Hyperprolactinaemia caused by antipsychotics

For advice on monitoring for and preventing antipsychotic adverse effects, see Overview of antipsychotic adverse effects. For children taking an antipsychotic, more frequent measurement of blood prolactin concentration (every 3 months for the first year) is required.

Many antipsychotics can cause dose-dependent hyperprolactinaemia—see Approximate relative frequency of common adverse effects of antipsychotics for approximate relative frequencies.

Hyperprolactinemia can cause infertility, sexual difficulties (eg decreased libido, impaired sexual arousal), gynaecomastia, galactorrhoea, menstrual disturbance, erectile dysfunction and pubertal delay. Chronic hyperprolactinaemia may reduce bone mineral density, which is particularly concerning in young people who have not reached their peak bone mass and people with osteoporosis.

It is unclear how best to balance the harms and benefits of antipsychotic therapy in a patient with asymptomatic hyperprolactinaemia, but adverse effects are likely to arise if the blood prolactin concentration remains high.

If other causes of hyperprolactinaemia (eg pregnancy) have been excluded, management options include:

reducing the dose of concurrent drugs that increase blood prolactin concentration (eg opioids, selective serotonin reuptake inhibitors [SSRIs], metoclopramide)
switching to an antipsychotic with a lower risk of hyperprolactinaemia
seeking psychiatric advice about adding aripiprazole to the existing antipsychotic, enabling dose reduction of the prolactin-inducing antipsychotic.

If hyperprolactinaemia does not resolve with the above actions, refer to an endocrinologist.