Hyperprolactinaemia is a common adverse effect of antipsychotic medication, primarily resulting from dopamine D2 receptor blockade. It is characterised by menstrual irregularities, gynaecomastia, galactorrhoea and, with prolonged exposure, an increased risk of osteoporosis and breast cancer. When switching towards a prolactin-sparing antipsychotic is not feasible, adjunctive use of aripiprazole - a dopamine D2 partial agonist - has emerged as a validated strategy to mitigate hyperprolactinaemia without compromising antipsychotic efficacy. However, alternative options are needed for patients who cannot tolerate aripiprazole. Here we report the use of brexpiprazole, a dopamine D2 partial agonist structurally related to aripiprazole, to counteract paliperidone-induced hyperprolactinaemia effectively in a patient who developed a cutaneous reaction to aripiprazole. During the follow-up period with adjunctive brexpiprazole in combination with paliperidone, neither a recurrence of psychotic symptoms nor a reappearance of the skin reaction previously experienced with aripiprazole was observed.

Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk. Aripiprazole can lower serum prolactin in a dose-related manner, and cases of poor milk supply and lactation cessation have been reported. Weight loss and poor weight gain have been reported in breastfed infants whose mothers were taking aripiprazole. Monitor the breastfed infant for dehydration and lack of appropriate weight gain. Cases of gynecomastia and galactorrhea have also been reported. Until more data become available, an alternate drug may be preferred, especially while nursing a newborn or preterm infant.[1]

Prolactinomas as the most common type of functional pituitary adenoma and most will respond to dopamine agonist (DA) therapy with normalization of prolactin levels, restoration of gonadal function and/or reduction in tumor volume. A minority of prolactinomas are refractory to conventional doses of DA and present a clinical challenge. Characteristics associated with DA resistance include male sex, certain radiologic features (large size, cavernous sinus invasion, other characteristics), histopathologic evidence of high cell proliferation, and in a small number of cases, inherited pathologic germline variants of genes associated with pituitary tumors, such as MEN1 and AIP. Clinical management often requires a multimodal approach including titration of DA to higher than usual doses, surgical resection or debulking, and targeted radiotherapy. Robust evidence is lacking for non-approved adjunct therapies, such as aromatase inhibitors and estrogen receptor modulators, although the somatostatin receptor ligand pasireotide may have potential in select patients.

Premature ovarian insufficiency (POI) in a young unmarried woman was detected in association with hypothyroidism, chromosome 9 (Inv 9, p12q13) inversion, and cavernous angioma. A 27-year-old unmarried female presented with complaints of infrequent cycles only after undergoing withdrawal treatment for menstruation for the past 11 years. She was diagnosed with hypothyroidism and was subsequently prescribed thyroid replacement therapy. On examination, bilateral galactorrhoea was identified. Oestradiol and anti-Mullerian hormone values were low, whereas her follicle-stimulating hormone value was elevated. Her brain magnetic resonance imaging revealed a solitary cavernous angioma, and her karyotype indicated 46 XX and Inv(9) p12q13. POI in a young woman is a devastating condition affecting both physical and emotional well-being. Chromosomal aberrations should be ruled out in such cases. Life-long oestrogen replacement therapy and alternate options for infertility issues such as ovum donation or adoption can be considered.

Metoclopramide is a prokinetic and antiemetic agent widely used in primary care. Its mechanism of action explains both its therapeutic effects, as well as certain adverse reactions, including hyperprolactinemia and galactorrhea. Metoclopramide-induced galactorrhea may prompt concern and lead to unnecessary diagnostic testing. This case report is about a healthy 21-year-old woman taking a combined oral contraceptive who was prescribed metoclopramide for gastroenteritis with vomiting. Forty-eight hours after starting treatment, she developed spontaneous, bilateral, multiductal, painless galactorrhea without menstrual changes, headaches, neurological symptoms, or signs of pregnancy. Physical examination confirmed bilateral milk secretion without inflammatory signs or palpable masses, and the neurological exam was normal. Given the clear temporal relationship and absence of alternative causes, metoclopramide was discontinued. At follow-up, complete resolution of symptoms occurred, supporting the diagnosis of drug-induced galactorrhea. This case underscores an adverse reaction associated with a commonly used medication in Family Medicine. Clinicians should remain vigilant for the early identification of potential adverse drug reactions and avoid unnecessary diagnostic testing while maintaining a person-centered approach in routine Family Medicine practice.