Persistent Gynecomastia. E2 in Check. Why Not Stay on Tamoxifen?

Pharma / TRT Testosterone Replacement
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I’m a mid-40s male having a problem with persistent gynecomastia on my left side. I have been on HRT since 2003, closely monitored by doctor and lab work. I use a T cream with a small amount of pregnenolone and DHEA in it. In 2009 I developed very minor gyno on the right side when I started hCG at 1000 IU per dose (too much), but then doc and I dropped hCG down to 230 IU EOD, added .25 mg anastrozole every day, and everything was fine. (I was reading KSMan and others at the time and truly benefited from your advice. Thank you!). I was also prescribed oxandrolone (Anavar) for a serious degenerative neurological condition. When insurance stopped paying for oxandrolone in 2017, we discontinued it and upped my T dose in hopes of preserving my muscle mass. I can’t just stop T, or I will waste away.

Toward the end of 2019, I developed a painful gynecomastia lump under my left nipple / areola. The nipple was hard and sensitive, the areola was rubbery feeling, there was redness around the areola, and the skin in the area was a little dry and itchy. My doctor prescribed 40 mg Tamoxifen, we reduced my T cream and hCG and bumped up the anastrozole. The lump went away for a while but then came back upon stopping Tamoxifen. My doctor and I have been playing cat and mouse with this gyno lump for almost six months, further reducing the T, cutting out hCG altogether, and bumping the anastrozole up to .75 mg / day. I take some prescription medications, and there’s a very outside chance that they may be influencing the problem, but switching all my meds is not feasible given my condition.

I’ve been on various doses of Tamoxifen over the past six months. We hit the lump hard with 40 mg until it shrank down and then tapered down by 10 mg per week. The first time the gyno came back when I stopped Tamoxifen. The second time it started coming back when I tapered down to 10 mg, and the third time it started coming back at 20 mg. I’m now on 40 mg of Tamoxifen, and after two weeks at this dose the lump is completely deflated. I suspect “it” is still there, but I can’t see or feel it at all.

Here is my January Sonora Quest blood work from when I was on 20 mg Tamoxifen per day, .75 mg anastrozole per day, 25 mg T cream per day (with 5 mg each of pregnenolone and DHEA), and only 175 IU hCG every third day:

LH = 0.3 (1.7-8.6)

FSH = 0.3 (1.5-12.4)

DHEA Sulfate = 275 (34-395)

DHT = 152 (12-65)

Estrone = <20 (< or = 68)

Estradiol, Ultra-sensitive = <2 (< or = 29)

Testosterone Total = 727 (250-1100)

T Bioavailable = 370 (110-575)

T Free = 166 (46-224)

SHBG = 17 (10-50)

Albumin = 4.9 (3.6-5.1)

Doctor has been pressing me to go get imaging (ultrasound, etc.) to rule out cancer, and I’m scheduled for a few weeks from now. I REALLY don’t want to go during pandemic since I’m high risk for respiratory stuff. I assume they’ll rule out cancer, but then what? 40 mg Tamoxifen is the only thing that has kept the gyno down. I’m not a good candidate for gyno surgery at all because of my neurological condition. Why not stay on Tamoxifen? (It doesn’t appear to be driving LH/FSH too high, so that’s good.) If that’s not an option, what can I do? If you have any insights into any of the above, I would be deeply grateful for your assistance. Thank you!

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The anastrozole should dropped as soon as possible, an E2 that low isn’t doing you any favours. You take Tamoxifen for gyno, not Anastrozole. You’d feel a lot better with some E2.

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I was going to say the same regarding that E2… that is horrendously low. NO ONE would feel good with it that low.

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I totally agree, thanks. How I feel is important but not my top priority until I get rid of this gyno.

Any thoughts on long-term Tamoxifen… anyone?

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I don’t know. Most people don’t just stay on it, they use it and stop based on what’s going on, ultimately just getting the surgery if it won’t stay under control.

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Here’s an old thread from the guys in the Pharma / TRT section:

I have some Tamoxifen on-hand in case I need it, but I’ve gone back to 0.125mg of anastrozole once per week for now. It is controlling nipple sensitivity just fine thus far. I deal with mild-to-moderate gyno anyway from puberty, so I’m way more conditioned to having it for decades than someone getting it for the first time in their 30s or 40s.

I am considering surgery some time later this year or early next. I’m getting as lean as I can first and then I’ll decide if I actually want to deal with the recovery and cost. It’s right on the cusp of being obnoxious enough to get cut out - sightly more than puffy nipples basically. If it was as bad as I see it in some guys I would have had it cut out a long time ago.

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Have you checked prolactin?
This is much more likely reason to cause gyno than e2…

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Breakerjump, thanks for linking that article and its discussion. Very interesting. Do you think I should post my question in the #pharma section, or is that looked down on as redundant?

Vonko1988, you’re right. I should have had prolactin checked with the other hormones. If the Tamoxifen is temporarily fixing the gyno, that would seem to suggest an estrogen sensitivity.

I know cabergoline is the typical go-to for prolactin stuff. Does Tamoxifen also alleviate prolactin-related gyno? If it does, prolactin may be at the root of the problem because the Tamoxifen works for me as long as I keep taking it. If Tamoxifen does nothing for prolactin-related gyno, then I’m probably not having a prolactin issue, right? What do you guys think?

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I know from the practice of doctors treating gyno that is not true. Gyno is very rarely due to estrogen sensitivity but takoxifen almost always helps at least a bit. According to one doctor here treating gyno very high levels of prolactine are the most common reason for gyno.
How tamoxifen helps at the estrogen receptor of the breast in case of elevated prolactine I have no idea. Maybe when prolactine is very high estrogen sensitivity is increased without having excessive estrogen

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Interesting, thanks, vonko.

Anyone know a good at-home prolactin test I could take and mail in (to avoid contact with blood draw people who may have the c virus)?

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If you live in USA arent Discounted Labs offering full spectrum of blood work from home?

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Not sure where you got that from. Your prolactin levels have to be very high to cause gyno in combination with low androgens, it’s pretty rare, unless you have a prolactinoma. Skewed e to t ratios are extremely common causes.

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Not so uncommon at all

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Prolactinoma occurs in about 1 out of every 10,000 men. Gyno occurs in as high as 40% of men at some point in their life. Most men who have gyno do not have prolactinoma. I’d like to see some evidence of what you’re saying because the numbers aren’t even close.

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Thanks for your thoughts!

Does anyone have any insight into my freakishly high DHT =152 (range 12-65)? This is while on my usual TRT regimen plus 20 mg Tamoxifen. Does DHT factor into the whole gyno scenario somehow? My PSA stays nice and low, and DHT is great for muscle and sex. My prostate does swell a bit when on the Tamoxifen, but it’s nothing unmanageable. Thoughts?