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Antipsychotic-induced hyperprolactinaemia — DFSRH MCQ

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EasyAntipsychoticsAntipsychotic-induced hyperprolactinaemiaDFSRH

A 30-year-old woman with schizophrenia is stable on amisulpride. She has had amenorrhoea and galactorrhoea for 14 months, with repeatedly elevated serum prolactin and no alternative endocrine cause. Her psychiatrist plans to switch her to aripiprazole because of the hyperprolactinaemia. She has capacity, does not wish to become pregnant and expects to resume vaginal intercourse soon. She has had no intercourse for 5 weeks, and a high-sensitivity urine pregnancy test today is negative. She asks whether she can wait for her periods to return before starting contraception. Which is the most appropriate advice?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Start a chosen medically eligible contraceptive method now, explaining that ovulation may resume before the first bleed

Amisulpride-associated hyperprolactinaemia has probably suppressed hypothalamic–pituitary–ovarian function, accounting for her amenorrhoea and reduced fertility. This is not reliable contraception. Switching to the prolactin-sparing antipsychotic aripiprazole may reduce prolactin and restore ovulation; because ovulation precedes menstruation, pregnancy can occur before the first apparent period. Pregnancy can be reasonably excluded because she has had no intercourse for more than 21 days and has a negative high-sensitivity pregnancy test. A medically eligible method can therefore be started now, with the usual method-specific advice regarding additional precautions. A and B expose her to pregnancy while awaiting clinical or biochemical evidence that fertility has already returned; condoms could be chosen as contraception, but their use does not justify delaying a preferred effective method. C inappropriately delays a psychiatrist-led change intended to treat an adverse effect; contraception does not need to be established for a complete cycle before switching. E confuses fertility investigation with pregnancy prevention. Progesterone testing is unnecessary and could identify ovulation only after a period of pregnancy risk. The key counselling point is that amenorrhoea caused by a prolactin-raising antipsychotic should not be regarded as contraceptive, particularly when treatment is changed to a prolactin-sparing agent.

Reference: Antenatal and postnatal mental health: clinical management and service guidance — recommendation 1.4.22 (December 2014) — https://www.nice.org.uk/guidance/cg192/chapter/recommendations Fertility problems: assessment and treatment — ovulatory disorders due to hyperprolactinaemia (31 March 2026) — https://www.nice.org.uk/guidance/ng257/chapter/Management-of-female-factor-fertility-problems Antipsychotics in pregnancy and breastfeeding (November 2018) — https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/antipsychotics-in-pregnancy