• Offer a nonsteroidal anti-inflammatory drug (NSAID) first line unless NSAIDs are contraindicated. Ibuprofen, naproxen, and mefenamic acid are the NSAIDs of choice
• Offer paracetamol first line if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if the response is insufficient
• Codeine may be added to paracetamol or an NSAID if the response is insufficient
• If the woman does not wish to conceive, consider hormonal contraception as alternative first-line treatment. Monophasic combined oral contraceptive (COC) preparations containing 30–35 micrograms of ethinylestradiol, and norethisterone, norgestimate, or levonorgestrel, are usually first choice
• Refer the woman if her symptoms are severe and not responding to initial treatment, or if there is doubt about the diagnosis
• Non-drug measures that may help to reduce pain include local application of heat and transcutaneous electrical nerve stimulation (TENS)
Source: NHS clinical knowledge summary June 2009







Readers' comments
Even sham acupuncture can have a 50% response rate, which is much higher than a placebo response. Although I have now retired, I started to use acupuncture extensively in my last 3 years of work, courtesy of the British Medical Acupuncture Society foundation course - I and my patients were equally gobsmacked by the response, e.g. 100% effective for hyperemesis gravidarum, also for chemotherapy induced nausea and vomiting, particularly remarkable in one patient who immediately stopped vomiting by needling PC6 where odansetron had failed, 90% response for frozen shoulder, and so on. I just wish I had cottoned on this remarkable phenomenon earlier in my career, and would suggest that all GP trainers and their registrars should look very seriously at undertaking at least basic training. Both of my assistants, my last appraiser and several physiotherapists took it up after seeing how useful it was!
The overall western medicinal approach to anything remotely 'non-mainstream' seems to have prevailed for aeons. All these exotic eastern medical fancies may not be so much quackery after all. For instance the Chinese have been using acupuncture extensively for thousands of years. So how many more cultural medical exchanges and medical trials are to be undertaken before it is brought in out of the cold?