Sexual dysfunction, prolactin and reproductive safety — Rapid

Synopsis

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.

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.

Key red flags

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.

Investigation priorities

Private sexual and medication historyFirst step

Define the affected domain and identify timing, distress and possible contributors.

Management branches

Sexual-health reviewClarify the problem and competing causes

The person reports sexual difficulty or stops medication because of suspected sexual adverse effects.

Offer private, non-judgemental assessment of symptoms, onset, relationship impact and what improvement the person wants.
Investigate relevant endocrine, vascular, metabolic and psychological contributors while reviewing the complete prescription.
Agree treatment of identified causes and consider a planned psychotropic adjustment when the medicine contribution is substantial.

Key medicines

Sildenafil for adult erectile dysfunctionUsually 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.

Aripiprazole augmentation for raised prolactinSpecialist 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.

Open full textbook →Answer 2 questions