追加：第 3 节第 25 条，痛经吃止痛药与何时去妇科

2026-10-07。起因是 issue #86 读者提到痛经，全书此前没有一处写到痛经或子宫内膜异位症（grep「痛经」「子宫内膜异位」只在第 6、27 节各有一处无关的「月经」）。条目追加在第 3 节节末，没有插在中间，已有条号不动；节首导览新加一块「身上的痛」挂这一条。

分工：用药安全不在本条重复，全部指到第 34 节：胃出血高危人群见第 3 条，怀孕 20 周以后见第 5 条，对乙酰氨基酚一日上限见第 1 条，止痛药过度使用门槛见第 9 条。

1. Marjoribanks 2015，Cochrane CD001751.pub3

• URL：https://doi.org/10.1002/14651858.CD001751.pub3（PMID 26224322；题录与摘要经 Europe PMC，作者串 Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M，2015 年第 7 期）。doi.org 跳转到 Wiley 被 Cloudflare 挡（403），按 Europe PMC 摘要核对。
• 原文：「We included 80 randomised controlled trials (5820 women).」
• 原文：「NSAIDs were more effective for pain relief than placebo (OR 4.37, 95% CI 3.76 to 5.09; 35 RCTs, I(2) = 53%, low quality evidence). This suggests that if 18% of women taking placebo achieve moderate or excellent pain relief, between 45% and 53% taking NSAIDs will do so.」
• 原文：「overall adverse effects: OR 1.29, 95% CI 1.11 to 1.51 … gastrointestinal adverse effects: OR 1.58, 95% CI 1.12 to 2.23 … neurological adverse effects: OR 2.74, 95% CI 1.66 to 4.53 … if 10% of women taking placebo experience side effects, between 11% and 14% of women taking NSAIDs will do so.」
• 原文：「NSAIDs appeared to be more effective for pain relief than paracetamol (OR 1.89, 95% CI 1.05 to 3.43, three RCTs, I(2) = 0%, low quality evidence).」
• 原文：「there was little evidence of the superiority of any individual NSAID」；「Most of the studies were commercially funded (59%)」；「We rated the quality of the evidence as low for most comparisons, mainly due to poor reporting of study methods.」
• 原发性痛经的定义取自摘要 Background：「which in the absence of any underlying abnormality is known as primary dysmenorrhoea」。

2. NICE NG73

• URL：https://www.nice.org.uk/guidance/ng73/chapter/Recommendations（带代理 curl 取到，页面写 Published 06 September 2017，Last updated 11 November 2024）
• 1.3.1：「Suspect endometriosis in women (including young women aged 17 and under) presenting with 1 or more of the following symptoms or signs: chronic pelvic pain; period-related pain (dysmenorrhoea) affecting daily activities and quality of life; deep pain during or after sexual intercourse; period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements; period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine; infertility in association with 1 or more of the above.」
• 1.4.2：「Consider a short trial (for example, 3 months) of paracetamol or a non-steroidal anti-inflammatory drug (NSAID) alone or in combination for first-line management of endometriosis-related pain.」
• 1.4.3：「If a trial of paracetamol or an NSAID (alone or in combination) does not provide adequate pain relief, consider other forms of pain management and referral for further assessment.」
• 1.5.4：「Do not exclude the possibility of endometriosis if the abdominal or pelvic examination and ultrasound scan are normal」。
• 标题里的「吃三个月药也压不住」对应 1.4.2 和 1.4.3；「痛到耽误上班上学」对应 1.3.1 的「affecting daily activities and quality of life」。

3. Nnoaham 2011，WERF 十国研究

• URL：https://doi.org/10.1016/j.fertnstert.2011.05.090（PMID 21718982；Fertil Steril 96(2):366-373.e8，经 Europe PMC）。2019 年同刊有一篇 Reprint（PMID 31623725），引原版。
• 原文：「Sixteen clinical centers in ten countries.」「A total of 1,418 premenopausal women, aged 18-45 years, without a previous surgical diagnosis of endometriosis, having laparoscopy to investigate symptoms or to be sterilized.」
• 原文：「There was a delay of 6.7 years, principally in primary care, between onset of symptoms and a surgical diagnosis of endometriosis, which was longer in centers where women received predominantly state-funded health care (8.3 vs. 5.5 years).」
• 原文：「Each affected woman lost on average 10.8 hours (SD 12.2) of work weekly, mainly owing to reduced effectiveness while working.」
• 样本是已经去做腹腔镜的女性，备注写明「不代表痛经的人多数有这个病」。

4. Schoep 2019，荷兰月经与生产力调查

• URL：https://doi.org/10.1136/bmjopen-2018-026186（PMID 31248919；BMJ Open 9(6):e026186，经 Europe PMC）。doi.org 跳转被 Cloudflare 挡（403），按摘要核对。
• 原文：「32 748 women aged 15-45 years, recruited through social media.」
• 原文：「A total of 13.8% (n=4514) of all women reported absenteeism during their menstrual periods … The mean absenteeism related to a woman's period was 1.3 days per year. A total of 80.7% (n=26 438) of the respondents reported presenteeism and decreased productivity a mean of 23.2 days per year. An average productivity loss of 33% resulted in a mean of 8.9 days of total lost productivity per year due to presenteeism.」
• 条目只用了 1.3 天和 8.9 天两个折算后的数，23.2 天（效率下降的天数）没写，免得读者把两个数相加。

5. Advil 说明书（DailyMed）

• URL：https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1f01c10a-9434-91a4-2ee4-352315a6b610（页面标题「ADVIL- ibuprofen capsule, liquid filled」；内容经 openFDA label 接口取，Haleon US Holdings LLC，effective_time 20260729）
• 原文：「Allergy alert: Ibuprofen may cause a severe allergic reaction, especially in people allergic to aspirin. Symptoms may include: hives facial swelling asthma (wheezing) shock …」
• 原文：「Ask a doctor before use if … you have high blood pressure, heart disease, liver cirrhosis, kidney disease, asthma, or had a stroke」
• 原文：「If pregnant or breast-feeding, ask a health professional before use. It is especially important not to use ibuprofen at 20 weeks or later in pregnancy unless definitely directed to do so by a doctor」
• 原文 Uses 一栏列有「menstrual cramps」。
• 21 CFR 201.326 里没有哮喘相关措辞（eCFR 正文 grep 过），所以哮喘这一句引说明书，不引 201.326。

定级

• 证据 A：止痛效果来自 80 项随机对照试验的 Cochrane 汇总，有具体数字。作者把多数比较评为低质量证据，备注已写明原因（方法报告不清、59% 药厂资助）。不标争议：没有找到反方证据说这类药对原发性痛经无效。
• 收益「中」，是判断：Cochrane 只量了缓解比例，没有量误工时间，套不上时间口径的阈值。凭的是 Schoep 的损失量级：缺勤 1.3 天加效率损失 8.9 天，每年约 10 天，按 8 小时工作日摊到每周约 1.6 小时，落在「每周小时级」。止痛药只能挽回其中一部分，所以不往上定「大」。
• 成本标签：钱=少（一盒布洛芬）、时间=少、毅力=否。去妇科那一步是有信号才做，不计入标签。

没写、没取到的

• 「止痛药会上瘾」「越吃越不管用」：没找到针对痛经用这类药的原始研究可以直接驳，条目不写这句断言，只用 Cochrane 的效果数字和第 34 节第 9 条（过度使用门槛管的是头痛）回应。
• 「生了孩子就好了」：没查到可逐字核对的原始文献，没写。
• 中国的数据：子宫内膜异位症诊治指南（第三版，中华妇产科杂志 2021）原文没取到，国内诊断延迟和痛经患病率都没写。
• 痛经时疼痛异常、同时月经推迟的宫外孕风险：本条范围之外，没写。