Edition: U.S. / Global

The Way We Live Now: 10-01-00; Female Troubles

By Peter D. Kramer
Published: October 1, 2000

A new prescription drug from Eli Lilly has recently reached the market. Carefully packaged to appeal to consumers, the pill is a pretty pink-and-lavender capsule, available in a light blue box. It's sold under the liltingly soft name Sarafem, which sounds like the angels known for the quality of their spiritual love. Although the name sounds equally like Esperanto for a beleaguered husband's fantasy -- a serene wife. So -- a prescription for divine quietism and devotion, clothed to appeal to the woman who favors Monet hues? Hard not to smile at the transparency of the imagery, especially when you discover that the medication is for premenstrual irritability and bloating -- and that it isn't a new drug at all, only Prozac in drag.

If drugs are carriers of cultural values, Sarafem looks like a harbinger of change. Women are the primary users of drugs that alter mood. At mid-century, Miltown and Valium were infamous for helping housewives cope, if sluggishly, in settings where discomfort may have been in order. By contrast, at the century's end, when women's place had moved from home to office, the drugs of the moment were ones that seemed to confer energy and resilience -- Prozac and its peers. There is about Sarafem something of Hillary discussing tollhouse cookies, careerist awkwardly outfitted as 50's mom. What does it mean that, at the start of a new century, a drug so many women say has caused them to be less retiring, more confident, is being repackaged as a ''mother's little helper''?

On the most concrete level, the pastel tones hide a familiar strategy. Other prescription drugs have been sold under two different names, for two different applications: the antidepressant Wellbutrin, for example, is also Zyban, a drug that helps people who are trying to quit smoking. But the antismoking pill resembles its antecedent, and the name Zyban has the same harsh, two-syllable ring as antidepressants -- Prozac, Zoloft, Luvox, Paxil -- that convey punch and vigor. Lilly claims that Prozac's effect on PMS is so different from its effect on depression as to merit a new ''method of use.'' Prozac goes off-patent next year; the Sarafem strategy gives Lilly the sole right for seven years to market the drug for PMS.

Lilly's argument is not entirely specious. Prozac takes weeks to treat depression. But given for premenstrual symptoms, Prozac (and Zoloft and the others -- they seem to work equally well) can diminish symptoms within days, sometimes within hours. The medications may be effective taken intermittently, for two weeks a month. And when the medications work, they affect not only emotional symptoms, like irritability, but also physical symptoms, like bloating and breast tenderness.

But the distinctiveness of the new drug use is by no means certain. Lilly is studying a one-a-week formulation of Prozac for chronically depressed patients. And the sex hormones play a role in depression. For instance, a recent study found that Zoloft has a stronger antidepressant effect in premenopausal women than in women past menopause or in men. In truth, no one knows exactly how these medicines relieve either depression or PMS; in both cases, the good responders are women with mood instability. And surveys show it is problems with mood, not physical symptoms, that determine whether a woman will get a prescription for PMS.

So Sarafem raises some of the same issues for medical ethics that Prozac did. We have had 10 years of debate about when drugs like Prozac are used to treat illness and when they are simply affecting personality traits, like pessimism, shyness and low self-esteem. The monthly cycle of menstruation is a natural function, which healthy women experience, and irritability can be a normal aspect of that function. What is a symptom? How bad must symptoms be to warrant medicating them and risking a drug's side effects? Who gets to decide, doctor or patient?

Severe PMS can be devastating to family life, job performance and happiness. But does medicating PMS in its milder forms constitute pathologizing an aspect of womanhood? Is it a question of women taking control of their lives? Or of conformity to cultural demands, for workers, mothers and wives to be even-tempered? Sarafem carries the risk of implicit coercion -- the existence of a treatment may pressure a woman to use it, say, to respond to demands that she be a more affable colleague.

The presentation of Sarafem seems an attempt to finesse these issues, as if it were simply a matter of self-soothing, like gazing at a crystal to induce

inner peace. Lilly's Web page for Sarafem features a strikingly yonic sunflower -- half blue and half yellow, to signify mood change -- and a copy line, ''More like the Woman you are.'' The implication is that the premenstrual self is inauthentic, that irritability is incompatible with the female gender. And that the truest state is the medicated one.

If marketing were everything, Sarafem might point to a retreat from feminism to bland femininity, signified by angels and flowers, not to mention the diminished libido that is a well-known side effect of Prozac. But as indicators of social trends, prescription drugs' messages may be less in the image-making than in the way we end up using the drugs themselves. Perhaps Prozac will seem too strong a remedy for any but the most extreme forms of PMS. And if it, or some future treatment, becomes widely accepted, it may have precisely the effect critics worry over, making even minor premenstrual irritability seem like an illness. All the same, Sarafem is a tool that gives women control over a distinctive aspect of their biology. Now that treatment for PMS has become a legitimate field for scientific inquiry, other drugs will almost certainly be developed, and someday medication to alter normal but undesirable traits may become unremarkable. It's not hard to imagine a manufacturer offering women similar benefits with a more direct appeal -- perhaps a PMS drug marketed in brassy colors with the slogan, ''Our Drugs, Your Selves.''

Photo (Superstock) Chart: ''A New Medication For . . . You Know'' ''What is Sarafem (fluoxetine hydrochloride)? New Sarafem is the first and only F.D.A.-approved prescription treatment for both the mood and physical symptoms of PMDD. Safe enough to take daily, many physicians believe that Sarafem helps to correct the imbalance of serotonin that could contribute to the cause of PMDD. And for many women, Sarafem can bring relief of their mood swings, irritability, bloating . . . by their next monthly period. . . . Talk to your doctor about your symptoms, when they occur, and their intensity to determine if you suffer from PMDD and if Sarafem can help.'' -- From Eli Lilly & Company's promotional materials for Sarafem