Tamoxifen first line treatment?

[Teatree76]

Hi there,

I am in my mid 40s and had gyno as a teenager that never corrected. I am 5'8" and weigh 170 lbs. Over the past year I've lost around two stone but my moobs are still there. Please see photos attached. So I was about to book a call with a surgeon when I came across a lot of studies on the use of Tamoxifen for gyno. It seems its used a lot with pubescent boys and body builders already but I wanted to know if it would work with me? It seems like Tamoxifen should be first line treatment - but this was REALLY not obvious to me. A lot of surgeon websites specifically down play the efficacy of medication but this is usually without reference to its very low cost and side effect profile (vs expensive and invasive surgery).

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

So, firstly is it possible to tell from the pictures if I have gyno or mostly pseudo gyno? If its gyno will Tamoxifen work on me? If its worth giviing it a go before surgery, why is this not mentioned more on forums like these?

[Michael Law, M.D.]

Pure glandular gynecomastia will in some cases respond to anti-estrogen medications.. Please note, however, that (1) not all patients respond to anti-estrogen drugs, (2) the most responders experience a partial reduction in gynecomastia, and (3) many patients experience re-growth of breast tissue when they stop their anti-estrogen drug.
 
Another extremely important consideration is that anti-estrogen drugs have significant potential side effects, which include: hot flashes, joint pain, leg cramps, hand and foot swelling, sweating and flu-like symptoms.
 
I have treated several patients who first tried anti-estrogen therapy. All of them experienced only a partial improvement in the size of the breast tissue mass (and only a partial improvement in pain and tenderness that some patients experience with gynecomastia), found that their breast tissue grew back to its larger size when they stopped the medication, and ended up undergoing surgical removal of breast tissue.

[Teatree76]

Dear Dr Law,

Thank you so much for responding with your insights. You are the first to have done so.

Along with your knowledge and experience with anti-estrogens I would just add that some of the scientific studies reported quite high remission and effect sizes. I think Tamoxifen is used widely by bodybuilders (needless to say I'm not one) and doctors in the male oncology setting. Tamoxifen also has a really mild and well characterised side effect profile - matching placebo in several studies. But the published studies all use small samples and the clinical ambiguity seems, in part, due to a lack of robust and corroborative studies (ie scientific consensus).

What seems clear to me though, and I'd hope you'd agree, is that a man with glandular gynecomastia should try anti-estrogen therapy as their first line therapy, where side effect profiles permit? It would be interesting to know with regard to the followings posts;

[Miguel Delgado MD]

Thank you for your question. It is a very important one. <a class="underlinelink" href="https://www.gynecomastia.org/doctors/michaellaw/profile"><a class="underlinelink" href="https://www.gynecomastia.org/doctors/michaellaw/profile">Dr. Law[/url][/url] has answered the question very well with experience with these patients as I.  However, I believe for the gynecomastia community we should give a more in-depth answer based on science but also experience.  I will research the topic and link it to a page with a thorough explanation.  I will also send out this question to <a class="underlinelink" href="https://www.gynecomastia.org/doctors/michaellaw/profile">Dr. Law[/url] and our other gynecomastia experts to ask about their experience. Thank you.

[Teatree76]

Thank you for the unexpected yet welcome intervention and escalation Dr Delgado. Primum non nocere.

[Dr. Elliot Jacobs]

It has been my experience that if Tamoxifen is to work at all, it has to be when gynecomastia is first starting.  If you are in your 40's and have had gyne since you were a teen, it is highly unlikely that you will have any significant reduction in your gyne.  Just my two cents.

Dr Jacobs

[Teatree76]

Thank you for your reply Dr Jacobs and for stating your experiences which resonate with those of Dr Law. With respect to the progress with my own course of Tamoxifen you may well be correct. But the side effects thus far are negligible and some clinical studies have found the drug very successful in long-standing gyno. 

Gyno experts both in the US and internationally advocate surgery only as a last resort yet it is notable that several of the experts on this forum, and indeed your industry body websites, are silent on this important protocol. One would think that few anywhere would recommend anything other than surgery once other tissue-sparing options have been exhausted. But are men today undergoing mastectomies on that basis? I do not know, but to address the wider issue Dr Delgado has undertaken to publish an updated view of gyno clinical guidelines.

[Dr. Cruise]

Tamoxifen is useful in a patient who has sudden onset steroid-induced gynecomastia that is painful to the touch. It is very reasonable to treat these patients with a short course of Tamoxifen assuming he has come off the steroids. However, as often stated, once gynecomastia is present for greater than 1-2 years it is very unlikely to go away. The problem with any oral medication is that it treats the entire body and not just the gyne. This systemic anti-estrogen effect is not desirable long term. For this reason, I no longer offer my patient's Tamoxifen for gyne greater than 1 year.

Because your gynecomastia has been present for so many years, treating the breast tissue with Tamoxifen is unlikely to resolve with satisfaction. 

[Miguel Delgado MD]

I have researched the topic of the benefits of Tamoxifen treatment for gynecomastia. I have added it as a page on the website for maximum exposure.  You can read the information here.

[Teatree76]

Dear Dr Delgado,

Thank you for posting your considered opinion on the role of Tamoxifen in treating gynecomastia on your website. It speaks volumes about your integrity as a man and professionalism as a key opinion leader. I hope that this is just the beginning of a more honest and open debate based on an objective and transparent assessment of the clinical data and free from personal interests.

Thanks again, truly,

Lany