Background <p>Dysmenorrhea is a common condition among women of reproductive age, yet some remain hesitant to use medications for pain relief. This study assessed the prevalence, perception toward medical treatment, reasons for medication hesitancy, alternative treatment practices, and predictors of medication hesitancy in dysmenorrhea management among Nigerian female undergraduates.</p> Methods <p>A cross-sectional study was conducted among 273 female undergraduate students at the University of Abuja, selected using multistage sampling. Data were collected with a semi-structured questionnaire administered physically and online. Perception of medical treatment was measured using a 12–60-point scale, with scores ≥ 30 indicating positive perception and scores &lt; 30 indicating negative perception. Descriptive statistics and binary logistic regression were used for analysis.</p> Results <p>Of 273 participants, 239 (87.5%) experienced menstrual pain, and 105 (38.5%) reported hesitancy to use medications. Major reasons included fear of side effects (81.9%), addiction (66.7%), and infertility (51.4%). Most students (73.6%) had a positive perception of medical treatment, while 25.2% and 15.2% used heat therapy and exercise, respectively, as alternatives. Ethnicity significantly predicted hesitancy: Hausa (OR = 2.63; 95% CI: 1.21–5.72; <i>p</i> = 0.015) and Igbo (OR = 3.10; 95% CI: 1.38–6.95; <i>p</i> = 0.006) students had higher odds compared with Yoruba students. Other factors, including age, religion, and perception score, were not significantly associated with hesitancy.</p> Conclusion <p>Medication hesitancy in dysmenorrhea management is common and largely influenced by cultural beliefs and fear of side effects rather than perception alone. Culturally tailored menstrual health education and university-based awareness programs are essential to improve trust in pharmacological options and promote evidence-based self-care.</p>