1Heilongjiang University of Chinese Medicine, Harbin, People’s Republic of China; 2Harbin Institute of Technology, Harbin, People’s Republic of China; 3First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, People’s Republic of China

We commend the authors of the recent systematic review on dysmenorrhoea treatment, which provides a comprehensive overview of various pharmacologic and non-pharmacologic interventions. Dysmenorrhoea remains a prevalent and impactful condition affecting women of reproductive age, and such reviews are crucial in guiding clinical practice.1 However, the review had certain limitations related to study heterogeneity and the rigor of inclusion criteria, which may influence the reliability and applicability of the findings. The article included a variety of studies covering a wide range of pharmacological, non-pharmacological, and surgical interventions. These studies exhibited heterogeneity due to the variety of participants, designs, interventions, and assessment criteria. For example, different types of NSAIDs exhibited variation in effectiveness for the treatment of dysmenorrhoea, but the article as a whole did not discuss in detail the impact of this heterogeneity on the results.2 Although the effects of the various types of treatments are summarised, the variability between studies is not analysed in depth, which may lead readers to misunderstand the generalisability of the overall conclusions.

Another significant concern is the varying quality of the studies included in the review. Whereas some studies, such as Cochrane reviews and large randomized controlled trials, provide high-quality evidence, others—particularly those addressing non-pharmacologic interventions—are characterized by small sample sizes and methodological limitations.3 The review acknowledges these issues but does not provide detailed inclusion criteria, which raises concerns about the robustness of the conclusions.4 The lack of stringent inclusion criteria could result in the inclusion of studies that do not fully align with the review’s objectives or that contribute low-quality data, potentially skewing the results.5 For example, the section on behavioural interventions and non-pharmacologic treatments discusses a variety of approaches, from exercise to the use of cannabinoids, yet many of the included studies lack rigorous control groups or sufficient sample sizes. The variability in study design and the limited evidence for these interventions make it difficult to establish their efficacy definitively. Without clear inclusion standards, the review risks overestimating the effectiveness of treatments with weaker evidence.

In conclusion, although the systematic review offers valuable insights into the treatment of dysmenorrhoea, the lack of detailed inclusion criteria and the handling of study heterogeneity are areas of concern. Future reviews should establish and transparently report rigorous criteria for study selection to include only high-quality, relevant studies. Additionally, addressing heterogeneity through subgroup or sensitivity analyses could enhance the reliability of the conclusions. By improving these aspects, systematic reviews can better serve as a foundation for evidence-based clinical guidelines and ultimately improve patient outcomes.

We thank all the participants for their contribution to this study.

We do not declare a specific grant for this research from any funding agency in public, commercial, or not-for-profit sectors.

The research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1. Kirsch E, Rahman S, Kerolus K, et al. Dysmenorrhea, a narrative review of therapeutic options. J Pain Res. 2024;17:2657–2666. doi:10.2147/JPR.S459584

2. Grandi G, Ferrari S, Xholli A, et al. Prevalence of menstrual pain in young women: what is dysmenorrhea? J Pain Res. 2012;5:169–174. doi:10.2147/JPR.S30602

3. Savović J, Weeks L, Sterne JA, et al. Evaluation of the Cochrane collaboration’s tool for assessing the risk of bias in randomized trials: focus groups, online survey, proposed recommendations and their implementation. Syst Rev. 2014;3(1):37. doi:10.1186/2046-4053-3-37

4. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.

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