Prevalence and predictors of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample

The study aimed at assessing the prevalence of premenstrual symptoms and of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) in a population-based sample of women of the entire reproductive age range, as well as to analyse predictors of PMS and PMDD in terms of socio-demographic, health status and health behavioural factors. A set of questions on PMS–based on the premenstrual syndrome screening tool developed by Steiner et al., translated into German and piloted—was integrated into the written questionnaire of the 2007 Swiss Health Survey. Weighted prevalence rates and multivariable regression analysis for the outcome variables PMS and PMDD were calculated. A total of 3,913 women aged 15 to 54 years answered the questions on PMS symptoms, and 3,522 of them additionally answered the questions on interference of PMS with life. Ninety one percent of the participants reported at least one symptom, 10.3% had PMS and 3.1% fulfilled the criteria for PMDD. The prevalence of PMS was higher in non-married women, in women aged 35–44 years and in women of the Italian-speaking region of Switzerland. Both PMS and PMDD were strongly associated with poor physical health and psychological distress. Socio-cultural factors seem to determine the prevalence, perception and handling of PMS. Considering the association with poor physical health and high psychological distress, a broader underlying vulnerability in women qualifying for PMDD must be assumed and should be taken into account in clinical management as well as in future research in this field.     

Relationship between premenstrual symptoms and dysmenorrhea in Japanese high school students

To determine the relationship between premenstrual symptoms and dysmenorrhea among Japanese adolescent girls, a total of 1,431 high school students were assessed. Of them, 11.3% were classified with “moderate to severe premenstrual syndrome (PMS)” and 3.2% with “premenstrual dysphoric disorder (PMDD).” Eighty-five percent of the girls had dysmenorrhea. The rates of prevalence of PMDD and moderate to severe PMS were increased according to the severity of dysmenorrhea (rs = 0.479), showing a correlation between the severity of PMS/PMDD and dysmenorrhea in adolescents.     

Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in Japanese women

Summary To investigate the prevalence and impact of premenstrual symptoms in Japanese women, we developed the PSQ “The Premenstrual Symptoms Questionnaire” for the screening of premenstrual symptoms. The PSQ translates DSM-IV criteria into a rating scale with degrees of severity. One thousand one hundred and eighty-seven Japanese women between the ages of 20 and 49 yrs, who were seen at a clinic for uterine cancer screening, were assessed regarding their premenstrual symptoms using the PSQ. As many as 95% of these women were found to suffer from premenstrual symptoms. The rates of prevalence of moderate to severe PMS and PMDD in Japanese women were 5.3 and 1.2%, respectively, which are lower than those in Western women. Only 5.3% of women with moderate to severe PMS and PMDD were treated. The results of this study suggest that race and ethnicity influence the expression of premenstrual symptoms and that the current state of medical care for Japanese women with moderate to severe PMS and PMDD is not satisfactory.     

Sleep quality and the sleep electroencephalogram in women with severe premenstrual syndrome

STUDY OBJECTIVES: Women with severe premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) commonly report sleep disturbances, but the few studies using conventional polysomnographic measures have produced conflicting results. We investigated sleep quality and sleep composition using conventional and quantitative electroencephalographic analyses in women with severe PMS, as compared with that of controls. DESIGN AND PARTICIPANTS: Women (aged 18-40 years) were screened to ensure that their PMS symptoms were severe and that they had ovulatory menstrual cycles. Nine women with PMS or PMDD and 12 asymptomatic control subjects then had laboratory-based polysomnographic recordings at 2 phases of the menstrual cycle: follicular phase and late luteal (premenstrual) phase. RESULTS: Women with severe PMS reported a significantly poorer subjective sleep quality during the late luteal phase (P = 0.02), but there was no evidence of disturbed sleep based on the polysomnogram specific to premenstrual symptom expression: both groups of women had increased wakefulness after sleep onset (P = 0.02) and increased sigma power (P < 0.01), especially in the 14-to 15-Hz band during non-rapid eye movement sleep, in the late luteal phase compared with the follicular phase. There were, however, some group differences in electroencephalographic measures regardless of menstrual phase, including decreased delta incidence (P = 0.02) and increased theta incidence and amplitude (P < 0.05) in women with PMS, suggesting the possibility of sleep electroencephalogram trait markers in women with PMS. CONCLUSION: Perceived poor quality sleep is a characteristic of severe PMS, but sleep composition based on polysomnographic measures and quantitative electroencephalographic analysis does not differ in association with premenstrual symptom expression in the late luteal phase.     

The CCK-system mediates adaptation to novelty-induced stress in the rat: A pharmacological evidence

Brain cholecystokinin (CCK) and its receptor CCK(2) have been implicated in the etiology of anxiety. CCK(2) antagonists, however, fail to ameliorate anxiety in humans. In this study, a role for CCK in adaptation to stress is investigated by testing carry-over effects of Ly225.910, a potent CCK(2) antagonist, in a rat model of individual differences in novelty-induced emotionality. Novelty-seeking behavior in the rat is thought to model some aspects of sensation-seeking, a personality trait closely associated with risk activities including substance abuse. Animals were categorized as high-responders (HR) and low-responders (LR) based on the activity response to an inescapable novel environment. High-responders exhibit increased exploration and proactive behavior while low-responders are less exploratory and deemed to behave more anxiously. We analyzed the effects of the CCK(2) antagonist Ly225.910 (0.1 mg/kg or 0.5 mg/kg, i.p.) on the anxiety displayed by HR and LR rats in the light–dark (LD) box test (Day 1). Treatment and phenotype effects were not acutely evident. LD-experienced rats were then re-exposed to drug-free LD-box (Days 4 and 11) and elevated plus-maze (EPM) test (Day 14). Drug-naïve HR rats behaved less anxiously than drug-naïve LR rats while exploring the open arms. Previous exposure to the antagonist curtailed these differences. The emotional responses in drug-naïve HR and LR rats to the EPM test could reflect different degrees of adaptation to anxiety-like training. Long-term effects of Ly225.910 on EPM-induced risk assessment in HR and LR rats suggest that CCK-system may be involved in modulating preparedness to arousing environmental changes.     

Examination of premenstrual symptoms as a risk factor for depression in postpartum women

Postpartum depression (PPD) is a significant public health concern with prevalence of major and minor depressions reaching 20 % in the first three postpartum months. Sociodemographic and psychopathology correlates of PPD are well established; however, information on the relationship between premenstrual disorders and the development of PPD is less well established. Thus, the aim of this study was to examine the role of premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) as a risk factor for PPD. Premenstrual symptoms were assessed retrospectively using the premenstrual symptoms screening tool (PSST) and depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria and assessed using the Hamilton Depression Rating Scale (HDRS). A two-stage screening procedure was applied. In the first stage, the Patient Health Questionnaire (PHQ-9) was employed. In the second stage, women endorsing ≥5 symptoms on the PHQ-9 were administered the Structured Clinical Interview for DSM-IV, HDRS, and PSST. Hierarchical linear regression showed that history of depression and PMS/PMDD contributed an additional 2 % of the variance (p?<?0.001), beyond that of sociodemographic factor effects. The full model accounted for 13 % of the variance in postpartum depressive symptoms. Using logistic regression, a significant association also emerged between PMS/PMDD and PPD (OR?=?1.97). The findings of this study suggest that PMS/PMDD is an important risk factor for PPD. Women endorsing a history of PMS/PMDD should be monitored during the perinatal period.     

Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review

We systematically reviewed empirical studies that investigated the use of cognitive-behavioral therapy (CBT) for premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). Our multi-database search identified seven published empirical reports. Three were identified as randomized controlled trials (RCTs). The methods utilized to investigate therapeutic efficacy of CBT in these studies varied widely from case reports to RCTs with pharmacotherapy comparison groups. Initially we provide a brief overview of CBT and justifications for its potential use to treat PMS/PMDD. Next, we provide critical evaluations of the analyses used in each study focusing on the detection of intervention effects assessed by statistically significant time by group interactions. When possible we calculate effect sizes to elucidate the clinical significance of results. Our review revealed a dearth of evidence providing statistically significant CBT intervention effects. Issues such as overall time investment, latency to treatment effects, and complementary and combined therapies are considered. We present a theoretical argument for applying mindfulness- and acceptance-based CBT interventions to PMS/PMDD and suggest future research in this area. In conclusion, to produce the necessary evidence-base support for PMS/PMDD given the limited empirical evidence reported here, researchers are called on to produce methodologically rigorous investigations of psychosocial interventions for PMS/PMDD.     

Resting heart rate (HR) in women with and without premenstrual symptoms (PMS)

A sample of 64 undergraduate female students participated in the present experiment. During 3 consecutive months women answered a chart of daily report of symptoms, and finally, two groups were formed: women with premenstrual symptoms (PMS group) and women without premenstrual symptoms (NPMS group). Heart rates (HR) at rest were recorded throughout premenstrual, menstrual, postmenstrual, and ovulatory phases. In the premenstrual phase, PMS group showed significantly higher resting HR levels than NPMS group. With regard to resting HR levels across the four phases studied, significant differences within PMS group were observed. Our results are discussed from a psychophysiological point of view.     

Previous experience affects subsequent anxiety-like responses in rats bred for novelty seeking

Novelty-seeking behavior in rats is deemed to model sensation seeking in humans, a personality trait related to some psychiatric conditions, including substance abuse. Animals characterized based on their locomotor response to novelty, namely high and low responders (HRs and LRs, respectively), show differences in anxiety and drug-taking behaviors. This study evaluates the effect of anxiety-provoking situations on subsequent behaviors in these endophenotypes. Selectively bred HR and LR rats were submitted to blocks of tests consisting of two-trial light- dark (LD) and two-trial elevated plus maze (EPM) tests arranged in counterbalanced, alternating order. No differences in anxiety-like behaviors were found in HR-bred and LR-bred rats in either LD trial, regardless of the test order. Repeated exposure to the EPM test, however, resulted in enhanced behavioral response under different test orders as a function of endophenotype. Compared with HR-bred animals, LR-bred animals exhibited increased anxiety on reexposure to EPM but only if both trials were preceded by an LD test session. The emotional responses in HR-bred and LR-bred rats reported here may reflect different degrees of adaptive processing regulated by both genetic and environmental factors.     

Evidence for different aetiologies of low estradiol response to FSH: age-related accelerated luteinization of follicles or presence of ovarian autoantibodies

BACKGROUND: We found granulosa cells of low responders (LR) expressed more LH receptors, suggesting that follicles were more luteinized than normal responders (NR). The objectives were to test the hypothesis that follicles of LR were more luteinized than follicles of NR, and to determine if LR with (LR+) and without (LR-) ovarian antibodies differed. METHODS: Hormone levels and ovarian autoantibodies (OVAB) were measured in follicular fluid from mature follicles (>17 mm), and in serum obtained on the day of oocyte retrieval during controlled ovarian stimulation. The gonadotrophin response was defined as a ratio of peak estradiol/number of FSH ampoules. RESULTS: NR (32.5 +/- 4.6 years; n = 11) were similar in age to LR+ (33.4 +/- 4.2 years; n = 9) and were younger than LR- (37.1 +/- 3.8 years; n = 12) (P = 0.03). Likewise, dehydroepiandrosterone sulphate was lower in LR- compared with LR+ or NR (P < 0.01). FSH, progesterone, inhibin-A and vascular endothelial growth factor levels were higher in follicular fluid of LR than NR. LR- and LR+ differed. For example, the follicular fluid progesterone/estradiol ratio was similar in NR (11.1 +/- 8.9) and LR+ (9.8 +/- 6.6) but was lower than LR- (22.9 +/- 19.6) (P = 0.05). Serum hormone levels did not reflect follicular fluid hormone profiles. CONCLUSIONS: In the absence of ovarian antibodies, low responses are associated with higher age and accelerated luteinization of mature follicles, rather than diminished responsiveness. Ovarian antibody may be an additional tool to predict and individualize treatment regimens in poor responders.     

The Iranian version of the Premenstrual Symptoms Screening Tool (PSST): a validation study

The objective of the current study was to translate and test psychometric properties of the Premenstrual Symptoms Screening Tool (PSST) in Iran. Using a standard “forward–backward” procedure, the English version of PSST was translated into Persian. A random sample of university students aged 18 years and over completed the questionnaire in Tehran, Iran. Psychometric properties of the Iranian version of PSST were assessed by performing reliability (internal consistency) and validity analyses [Content Validity Ratio (CVR) and Content Validity Index (CVI)]. In all, 925 female students took part in the study. Of these, 284 (30.7 %) had premenstrual syndrome (PMS) and 119 (12.9 %) had premenstrual dysphoric disorder (PMDD). Reliability of the PSST as measured by internal consistency was found to be satisfactory (Cronbach’s alpha coefficient, 0.93). The content validity as assessed by CVR and CVI were desirable (0.7 and 0.8, respectively). The Iranian version of PSST seems to be a reliable and valid measure of detecting PMS and PMDD in Iranian young female populations.     

Emotional regulation difficulties and premenstrual symptoms among Israeli students

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS) reported to affect 3–8 % of women of reproductive age and resulting in marked emotional and occupational impairment. Despite its prevalence, the etiology of PMDD is largely unknown, and patients remain mostly undiagnosed and poorly treated. It has been suggested that PMDD is a manifestation of underlying depressive disorder which is associated with the inability to regulate emotions in an adaptive manner. Therefore, we hypothesized that women with PMDD would exhibit increased difficulty with emotional regulation. A total of 648 female Israeli college students were assessed by the Premenstrual Symptoms Screening Tool (PSST) and the Difficulties in Emotion Regulation Scale (DERS). Of these women, 166 (25.6 %) met the criteria for PMS. Sixty-four (9.9 %) suffered from PMDD. More emotion regulation deficits were observed in the PMDD and PMS groups compared to the control group. Furthermore, there were more emotional regulation deficits among the predominantly psychological and mixed symptom subtype compared to the predominantly physical symptom subtype group. This is the first study to report an association between emotional dysregulation and PMDD. These findings may lead to development of more individually tailored treatment protocols focused on improving emotional regulation techniques.     

Posttraumatic stress disorder and trauma characteristics are correlates of premenstrual dysphoric disorder

Posttraumatic stress disorder (PTSD) is often comorbid with premenstrual dysphoric disorder (PMDD) in women; however, it is unclear whether this relationship is driven by the trauma that may lead to PTSD or if PTSD is uniquely associated with PMDD. In this study, we examine trauma and PTSD as independent correlates of PMDD. Researchers conducted a cross-sectional, secondary data analysis of 3,968 female participants (aged 18–40) of the Collaborative Psychiatric Epidemiology Surveys. Women who had a history of trauma with PTSD (odds ratio, OR = 8.14, 95% confidence interval, CI = 3.56–18.58) or a history of trauma without PTSD (OR = 2.84, 95% CI = 1.26–6.42) were significantly more likely than women with no history of trauma to report PMDD. This graded relationship was also observed in association with premenstrual symptoms. Among trauma survivors, PTSD was independently associated with PMDD, although characteristics of participants' trauma history partially accounted for this association. Our study demonstrated that trauma and PTSD were independently associated with PMDD and premenstrual symptoms. Clinicians should be aware that women who present with premenstrual symptomatology complaints may also have a history of trauma and PTSD that needs to be addressed. This pattern of comorbidity may complicate the treatment of both conditions.     

Effects and treatment methods of acupuncture and herbal medicine for premenstrual syndrome/premenstrual dysphoric disorder: systematic review

Background

During their reproductive years about 10% of women experience some kind of symptoms before menstruation (PMS) in a degree that affects their quality of life (QOL). Acupuncture and herbal medicine has been a recent favorable therapeutic approach. Thus we aimed to review the effects of acupuncture and herbal medicine in the past decade as a preceding research in order to further investigate the most effective Korean Medicine treatment for PMS/PMDD.

Methods

A systematic literature search was conducted using electronic databases on studies published between 2002 and 2012. Our review included randomized controlled clinical trials (RCTs) of acupuncture and herbal medicine for PMS/PMDD. Interventions include acupuncture or herbal medicine. Clinical information including statistical tests was extracted from the articles and summarized in tabular form or in the text. Study outcomes were presented as the rate of improvement (%) and/or end-of-treatment scores.

Results

The search yielded 19 studies. In screening the RCTs, 8 studies in acupuncture and 11 studies in herbal medicine that matched the criteria were identified. Different acupuncture techniques including traditional acupuncture, hand acupuncture and moxibustion, and traditional acupuncture technique with auricular points, have been selected for analysis. In herbal medicine, studies on Vitex Agnus castus, Hypericum perforatum, Xiao yao san, Elsholtzia splendens, Cirsium japonicum, and Gingko biloba L. were identified. Experimental groups with Acupuncture and herbal medicine treatment (all herbal medicine except Cirsium japonicum) had significantly improved results regarding PMS/PMDD.

Conclusions

Limited evidence supports the efficacy of alternative medicinal interventions such as acupuncture and herbal medicine in controlling premenstrual syndrome and premenstrual dysphoric disorder. Acupuncture and herbal medicine treatments for premenstrual syndrome and premenstrual dysphoric disorder showed a 50% or better reduction of symptoms compared to the initial state. In both acupuncture and herbal medical interventions, there have been no serious adverse events reported, proving the safety of the interventions while most of the interventions provided over 50% relief of symptoms associated with PMS/PMDD. Stricter diagnostic criteria may have excluded many participants from some studies. Also, depending on the severity of symptoms, the rate of improvement in the outcomes of the studies may have greatly differed.     

Differential novelty detection in rats selectively bred for novelty-seeking behavior

“Novelty-seeking” behavior describes the variability of rats’ locomotor response, namely high and low responders (HR and LR respectively), when exposed to a novel environment. Novelty-seeking in the rat is considered to model “sensation-seeking” in humans, a personality trait related to substance abuse. It is assumed that HR rats and LR rats differ in their emotional reactivity because of the disparate incentive value of contextual stimulus, thus differentially interacting with their environment. However, little is known about how HR and LR rats recognize novelty arising from the environment. The present study evaluates whether phenotype may affect spontaneous, non-spatial novelty discrimination. Selectively bred HR and LR rats were submitted to the novel-object recognition test. The task involved a delay of 3 h after a first encounter with an object (“old”), which had to be discriminated from a second object (“new”). Object discrimination was assessed minute-by-minute during a 3-min choice session. Amnesic effects of scopolamine (0.5 mg/kg, intraperitoneal) were also analyzed. HR-bred rats showed sustained novel-object recognition throughout the 3-min choice session, whereas LR-bred rats began to discriminate between objects only in the last minute. Surprisingly, level of discrimination in scopolamine-treated HR-bred rats was significant during the first minute of the choice test and diminished thereafter, presumably because both objects became equally familiar as they were explored. Additionally, scopolamine induced changes in muscarine M₂ receptor gene expression in a phenotype-dependent manner. Because consistent object discrimination mainly arises during the first minute, these findings may reflect differential novelty detection in HR-bred respect to LR-bred rats.     

Novelty response of rats determines the effect of prefrontal alpha-2 adrenoceptor modulation on anxiety

In this study we provide evidence that animals of the same population, although identical in age and sex, have individual reactions to the prefrontal modulation of adrenoceptors. We have examined the dose-dependent action of α(2)-adrenoceptor agents on the anxiety of rats with different response to novelty in the elevated plus maze (EPM) apparatus. Rats were divided into high (HR) and low responder (LR) groups based on their locomotor activity in a novel open field environment. HR rats also showed increased locomotion and low anxiety in the EPM. Prefrontal injection of α(2)-receptor antagonist yohimbine, BRL44408 or imiloxan caused anxiety only in HR rats. The α(2A/D)-receptor agonist guanfacine increased anxiety levels of both groups. However, the effective dose was lower in HR rats. The present results propose different prefrontal adrenoceptor sensitivity of rats showing distinct baseline activity levels.     

Histories of depression, allopregnanolone responses to stress, and premenstrual symptoms in women

Twenty-six women meeting DSM criteria for premenstrual dysphoric disorder (PMDD) and 39 non-PMDD controls were tested for allopregnanolone (ALLO) responses to mental stress. Approximately half of each group had a history of depression (DEP) (14 PMDD, 17 non-PMDD), though all were free of current psychiatric illness. ALLO was sampled in response to venipuncture stress, after an extended baseline, and again 30 and 60 min following the onset of mental stressors. All women with prior DEP, regardless of PMDD status, showed a blunted ALLO stress response at 30 and 60 min (p < 0.05), and also failed to show the expected decrease from venipuncture to baseline rest (p = 0.08) compared to women with no prior DEP. Women with prior DEP did not show the expected correlation between progesterone and ALLO (r = 0.16) that was seen in those with no prior DEP (r = 0.37, p < 0.05). ALLO levels at extended baseline and blunted ALLO reactivity predicted more severe premenstrual symptoms, but only in PMDD women with prior DEP (p values <0.05). These results suggest that a history of DEP is associated with a failure of ALLO to be appropriately responsive to challenge, with alterations in the conversion of progesterone to ALLO, and confirm prior reports linking ALLO to symptoms in PMDD, but only in PMDD women with histories of DEP.     

Symptom-onset dosing with citalopram in the treatment of premenstrual dysphoric disorder (PMDD): a case series

Summary The efficacy and tolerability of symptom-onset dosing with citalopram in the treatment of premenstrual dysphoric disorder (PMDD) was evaluated in an open trial. Eight outpatients, aged 18–45 years and diagnosed with PMDD, were treated with 10–20 mg of citalopram from the start of premenstrual symptoms until the onset of menses. Primary efficacy variables were the premenstrual tension scale (PMTS-O) and the clinical global impression of improvement (CGI). Treatment was associated with significant improvement in PMDD symptoms (p < 0.001).     

Circadian phase and sex effects on depressive/anxiety-like behaviors and HPA axis responses to acute stress

Circadian dysregulation in sleep pattern, mood, and hypothalamic-pituitary-adrenal (HPA) axis activity, often occurring in a sexually dimorphic manner, are characteristics of depression. However, the inter-relationships among circadian phase, HPA function, and depressive-like behaviors are not well understood. We investigated behavioral and neuroendocrine correlates of depressive/anxiety-like responses during diurnal (‘light’) and nocturnal (‘dark’) phases of the circadian rhythm in the open field (OF), elevated plus maze (EPM), forced swim (FST), and sucrose contrast (SC) tests. Plasma corticosterone (CORT) was measured after a) acute restraint and OF testing and b) FST. Both phase and sex significantly influenced behavioral responses to stress. Males were more anxious than females on the EPM in the light but not the dark phase. Further, the open:closed arm ratio was lower in the dark for females, but not males. By contrast, in the FST, females showed more “despair” (immobility) when tested in the dark, while phase did not affect males. Acute restraint stress increased OF activity in the light, but not the dark, phase. CORT levels were increased in both sexes following the FST, and in males and light phase females post-OF. As expected, females had higher CORT levels than males, even at rest, and this effect was more pronounced in the dark phase. Together, our data highlight the sexually dimorphic influences of circadian phase and stress on behavioral and hormonal responsiveness.     

Fluoxetine improves functional work capacity in women with premenstrual dysphoric disorder

Summary Interference with social and occupational functioning is a key criterion for premenstrual dysphoric disorder (PMDD) and distinguishes it from the less severe premenstrual syndrome (PMS). We conducted a post hoc analysis of the results of a previously reported study evaluating the efficacy of fluoxetine in the management of PMDD, to determine the extent to which women with PMDD perceived impairment in their functional work capacity during the luteal phase of their menstrual cycle. The effects of two doses of fluoxetine vs placebo in alleviating PMDD symptoms and restoring normal work capacity during this period were assessed. We measured baseline follicular vs luteal phase presence of 8 patient-rated functional work capacity-related symptoms on the Premenstrual Tension Scale-Self Rated in 320 women who met diagnostic criteria for late luteal phase dysphoric disorder, now known as PMDD. Women were then randomized to double-blind treatment with either fluoxetine 20 mg/d, fluoxetine 60 mg/d, or placebo daily for 6 menstrual cycles. All 8 work capacity-related symptoms were more likely to be present in the baseline luteal phase than in the baseline follicular phase. A statistically significant improvement from baseline to the average treatment score for the work capacity subscale was detected for both fluoxetine groups compared to the placebo group. This beneficial response to fluoxetine was evident by the first cycle of treatment. Our results demonstrate that fluoxetine at a relatively low dose of 20 mg/d quickly reduced symptoms that negatively affect work capacity and was well tolerated. Received June 17, 2002; accepted November 19, 2002 Published online January 31, 2003 Correspondence: Meir Steiner, MD PhD FRCPC, Women's Health Concerns Clinic, St. Joseph's Healthcare, Fontbonne Building, 301 James St. S., Hamilton, ON L8P 3B6, Canada; e-mail: mst@mcmaster.ca