500 mg/day), hyoscine butylbromide alone, paracetamol alone, or placebo. The differences between the combined preparation and placebo, as well as hyoscine and placebo were statistically significant. Moreover, patients given hyoscine and paracetamol had greater reductions in the severity of pain (VAS) than those receiving paracetamol after 4 weeks. After four weeks, those on the combined therapy reported marked or some improvement in symptoms at a rate of 81%, compared to 64% in the placebo group, highlighting the superior effectiveness of the dual-action approach [ 135 ].

Globally, dysmenorrhea is a leading reason for seeking gynecologic care, affecting 50–90% of adolescent girls and young women [ 20 , 24 ]. A systematic review and meta-analysis involving over 20,000 young women across 38 countries found a prevalence rate of 71.1% [ 24 ]. Primary dysmenorrhea, characterized by menstrual pain without underlying pelvic pathology, is the most common form, typically emerging 6–12 months after menarche due to uterine contractions and prostaglandin release [ 24 ]. Approximately 10% of adolescents experience symptoms severe enough to disrupt daily life, making dysmenorrhea a significant cause of absenteeism from school and work [ 25 ]. In the Middle East and Africa (MEA) region, prevalence rates are notably high, with reports of up to 96% in Jordan and around 80% in Ethiopia [ 26 , 27 ]. Studies in countries such as Iran, Iraq, Israel, Jordan, and Kuwait indicate that 14% to 92% of women report experiencing dysmenorrhea [ 28 – 35 ]. For instance, a 2018 study in Iran found a pooled prevalence of 73.3%, while research conducted between 2010 and 2020 in Nigeria, Turkey, Iran, Israel, Egypt, Ethiopia, Saudi Arabia, and Jordan showed prevalence rates ranging from 70% to 90% [ 33 , 36 – 45 ]. In African countries like Cameroon, Lebanon, Ghana, Turkey, Israel, and Ethiopia, over 50%−70% of women of reproductive age report dysmenorrhea, impacting their daily activities [ 46 , 47 ]. A meta-analysis by Gedefaw et al. in 2022, which included 96 studies involving 78,068 students, found that 66.1% suffered from primary dysmenorrhea [ 47 ]. Contributing factors include being underweight, insomnia, family history, irregular menstrual cycles, stress, and negative emotions during menstruation [ 47 ]. The age at menarche significantly influences the likelihood of developing dysmenorrhea. Studies indicate that when the average age at menarche is 12.3 ± 1.5 years, 66% of women experience dysmenorrhea, increasing to 95% when the average age is 14 years [ 41 , 48 ]. This may be due to longer exposure to uterine prostaglandins in girls with later menarche [ 49 ]. Social support also plays a role in the severity of dysmenorrhea [ 50 ]. A study in Iran found that 86% of women reported primary dysmenorrhea, with varying levels of social support affecting their experience [ 50 ]. Pain intensity varies significantly, with some studies reporting mild, moderate, and severe pain in different proportions [ 41 , 48 ]. These variations in prevalence may be attributed to sociocultural beliefs, geographical factors, and the lack of a universally accepted definition of dysmenorrhea [ 46 , 51 ]. Despite these differences, the high prevalence in the MENA region underscores the need for better understanding and management of dysmenorrhea, considering available over-the-counter treatments and addressing climatic and sociocultural barriers impacting women’s health [ 52 ].

The Middle East and Africa (MEA) region, encompassing a diverse population of nearly 140 million young individuals aged 10–24 years, plays a pivotal role in shaping the region’s health landscape [ 1 ]. This demographic is crucial for understanding health dynamics, particularly in the context of women’s health, which remains a significant concern. Women constitute approximately 50% of the population in these countries, highlighting the importance of addressing their health needs [ 2 , 3 ]. Despite substantial progress in health outcomes over recent decades, driven by improved health systems, enhanced service delivery, and public health initiatives, women’s health issues continue to be inadequately addressed in the MEA region [ 4 , 5 ]. This contrast highlights persistent gaps in women’s health amidst overall health improvements. Women’s health focuses on achieving measurable health outcomes through targeted healthcare interventions [ 6 ]. This includes screening, diagnosis, and management of conditions unique to women, more prevalent in them, or with different manifestations, risk factors, or interventions compared to men [ 6 ]. It also involves understanding gender differences and addressing the diverse health needs of women throughout their life cycle [ 6 ]. Women’s health needs evolve across different life stages, beginning from birth and early childhood. As women age, their health requirements change significantly [ 3 ]. Proper nutrition and timely vaccinations are essential from infancy to establish a foundation for good health. During the reproductive years, education on menstruation, contraceptive methods, prenatal and postnatal care, and breastfeeding is vital for maternal and child health [ 3 ]. A comprehensive approach to women’s health that addresses these changing needs is necessary for promoting long-term health outcomes [ 3 ]. Dysmenorrhea, a prevalent gynecological condition affecting approximately 75% of women, particularly teenagers and young adults, is a significant public health issue in the MEA region [ 7 ]. Dysmenorrhea is characterized by painful menstrual cramps, often accompanied by symptoms such as abdominal pain, backache, nausea, vomiting, headaches, dizziness, fatigue, and sleep difficulties [ 8 – 14 ]. These symptoms typically occur just before or during menstruation and can be severe, impacting women’s quality of life (QoL) [ 15 , 16 ]. Dysmenorrhea is classified into primary and secondary types. Primary dysmenorrhea, the most common form, occurs without underlying pelvic conditions and is influenced by increased levels of prostaglandins and leukotrienes, leading to uterine contractions and cramping pain [ 17 – 20 ]. Secondary dysmenorrhea, accounting for about 10% of cases, is caused by pelvic pathologies or recognized medical conditions, with endometriosis being the most prevalent cause [ 20 , 21 ]. The mechanisms underlying primary dysmenorrhea are not fully understood, but they are primarily linked to hormonal changes and biochemical processes [ 14 ]. Progesterone levels fluctuate after ovulation, and as they decrease, lysosomes in endometrial cells release phospholipase A2, converting fatty acids into arachidonic acid, a precursor for prostaglandins [ 22 ]. Excessive production of prostaglandins, particularly F2α and E2α, leads to uterine hypercontractility, causing painful cramps and symptoms like nausea and diarrhea [ 23 ]. This hypercontractility, along with decreased progesterone, results in ischemia, sensitizing nerve fibers to inflammation and pain as shown in Fig. 1 . Additionally, elevated vasopressin levels, which promote uterine contractility, further exacerbate cramping and ischemic conditions [ 22 , 23 ]. Fig. 1 Pathophysiology of dysmenorrhea Pathophysiology of dysmenorrhea Understanding the mechanisms underlying dysmenorrhea, particularly the role of prostaglandins and vasopressin in promoting uterine contractility and ischemia, is crucial for developing effective management strategies and improving women’s health outcomes in the MEA region [ 22 , 23 ].