Is it safe to continue Tamoxifen (tamoxifen citrate) in a patient with a history of unprescribed anabolic steroid use and associated gynecomastia?

Tamoxifen for Gynecomastia Secondary to Anabolic Steroid Use

Tamoxifen should be discontinued in this patient with gynecomastia secondary to anabolic steroid use, as it is not an FDA-approved indication and carries significant risks that outweigh potential cosmetic benefits.

Background and Assessment

Gynecomastia is a common condition characterized by proliferation of the glandular component of the male breast, often resulting from an imbalance in sex hormones. In the context of anabolic steroid use, gynecomastia occurs because:

• Anabolic steroids can be aromatized to estrogens
• The resulting hormonal imbalance leads to breast tissue proliferation
• This is essentially a self-induced condition from illicit drug use

Evidence Review

While some small studies suggest tamoxifen may reduce gynecomastia:

• These studies primarily focused on physiological or idiopathic gynecomastia 1, 2
• Response rates vary based on size and duration of gynecomastia 3
• None of the major oncology guidelines support tamoxifen use for steroid-induced gynecomastia

The FDA-approved indications for tamoxifen are limited to:

• Breast cancer risk reduction in high-risk women 4
• Treatment of breast cancer 4

Risk Assessment

Tamoxifen carries significant risks including:

• Thromboembolic events: 1.9-fold increased risk of venous thromboembolism 4
• Stroke risk, particularly in those over 50 years 4
• Potential drug interactions with CYP2D6 inhibitors 4

Recommendation Rationale

1. Not FDA-approved indication: Tamoxifen is not approved for treatment of gynecomastia, particularly when caused by illicit anabolic steroid use

2. Risk-benefit imbalance: The risks of serious adverse events outweigh the purely cosmetic benefit in this scenario

3. Ethical considerations: Continuing tamoxifen may inadvertently support continued anabolic steroid misuse by mitigating one of its visible side effects

Alternative Approach

The appropriate management should include:

• Patient education about the risks of anabolic steroid use
• Counseling about proper discontinuation of anabolic steroids
• Monitoring for natural regression of gynecomastia after steroid cessation
• Consideration of surgical options only if gynecomastia persists long-term and causes significant psychological distress

Conclusion

While tamoxifen has shown some efficacy for gynecomastia in small studies, its use in the context of anabolic steroid abuse represents an unapproved, high-risk application that should be discontinued. The focus should be on addressing the underlying cause (steroid abuse) rather than treating the symptom with a medication that carries significant risks.