Serum prolactin levels following intramuscular chlorpromazine: two- and three-hour response as predictors of six-hour response

Psychotropics and Male Reproduction

Psychotropic drugs, including antidepressants, antipsychotics, and anticonvulsants, all have negative effects on sexual function and semen quality. These adverse events vary among men and are less pronounced for some medications, allowing their effects to be managed to some extent. Use of specific serotonin reuptake inhibitors (SSRIs) is prevalent in men of reproductive age; and application to treat premature ejaculation increases the number of young men on SSRI therapy. Oxidative damage to sperm can result from prolonged residence in the male reproductive tract. The increase in ejaculatory latency seen with SSRIs likely underlies some of their negative effects on semen quality, including higher sperm DNA fragmentation, seen in all SSRIs evaluated thus far. These medications increase prolactin (PRL) levels in some men, and this is often credited with inhibitory effects on male reproduction; however, testosterone levels are generally normal, reducing the likelihood of direct HPG axis inhibition by PRL. The tricyclic antidepressants have also been shown to increase PRL levels in some studies but not in others. The exception is the tricyclic antidepressant clomipramine, which profoundly increases PRL levels and may depress semen quality. Other antidepressants modulating synaptic levels of serotonin, norepinephrine, and/or dopamine may have toxicity similar to SSRIs, but most have not been evaluated. In limited studies, norepinephrine-dopamine reuptake inhibitors (NDRIs) and serotonin agonist/reuptake inhibitors (SARIs) have had minimal effects on PRL levels and on sexual side effects. Antipsychotic medications increase PRL, decrease testosterone, and increase sexual side effects, including ejaculatory dysfunction. The greatest evidence is for chlorpromazine, haloperidol, reserpine, risperidone, and thioridazine, with less effects seen with aripiprazole and clozapine. Remarkably few studies have looked at antipsychotic effects on semen quality, and this is an important knowledge gap in reproductive pharmacology. Lithium increases PRL and LH levels and decreases testosterone although this is informed by few studies. The anticonvulsants, many used for other indications, generally decrease free or bioavailable testosterone with variable effects on the other reproductive hormones. Valproate, carbamazepine, oxcarbazepine, and levetiracetam decrease semen quality; other anticonvulsants have not been investigated for this adverse reaction. Studies are required evaluating endpoints of pregnancy and offspring health for psychotropic medications.

Hyperprolactinemia associated with psychotropics--a review

INTRODUCTION

Different classes of psychotropics can cause hyperprolactinemia to varying degrees. Among antipsychotics, typical agents and risperidone are the most frequent and significant offenders. In this review we discuss the pathophysiology, offending medications, assessment and management of hyperprolactinemia.

METHODS

We did a literature review between 1976 and 2008 using PubMed, MEDLINE, PsychINFO and Cochrane database. Search terms used were prolactin, hyperprolactinemia, psychotropics, antipsychotics, typical antipsychotics, atypical antipsychotics, antidepressants and SSRIs.

RESULTS

Prolactin elevation is more common with antipsychotics than with other classes of drugs. Typical antipsychotics are more prone to cause hyperprolactinemia than atypical agents. Management options include discontinuation of offending medication, switching to another psychotropic, supplementing concurrent hormonal deficiencies and adding a dopamine agonist or aripiprazole.

CONCLUSION

Clinicians need to be alert about the potential for hyperprolactinemia and its manifestations with these medications. Prolactin levels need to be monitored and other causes of hyperprolactinemia ruled out in suspected cases.

Prolactin responses to haloperidol in normal young women

The prolactin (PRL) responses to intramuscular haloperidol (HPD) (0.5, 1.0, and 1.5 mg) were evaluated in six normal premenopausal women during the follicular and luteal phases of their menstrual cycles. These were compared to the PRL responses to these doses of HPD in normal young men. PRL responses to HPD did not differ between the follicular and luteal phases. The mean log-transformed PRL response to the lowest HPD dose (0.5 mg) in women was less than that in the men, but the women had greater PRL responses than the men to the higher haloperidol doses (1.0 mg and 1.5 mg).

Lack of tolerance to long-term neuroleptic treatment in dopamine tuberoinfundibular system

The plasma prolactin (PRL) levels of 35 chronic schizophrenic patients undergoing long-term maintenance treatment with neuroleptic drugs were measured before and after either neuroleptic withdrawal or a switch to a fixed dose of chlorpromazine 900 mg/day. In both men and women there tended to be a significant correlation between the initial log plasma PRL level while on neuroleptic maintenance treatment and the dosage received converted to chlorpromazine equivalents. Neuroleptic withdrawal in ech of 19 cases was followed by a decline in PRL plasma levels. Switching to chlorpromazine 900 mg/day (16 cases) produced either increases or decreases in PRL plasma levels that were significantly correlated with the change in neuroleptic dosage converted to chlorpromazine equivalents. Thus there was no evidence of tolerance to the PRL-elevating effect of neuroleptics in these patients who had been treated for many years with neuroleptics.

Effect of intramuscular chlorpromazine on serum prolactin levels in schizophrenic patients and normal controls

Serum prolactin levels were monitored for 2 hours after injection of chlorpromazine (CPZ) 50 mg intramuscularly (i.m.) in 6 male normal controls and 14 newly admitted male chronic schizophrenics. The increase in serum prolactin levels in the male normal controls was not significantly different from that in patients. Serum prolactin levels were compared in 18 male and 22 female psychotic patients of various psychiatric diagnoses who received 50 mg of CPZ i.m., and 7 male and 6 female patients who received 25 mg CPZ i.m. No significant sex or dose differences were seen in the magnitude of the prolactin response after i.m. CPZ. These results suggest that doses of CPZ 25 or 50 mg i.m. may result in maximal prolactin secretion in most subjects and that lower doses are needed to test the hypothesis that dopamine receptors are supersensitive in schizophrenia or the affective psychoses. In six patients with mixed diagnoses, serum levels of CPZ and other active metabolites were determined by radioreceptor binding assay; peak serum drug levels were highly correlated with peak serum prolactin levels (4 = 0.92) during the first 2 hours following CPZ 50 mg i.m.