A 36-year-old woman with two children visited a psychiatric outpatient clinic on an ambulatory basis. She had no history of endocrine or reproductive pathology or psychiatric problems. Although she had been receiving a conservative treatment for iron deficiency anemia and transient hematuria, there was no specific hematologic and nephrologic finding and she had not taken any dopamine antagonistic agents including gastrointestinal motility drugs and antipsychotic agents except ferrous sulfate. Her son had been diagnosed with pervasive development disorder and mental retardation. She had suffered symptoms of depressed mood, nihilistic ideation, decreased volition, decreased psychomotor activity, loss of appetite, and sleep disturbance, which occurred after her son's diagnosis 2 years ago. Diagnostic tests were performed to ascertain whether she had neurologic or any other systemic organic disease that could explain her symptoms. Following a detailed psychiatric examination with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), escitalopram 10 mg per day was prescribed to the patient with the diagnosis of major depressive disorder. She scored 26 on the Hamilton rating scale for depression (HRSD), and 25 on the Beck depression inventory (BDI)., After 2 weeks of medication, her complaints declined, her HRSD score was 18 and her BDI score further decreased to 20. However, she developed galactorrhea with breast pain (the nonpuerperal discharge of milk-containing fluid from the breast). She had no history of galactorrhea. She first noticed the discharge on treatment day 14 and described it as white-creamy and from both nipples. She did not notice any bloody, greenish, or foul-smelling discharge nor report sexual dysfunction. She consulted her gynecologist, who recommended mammography and breast ultrasonography. The results of these tests were normal. However, serum prolactin level on treatment day 14 was 200 ng/mL (reference range: 1.2-24.2 ng/mL). There were no abnormalities in blood chemistry, thyroid function tests, or electrocardiogram. She was recommended to undergo magnetic resonance imaging (MRI) of the hypothalamic/pituitary area to exclude mass lesions. However, she refused the test, which was not done. Because her galactorrhea developed after initiations of her medication with escitalopram, we stopped her medication. After cessation of the medication, the discharge abated and breast pain was relieved. Her serum prolactin level decreased to 2.38 ng/mL five days after discontinuing escitalopram.
A 31-year-old unmarried woman, without significant family/personal history or medical comorbidity, presented with complaints of fear from dirt, excessive checking and washing behaviors and repeated intrusive thoughts, gradually deteriorating for 2 years. She acknowledged the thoughts to be her own, and that they were unnecessary and baseless; but also expressed her inability to resist them at all. The thoughts did cause her severe anxiety. Because of an increase in severity, she had discontinued her job for last 3 months and was having difficulty in sleeping at night. At presentation, she was restlessness with psychomotor agitation, and had anxious, irritable affect. Enquiries regarding thought possession revealed severe obsessions and compulsion. She was diagnosed as obsessive-compulsive disorder according to ICD 10. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 30 which showed ‘extreme’ symptoms severity. Her physical examination and laboratory tests including blood biochemistry, electrocardiogram, and radiological examinations were within normal limits. Her treatment was started with FXT (20 mg/day) according to available treatment guidelines, and it was decided to keep a watch for further deterioration of anxiety symptoms due to activating side-effects of FXT. The treating team decided to use short-term clonazepam cover for anxiety symptoms, but the patient did not require this rescue regimen. After two weeks of initiation, FXT was hiked to 40 mg/day. After 3 weeks of increasing FXT to 40 mg/day, there was significant improvement in Y-BOCS score (Y-BOCS=19), and she was advised to continue the drug at this dose. We used an immediate-release formulation of FXT in our patient.\nAfter 8 months, the patient came with 3-months’ amenorrhea and 15-days’ history of milky, non-hemorrhagic bilateral breast discharge on 40 mg/day FXT. The discharge had begun after 7 and a half month of hiking FXT to 40 mg/day, and was first noted by the patient who brought this to clinician’s notice. Her serum prolactin level was investigated for and found to be 122 ng/ml. Her physical manifestations were highly suggestive of hyperprolactinemia associated with amenorrhea and GLH. Her urea, creatinine, thyroid-stimulating hormone, free-T4 and beta human chorionic gonadotropin were all normal; and thus we excluded underlying kidney disease, hypothyroidism or pregnancy as possible causes of GLH.\nTreatment was first modified by discontinuing FXT over one week and adding clonazapam 0.5 mg/day to decrease anxiety. Sertraline was started after allowing for 7 days’ washout time after last dose of FXT, and slowly built up-to 200 mg/day over next 2 weeks. Two months after initiation of Sertraline, and one and a half month after a dose of sertraline 200 mg/day was reached, her serum prolactin level normalized (12 ng/ml) and menstrual abnormalities were resolved. Over next 10 months, the patient remained on same therapeutic regimen and continued to be mentally stable with regular menstrual cycles and no GLH.