You offered Tamoxifen first?

[Teatree76]

Tamoxifen (aka Novaldex) has been shown in many scientific studies to work well with gyno with very few side effects. It is recommended as first treatment for men with gyno (albeit off label). Did your doctor and/or surgeon offer this before your surgery?

[FredL]

Your post is the first I ever heard of it. You mean I didn't need to get surgery? I could have just taken a drug and my boobs would have gone away? I'm skeptical. 

I'm thrilled to have had my boobs reduced but I feel that my PS could have been more aggressive with the lypo.  I wonder if this drug could take the place of a revision procedure, which I am considering once I'll all healed. 

Post about it in the Dr section, I'm curious to read what they think. 

[Teatree76]

Thanks for the reply. This is just the sort of thing I am exploring. Tamoxifen is a generic drug so widely available and very cheap at <$1 per tablet. The side effect profile seems very benign. There seems some ambiguity to whether it only works with pubescent boys/body builders - where the breast tissue has yet to settle - but it appears to work well with both as well as with adult idiopathic (unexplained) gyno with 80-90% efficacy! But I am no doctor. So there is a compelling reason to try Tamoxifen before surgery as the medication costs $100 for a three month course and is non-invasive. 

Patient education: Gynecomastia (breast enlargement in men) (Beyond the Basics) - UpToDate

Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study - PubMed (nih.gov)

Thanks for the tip re the Dr section - I do worry that there is too strong an incentive for doctors to perform $5,000-10,000 surgeries to get them to recommend a course of medication.

[FredL]

I am in my mid 40s and had gyno as a teenager that never corrected....

(I pulled this from your post in the Dr section)

According to the site linked in this thread, surgery is the option for you.

Tell your Dr or PS that you've had breasts since puberty and they'd be in error to recommend this drug.

Although tamoxifen and raloxifene are effective for men and boys who have had enlarged breasts for a few months, the drug is not effective in men whose breast tissue is not tender or who have had the condition for more than one year. For these men, surgery is an option to reduce the size of the breasts

[Teatree76]

Thanks so much FredL. In addition to your quotation I would highlight another,

"Adult men — Treatment is not usually recommended in adult men whose gynecomastia is likely to be caused by an underlying health problem or by drugs. In these men, treating the underlying condition or stopping the problematic drug usually allows the gynecomastia to resolve. For men with idiopathic gynecomastia that causes discomfort and lasts more than three months, a short course (three to six months) of tamoxifen or raloxifene may be recommended." Patient education: Gynecomastia (breast enlargement in men) (Beyond the Basics) - UpToDate

On the same 'Ask a Doctor' forum you will see I have started a course of Tamoxifen treatment and await a comprehensive answer to this issue from Dr Delgado.

[Teatree76]

Gynaecomastia--pathophysiology, diagnosis and treatment Gynaecomastia (enlargement of the male breast tissue) is a common finding in the general population. Most cases of gynaecomastia are benign and of cosmetic, rather than clinical, importance. However, the condition might cause local pain and tenderness, could occasionally be the result of a serious underlying illness or a medication, or be inherited. Breast cancer in men is much less common than benign gynaecomastia, and the two conditions can usually be distinguished by a careful physical examination. Estrogens are known to stimulate the growth of breast tissue, whereas androgens inhibit it; most cases of gynaecomastia result from deficient androgen action or excessive estrogen action in the breast tissue. In some cases, such as pubertal gynaecomastia, the breast enlargement resolves spontaneously. In other situations, more active treatment might be required to correct an underlying condition (such as hyperthyroidism or a benign Leydig cell tumour of the testis) or medications that could cause breast enlargement (such as spironolactone) might need to be discontinued. For men with hypogonadism, administration of androgens might be helpful, as might antiestrogen therapy in men with endogenous overproduction of estrogens. Surgery to remove the enlarged breast tissue might be necessary when gynaecomastia does not resolve spontaneously or with medical therapy.
Harmeet S Narula ¹, Harold E Carlson ²
PMID: 25112235 DOI: 10.1038/nrendo.2014.139 

[FredL]

I await what Dr Delgado has to say, as well. But I'm not hopeful. I, like you, developed breasts at puberty and they didn't go away. My boobs hung around for 45 years and my condition is/was not idiopathic and were never tender, so this drug would not work for me, according to the data.

Are you self-medicating with a controlled cancer drug? I thought you needed be under a Dr's supervision to take that kind of stuff.

[Teatree76]

Health information you can trust

The 'Patient' website empowers everyone to take charge of their health. Our trusted clinical information, written and reviewed by an extensive network of doctors and healthcare professionals, helps people to feel better and live longer.- About Patient.info | Our History and Clinical Expertise | Patient

• "Of the medical treatments used, tamoxifen is the most effective, particularly for pain in acute gynaecomastia. It is effective because of its anti-oestrogen effect. It may be used if physiological or medication-induced gynaecomastia is painful.^[1] Other medications which have been used, with limited evidence of benefit, are danazol, raloxifene and clomifene.
• If no underlying cause is discovered or gynaecomastia is long-standing with development of fibrosis then surgical removal of breast tissue is the only effective therapy. Surgery involves subcutaneous mastectomy or liposuction associated mastectomy.^[9]However, surgery can be associated with nipple inversion, nipple necrosis, painful scar tissue and possible sensory changes. It is considered an option only where medical treatment has failed or side-effects are unacceptable, there is malignancy, or if gynaecomastia is long-standing and symptoms are severe."

Gynaecomastia
Authored by Dr Mary Harding, Reviewed by Dr Adrian Bonsall | Last edited 20 Oct 2014 |

This article is for Medical Professionals. Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Male Breast Reduction for Gynaecomastia article more useful, or one of our other health articles. Gynaecomastia. Information about Gynaecomastia | Patient

Our editorial policy and practice
We provide trusted, accurate and up-to-date health information to the public and healthcare professionals around the world.
All the health information, professional reference articles, medicine leaflets and clinical tools on Patient.info are kept free from commercial interests and pressures.
Our information reflects reliable research evidence, recognised UK and European medical guidelines and best clinical practice. Our editorial uses UK spelling and terminology.

Clinical information
Our health information leaflets are written in clear, easy-to-understand language for the general public and patients. They’re formatted to make it simple for healthcare professionals to print and translate for patients during consultations. This information is authored and peer reviewed by our team of doctors, covering a comprehensive range of medical conditions which is being frequently expanded. Multimedia (video and audio) content produced by patient.info follows similar procedures. A live peer review takes place during recording and a second review of the content is conducted at the final edit stage to ensure accuracy.

[Teatree76]

"Surgery is only the last resort"

American Society of Andrology and European Academy of Andrology have released guidelines on gynecomastia evaluation and management. The guidelines have been published in the Journal Andrology,

"Surgical treatment

• Recommendation 15. We suggest surgical treatment only for patients with long‐lasting GM, which does not regress spontaneously or following medical therapy. The extent and type of surgery depend on the size of breast enlargement, and the amount of adipose tissue".

New guideline recommendations for addressing gynecomastia (esanum.com)

Gynecomastia evaluation and management- EAA clinical practice guidelines (medicaldialogues.in)

[Teatree76]

Tamoxifen in men: a review of adverse events

“Few adverse events have been documented in men receiving tamoxifen for infertility and idiopathic gynecomastia. Less than 5% of men withdrew from tamoxifen therapy because of toxicity. This suggests that for most men, tamoxifen is well-tolerated. Of those who discontinued tamoxifen, the majority were male breast cancer patients, and cardiovascular events were the most common reason for stopping tamoxifen treatment. Unfortunately, in many cases, the reasons for withdrawing tamoxifen were unspecified. Based on the available evidence, tamoxifen's AE profile appears to vary depending upon which male population is treated. Also, the frequency at which AEs occur varies - less AEs in men with infertility and idiopathic gynecomastia compared to men with prostate cancer or breast cancer.”

© 2016 American Society of Andrology and European Academy of Andrology.

https://pubmed.ncbi.nlm.nih.gov/27152880/

[Teatree76]

This is what T-nation, the self-professed “world’s largest hardcore training site” for more advanced fitness enthusiasts and with 1.4m Facebook followers, advises its readers,

"ANTI-ESTROGENS (CLOMIPHENE, TAMOXIFEN)
The use of 100 mg. a day of clomiphene has had a 64% response rate, whereas tamoxifen has had, depending on which study you believe, either a 78% success rate or a 90% success rate. There’s always a chance of reoccurrence when choosing these drugs as a treatment, but the risk of side effects is low.

SURGICAL TREATMENT OF GYNO
Surgeons have been tackling gynecomastia for a long time. We can trace the first description of surgical intervention to Paulus Aegineta back in 1538. Back then, it was likely the only treatment. Today, it’s the final option.

It’s usually reserved for patients with long-standing gyno who are experiencing psychological stress because of the social stigma involved.Surgery isn’t recommended for gyno-plagued adolescents, though, as there’s always the risk that the tissue could grow back. Surgeons usually recommend waiting until the patient’s testes have reached adult size before agreeing to the surgical option. I actually was allowed to witness one of these surgeries. What the doctor does is in effect a sub-Q mastectomy where they remove all the breast tissue through an incision while of course sparing the skin, areola, and nipple.Any fibrotic tissue is, of course, removed too. (In the surgery I witnessed, removing this tissue reminded me of the rubbery, elastic gristle you sometimes pull out of a bad cut of steak with your teeth.)

Afterwards, the surgeon performs liposuction to remove any residual fatty tissue to ensure a smooth contour. While this surgery is minimally invasive and there are usually few complications, they do occur. Problems like irregularity in the contour of the pec, hematomas, lasting numbness in the nipple and areolar areas, asymmetry between the two pecs, and even nipple necrosis or flattening are possible.

It should also be stated that up to 50% of the patients find the results cosmetically unsatisfactory, which points to the necessity of finding a surgeon who’s had plenty of experience with this type of surgery."

Gyno: Everything You Need to Know | T NATION (t-nation.com)

[Teatree76]

A wonderful review and excerpts below from Ronald S Swerdloff, MD, MACP, Distinguished Professor of Medicine, UCLA; Chief, Division of Endocrinology, Harbor-UCLA Medical that is just two years old. I have included their summary of gyno with prostate cancer for completeness.  

"Investigators have reported a 64 percent response rate with 100 mg/day of clomiphene citrate, a weak estrogen and moderate anti-estrogen (68). Lower doses of clomiphene have shown varied results, indicating that higher doses may need to be administered, if clomiphene is to be attempted. Tamoxifen, also an anti-estrogen, has been studied in 2 randomized, double-blind studies in which a statistically significant regression in breast size was achieved, although complete regression was not documented (69). One study compared tamoxifen with danazol in the treatment of gynecomastia. Although patients taking tamoxifen had a greater response with complete resolution in 78 percent of patients treated with tamoxifen, as compared to only a 40 percent response in the danazol-treated group, the relapse rate was higher for the tamoxifen group (70). Another prospective cohort study found that 90% of patients taking tamoxifen had successful resolution of their symptoms (89). Although there is a chance of recurrence with cessation of therapy, tamoxifen, due to relatively lower side effect profile and high efficacy, may be a more reasonable choice when compared to the other therapies. If used, tamoxifen should be given at a dose of 10 mg twice or 20 mg daily a day for 3-6 months (24). Responders usually improve with reduced pain within 1 month. Another anti-estrogen, raloxifene, has also been used in the treatment of pubertal gynecomastia but its efficacy needs to be evaluated in randomized prospective studies (71).

Surgical Treatment
When medical therapy is ineffective, particularly in cases of longstanding gynecomastia, or when the gynecomastia interferes with the patient's activities of daily living, or when there is suspicion of malignancy of breast, then surgical therapy is appropriate. On the other hand, surgical treatment should be postponed in pubertal gynecomastia, preferably until after completion of puberty, so as to minimize the chance of recurrent gynecomastia after surgery (62). Surgery should also be deferred until the underlying cause of gynecomastia has resolved or been treated. Surgical treatment includes removal of glandular tissue coupled with liposuction, if needed, preferably with individualized approach (78, 79). Nowadays, minimally invasive surgery is available and it may be associated with few complications and prompt recovery (80). Of note if malignancy is suspected, histological examination is mandatory (56). Uses of delicate cosmetic surgical techniques are warranted to prevent unsightly scarring.

PREVENTION OF GYNECOMASTIA IN MEN WITH PROSTATE CANCER
Because androgen deprivation is one of the commonly used treatment modalities for advanced prostate cancer, its possible role in the development of gynecomastia is of particular concern to clinicians. Up to 80% of patients receiving non-steroidal anti-androgen therapy may develop gynecomastia, usually 6-9 months after hormonal treatment. Some patients may have painful and disfiguring gynecomastia (81). Several preventive strategies have been proposed: Tamoxifen has demonstrated its efficacy versus radiotherapy in preventing gynecomastia in patients receiving bicalutamide (Casodex) for prostate cancer in a randomized controlled trial (82). Boccardo et al showed 10% patients in the tamoxifen group (20 mg daily dose) developed gynecomastia, whereas 51% in the anastrozole group and 73% in placebo group had gynecomastia over a period of 48 weeks (74). Fradet et al showed tamoxifen reduced the incidence of gynecomastia in patients with prostate cancer receiving bicalutamide in dose dependent manner (83). Likewise, it has been shown that low dose tamoxifen (20 mg/week) is inferior to the daily regimen (20mg/day) in terms of the prevention and treatment of gynecomastia (84). Current data suggests tamoxifen 10-20mg per day is the optimum dose required for prophylaxis of gynecomastia in patients with prostate cancer receiving androgen deprivation therapy (84, 83, 85)."

Swerdloff RS, Ng CM. Gynecomastia: Etiology, Diagnosis, and Treatment. [Updated 2019 Jul 7]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279105/

[Teatree76]

Professor Swerdloff's erudite exposition above is a hard act to follow. But I'm tempted to try with a recent discovery and quick favourite. 

Before I began my course of Tamoxifen I did a lot of research into it. Dr Viviane Quirke's delightful history of the drug is a treasure that had me hooked after five sentences. I hope you'll like it too.

"Although designed to act as an anti-estrogen, the compound was found to stimulate, rather than suppress ovulation in women. This, and the fact that at first it could not be patented in the USA, its largest potential market, meant that ICI nearly stopped the project. If it was saved, it was partly because the team’s leader, Arthur Walpole, threatened to resign, and pressed on with another project: to develop tamoxifen as a treatment for breast cancer."

.And concludes,

"This (paper's) particular focus also throws into sharp relief the contribution made by applied research to the advancement of scientific knowledge: in the case of tamoxifen, more specifically to the understanding of basic physiological processes involved in human reproduction and malignant disease. Such a contribution is in part due to the fact that industry, perhaps more easily than academia with its rigid disciplinary boundaries, enables a to-ing and fro-ing between separate, yet contiguous research projects and therapeutic areas (in this instance, between contraception, fertility, and cancer). This to-ing and fro-ing between projects illustrates once again the non-linear nature of pharmaceutical innovation. Typified by blind alleys, fresh departures, feedback loops between the laboratory and the clinic, as well as serendipitous discoveries, the early history of tamoxifen brings to the fore the role of human agency, the institutional memory that is often associated with long-term investment in particular areas of expertise, and is embodied in individual researchers like Walpole".


Quirke VM (2017) Tamoxifen from Failed Contraceptive Pill to Best-Selling Breast Cancer Medicine: A Case-Study in Pharmaceutical Innovation. Front. Pharmacol. 8:620. doi: 10.3389/fphar.2017.00620