For women with premenstrual dysphoric disorder (PMDD), selective serotonin reuptake inhibitors (SSRIs) are the first line of pharmacological treatment. A significant body of evidence, including numerous double-blind, randomized studies, supports the effectiveness of SSRIs in reducing both the emotional, as well as physical symptoms, of PMS and PMDD. In general, women respond to low doses of SSRIs, and treatment response usually occurs rapidly, often within several days.

While treatment with SSRIs is highly effective, some women continue to have residual symptoms despite adequate dosing of SSRIs.  Other women may not be able to tolerate increasing doses of SSRIs due to side effects.  Few studies have addressed how to manage residual PMDD symptoms.  One study demonstrated that augmenting with the oral contraceptive Yasmin was beneficial in women with premenstrual symptoms. This is an option we often recommend; however, there are many women who are unwilling or unable to take oral contraceptives.

A recent study suggests that adjunctive quetiapine (Seroquel) may be helpful for women with PMDD.  This study was small, including 20 women with PMDD who had an inadequate response to selective serotonin reuptake inhibitor/serotonin–norepinephrine reuptake inhibitor treatment for their symptoms.  The participants were randomized to receive quetiapine sustained-release (SR, 25 mg starting dose) or placebo during the luteal phase for 3?months. Outcome variables included the Hamilton Depression and Anxiety Scales, Clinical Global Impression Scale, and the Prospective Record of the Impact and Severity of Premenstrual Symptoms (PRISM).

Although the study was small and thus underpowered, the researchers observed greater reductions in luteal phase mood ratings in the quetiapine group on the Hamilton Depression Rating Scale, Clinical Global Impression improvement rating, and PRISM daily scores. The greatest improvements in the quetiapine group were observed for  the symptoms of mood lability, anxiety, and irritability.

Ruta Nonacs, MD PhD

Jackson C, Pearson B, Girdler S, et al.   Double-blind, placebo-controlled pilot study of adjunctive quetiapine SRin the treatment of PMS/PMDD.  Hum Psychopharmacol. 2015 Jul 19.