PMDD treatment may require fine tuning. (Selective serotonin reuptake inhibitors).

Earlier this year, sertraline joined fluoxetine as an approved medication for premenstrual dysphoric disorder, both in intermittent and continuous dosing schedules.

The use of these drugs for this indication is associated with a good response in up to 90% of patients treated, according to Dr. Ten Pearlstein, director of Women's Behavioral Health at the Women and Infants Hospital, Providence, R.I.

Premenstrual dysphoric disorder (PMDD) is defined rather strictly in DSMIV: five or more symptoms during the luteal phase (one of which must be depressed mood, anxiety or tension, affective lability or anger or irritability) severe enough to markedly interfere with work, school, social activities, or personal relationships. But many clinicians consider a broader spectrum of women as candidates for treatment.

In a community survey of 519 women by Dr. Meir Steiner, director of the Women's Health Concerns Clinic at St. Joseph's Hospital, Hamilton, Ont., 5% of the women satisfied syndromal criteria. In another 20.7% who "marginally missed" the criteria, however, the impact on ability to function was moderate to severe.

"In the past, we've been accused of medicalizing [premenstrual syndrome]," Dr. Steiner explained, with as many as 85% of women said to suffer from it.

The pendulum has swung to the other extreme. Women who are missing one criterion but are severely affected should be treated, and in real life they are," she said.

Whatever the number of symptoms, their temporal distribution is a key issue. Premenstrual exacerbation of depression, anxiety, and other psychiatric or medical conditions is as least as prevalent as true PMDD, and the distinction should be made by tracking mood and other manifestations over two menstrual cycles.