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Purpose and principlesIndications, selection and cautionsAssessment before treatmentTreatment approachRegimens, contraindications and interactionsComplications, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Sexual dysfunction, prolactin and reproductive safety

Psychiatry · UK scope · Sources checked 7 Sept 2026 · Clinical review pending

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Do not miss urgent reproductive or endocrine problems

Severe sudden headache with visual loss, a prolonged painful erection, or pregnancy during valproate treatment requires prompt clinical action appropriate to the syndrome.

Action: Arrange emergency assessment for suspected pituitary apoplexy or priapism; for pregnancy on valproate obtain urgent specialist psychiatric or neurological and maternity advice without advising unsupervised abrupt withdrawal.

Purpose and principles

Assess sexual and prolactin-related adverse effects sensitively, investigate competing endocrine and vascular causes, and integrate fertility, contraception and pregnancy planning into safe long-term psychotropic treatment.

Sexual adverse effects often remain hidden because patients and clinicians each wait for the other to raise them. A neutral introduction helps: explain that mood, physical illness and medicines can affect sexual function, then ask which aspect has changed. Offer privacy, appropriate language and a choice about involving a partner. Do not assume sexual activity, fertility goals or relationship structure from age, marital status or diagnosis. The person's own distress and priorities determine whether an intervention is needed.

Antidepressants may affect desire, orgasm and genital sensation. Antipsychotics can impair sexual function through prolactin elevation, sedation, autonomic effects and metabolic disease. High prolactin suppresses reproductive hormonal signalling and can produce menstrual irregularity, anovulation, reduced testosterone, galactorrhoea or erectile difficulty. However, a normal prolactin does not exclude medicine-related sexual dysfunction, and a high result does not prove that all symptoms have the same cause.

Indications, selection and cautions

Prolactin-related symptoms

Amenorrhoea, irregular periods, galactorrhoea, reduced libido or erectile difficulty developing after a prolactin-raising antipsychotic deserves direct assessment.

Non-prolactin sexual dysfunction

Delayed orgasm or reduced genital sensation during SSRI treatment can occur with normal prolactin and may be more relevant than a mild laboratory change.

Vascular or metabolic contributors

Erectile difficulty may be an early sign of diabetes or cardiovascular disease and should not be automatically attributed to psychiatric treatment.

Changing reproductive circumstances

A new relationship, contraceptive change, missed period or desire for pregnancy can alter the risk-benefit balance of an otherwise stable prescription.

Red flags requiring action

  • A new severe headache, visual-field disturbance or ophthalmoplegia with endocrine symptoms needs urgent assessment for a structural pituitary emergency.
  • An erection lasting four hours or more requires urgent emergency care, including when it follows a psychotropic or erectile-dysfunction medicine.
  • Pregnancy or a wish to conceive during valproate use requires urgent specialist review of treatment and reproductive precautions.

Assessment before treatment

  1. 01
    Private sexual and medication historyFirst step
    Why
    Define the affected domain and identify timing, distress and possible contributors.
    Interpretation and limitations
    Distinguish desire, arousal and orgasm problems; compare with pretreatment function and include non-psychiatric medicines and substances.
  2. 02
    Prolactin with appropriate repeat testing
    Why
    Assess endocrine effects while avoiding overinterpretation of an isolated result.
    Interpretation and limitations
    Stress, recent exercise, pregnancy and macroprolactin can influence results; interpret using local assay ranges, symptoms and persistence rather than one universal referral threshold.
  3. 03
    Pregnancy, thyroid and renal assessment
    Why
    Identify important alternative causes of hyperprolactinaemia or menstrual change.
    Interpretation and limitations
    Offer a pregnancy test when relevant, check thyroid and renal function, and investigate additional hormonal abnormalities with endocrine advice.
  4. 04
    Cardiometabolic and selected sex-hormone evaluation
    Why
    Investigate erectile dysfunction or persistent hypogonadal symptoms beyond prolactin.
    Interpretation and limitations
    Assess blood pressure, glucose and vascular risk; appropriately timed hormone testing is guided by symptoms and followed by confirmation before diagnosing hypogonadism.

Treatment approach

01Sexual-health reviewClarify the problem and competing causesFirst stepThe person reports sexual difficulty or stops medication because of suspected sexual adverse effects.+
  1. 1Offer private, non-judgemental assessment of symptoms, onset, relationship impact and what improvement the person wants.
  2. 2Investigate relevant endocrine, vascular, metabolic and psychological contributors while reviewing the complete prescription.
  3. 3Agree treatment of identified causes and consider a planned psychotropic adjustment when the medicine contribution is substantial.
02Raised prolactinProtect endocrine and psychiatric healthProlactin is persistently raised or symptoms suggest clinically important hypogonadism.+
  1. 1Confirm the finding as appropriate and exclude pregnancy, thyroid or renal causes and laboratory macroprolactin effects.
  2. 2

Regimens, contraindications and interactions

A treatment option for erectile dysfunction after assessment of the cause and fitness for sexual activity.

Sildenafil for adult erectile dysfunction

Usually give 50 mg orally as needed about one hour before sexual activity; adjust to 25–100 mg according to efficacy and tolerability, no more than once daily.

Do not combine with nitrates, nitric oxide donors or riociguat; consider 25 mg with severe renal impairment or relevant CYP3A4 inhibitors, and assess hypotension and alpha-blocker use.

An option for persistent symptomatic antipsychotic-associated hyperprolactinaemia when changing the effective primary treatment is difficult.

Aripiprazole augmentation for raised prolactin

Specialist off-label augmentation commonly uses approximately 5 mg orally once daily; the exact dose and review interval should be set alongside the existing antipsychotic regimen.

This is off-label and creates combination antipsychotic exposure; assess akathisia, insomnia, impulse-control symptoms, interactions and whether benefit justifies continued augmentation.

Complications, monitoring and follow-up

  • Revisit sexual symptoms after a medicine change, documenting both function and psychiatric stability rather than relying only on the prolactin result.
  • Follow prolactin and hormonal abnormalities according to the confirmed cause and specialist plan, including bone-health assessment when prolonged hypogonadism is present.
  • For a person on a prolactin-raising antipsychotic who plans pregnancy, measure prolactin and discuss a prolactin-sparing option if it is raised.
  • Maintain annual specialist review and required risk documentation for valproate, reviewing contraception, understanding and changes in reproductive plans.
  • For male valproate use reinforce contraception and no sperm donation during treatment and for at least three months afterwards. MHRA advises condoms plus partner contraception, but condoms are unnecessary for pregnancy prevention if the partner uses a highly effective method or there is no pregnancy risk.
  • During pregnancy coordinate psychiatric and maternity care, including metabolic monitoring for antipsychotic exposure and planning for the increased postnatal relapse risk.

Special situations

Amenorrhoea is not contraception

Ovulation may occur despite irregular or absent periods, and fertility can recover after prolactin falls, so contraceptive planning must accompany successful treatment.

Normal prolactin does not exclude harm

Serotonergic, vascular, sedative and psychological mechanisms can impair sexual function without any prolactin elevation, requiring a broader assessment.

Paternal evidence remains observational

The valproate advice for men is precautionary; counselling should distinguish a possible association from proven causation while explaining the current recommended precautions.

Endocrine treatment may affect psychosis

Dopamine agonists can improve prolactin-related symptoms while worsening psychiatric illness, making joint endocrine and psychiatric oversight important.

Common pitfalls

  1. 01

    Waiting for patients to volunteer sexual symptoms despite a medicine with a well-recognised sexual adverse-effect profile.

  2. 02

    Assuming a raised prolactin result proves infertility or removes the need for contraception.

  3. 03

    Attributing headache and visual changes to antipsychotic adverse effects without considering pituitary disease.

  4. 04

    Stopping valproate abruptly after a positive pregnancy test without arranging urgent specialist treatment planning.

  5. 05

    Prescribing sildenafil without asking about nitrates, recreational nitrites, cardiovascular symptoms or alpha-blockers.

Practice

Two practice questions

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Question 1 of 2
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PsychiatryOriginal SBA

Fertility after prolactin review

A patient taking risperidone has amenorrhoea and raised prolactin. They do not want pregnancy and ask whether contraception is unnecessary. Which advice is most accurate?

Choose one answer, then submit
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Sources and review status7 sources · checked 7 Sept 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.

  • NICE CG192 perinatal mental-health recommendationsProlactin before conception and perinatal treatment planning.
  • MHRA valproate reproductive-risk guidancePregnancy Prevention Programme and initiation restrictions.
  • MHRA valproate advice for menContraception and sperm donation precautions.
  • Royal United Hospitals prolactin laboratory guidancePhysiological, medicine and macroprolactin explanations.
  • NHS GGC antipsychotic combination guidanceSpecialist low-dose aripiprazole for hyperprolactinaemia.
  • Sildenafil 50 mg tablets SmPCAdult dose, contraindications and interaction precautions.
  • Risperidone 0.5 mg tablets SmPCProlactin effects and associated symptoms.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·

Investigate proportionately. Clarify onset relative to treatment, whether symptoms occur in all contexts, and the presence of spontaneous erections, genital pain, menstrual change or galactorrhoea. Review diabetes, cardiovascular risk, alcohol, smoking, trauma, relationship difficulties and other medicines. For an unexpected modest prolactin elevation, repeat under suitable rested conditions according to the laboratory protocol and check for macroprolactin when the clinical picture is discordant. Marked, persistent or unexplained elevation and mass-effect symptoms need endocrine assessment.

Management can include treating a physical cause, adjusting an antidepressant or antipsychotic, choosing a lower-prolactin option, or using a specific sexual-health treatment. Any psychotropic switch should preserve a relapse plan. Specialist low-dose aripiprazole augmentation is sometimes used off-label for antipsychotic-associated hyperprolactinaemia; it adds another antipsychotic and requires a clear rationale and monitoring. Dopamine agonists can worsen psychosis, so endocrine treatment must be coordinated with psychiatry rather than started reflexively.

Reproductive safety extends beyond teratogenicity. Consider whether a medicine affects ovulation, sperm, contraception or future treatment stability. Carbamazepine can reduce the effectiveness of some hormonal contraceptives, while oestrogen-containing contraception can lower lamotrigine exposure and stopping it can raise exposure. Preconception counselling should include the whole regimen, the severity of prior illness, previous relapse after withdrawal and plans for pregnancy and the postnatal period. A person doing well on an antipsychotic may be advised to continue when relapse risk is substantial.

Valproate requires particularly explicit counselling. Maternal pregnancy exposure carries established substantial fetal risks; paternal advice is precautionary because observational data raise concern about neurodevelopmental outcomes without proving causation. Explain the distinction without weakening the current UK precautions. New initiation below age fifty-five requires two independent specialists to document that other effective or tolerated options are unavailable, or compelling reasons show reproductive risks do not apply. Continue the applicable specialist review and risk documentation for established treatment.

Key points

  • Ask privately about desire, arousal, erection, lubrication, orgasm, pain and the effect on relationships rather than using one general question about side effects.
  • Sexual dysfunction may arise from depression, psychosis, diabetes, vascular disease, hormonal disturbance, medicines or several factors together.
  • Dopamine-blocking antipsychotics can raise prolactin, producing menstrual disturbance, galactorrhoea, reduced libido and hypogonadism.
  • A raised prolactin result requires interpretation against symptoms, pregnancy, stress, thyroid and renal function, medicines and possible macroprolactin.
  • Hyperprolactinaemia can reduce fertility but does not provide reliable contraception; fertility may return after treatment changes.
  • Valproate is contraindicated for bipolar disorder in pregnancy and restricted in those able to become pregnant through the Pregnancy Prevention Programme.
  • For male valproate treatment, advise condoms plus partner contraception during treatment and for at least three months after stopping, with no sperm donation; condoms are unnecessary for pregnancy prevention if the partner already uses highly effective contraception or there is no pregnancy risk.
  • Discuss perinatal treatment before conception whenever possible, balancing medicine risks against relapse and untreated illness.
  • 05
    Endocrine referral and pituitary imaging
    Why
    Investigate persistent unexplained elevation or possible mass effect.
    Interpretation and limitations
    Headache, field defects, neurological change or other pituitary hormone deficits alter urgency; do not delay referral merely because a prolactin-raising medicine is present.
    • Discuss dose reduction or a lower-prolactin antipsychotic with the treating psychiatrist, considering relapse history and current stability.
  • 3Seek endocrine input for persistent, marked or symptomatic abnormalities and coordinate any hormone or dopamine-agonist treatment with psychiatry.
    • 03Conception planningReview treatment before pregnancyA patient or partner is planning conception, pregnancy is possible or contraceptive arrangements change.+
    1. 1Discuss the psychiatric indication, relapse risks, reproductive effects and interactions for every relevant medicine.
    2. 2For valproate apply current MHRA initiation and Pregnancy Prevention Programme requirements, and arrange specialist review before altering therapy.
    3. 3Record contraception advice, preconception and maternity referrals, and an urgent contact plan for suspected pregnancy or medication problems.
    Content changes
    Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom