Tamoxifen and Estrogen Effects in Women

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I was recently diagnosed with BC and naturally, like many of you, I started doing research into possible treatments in store for me. Has anyone else come across studies showing a link between Tamoxifen and increasing estrogen levels? This one is a little concerning:

1997 May;173(5):399-402.

Changes in serum estrogen levels in women during tamoxifen therapy.

Lum SS1, Woltering EA, Fletcher WS, Pommier RF.

Abstract

BACKGROUND:

Tamoxifen is considered an antiestrogen against breast cancer, yet it has known estrogenic side effects. We hypothesized that long-term administration of tamoxifen may significantly increase circulating estrogen levels in women with breast cancer.

METHODS:

Serum dehydroepiandrosterone (DHEA), estrone (E1), and estradiol (E2) levels were prospectively measured in 47 breast cancer patients before and during tamoxifen therapy for 2 years. Differences in baseline and peak hormone levels during treatment were compared, and significance was determined by paired Student's t test.

RESULTS:

Mean DHEA levels increased by 133% from 61 mg/L to 142 mg/L (P <0.001) and mean E2 levels increased by 239% from 28 pg/mL to 95 pg/mL (P <0.05). Mean E1 levels increased by 264% from 42 pg/mL to 153 pg/mL (P = 0.06).

CONCLUSIONS:

Long-term tamoxifen therapy can be associated with increased serum levels of DHEA, E1, and E2. Elevated serum estrogens may explain tamoxifen's estrogenic effects and may represent a mechanism for the development of drug resistance.


Comments

  • Lula73
    Lula73 Member Posts: 1,824
    edited August 2017

    this is true. The tamoxifen sits on the estrogen receptors of the cells in our body and blocks the estrogen from being able to be used at the cellular level. This means the estrogen is trapped in the bloodstream. We keep making new estrogen (and the body may try to ramp things up since the estrogen isn't getting into the cells). Estrogen is metabolized in the liver and it can only clear so much at once. The result is high serum estrogen. Short of an oophorectomy or taking Lupron shots to shut down your ovaries so you can take an AI, tamoxifen is all we have to starve any remaining hormone positive breast cancer cells in women who are pre-menopausal.

    On tamoxifen I had an awful rash (felt like a really bad yeast infection) on my torso, hundreds of little acne bumps and cystic acne on face and chest, stiff joints, memory issues (forgetting the next word in a sentence in the middle of a conversation type of memory issues), unbearably itchy eyes and finally a dvt and bilateral blood clots in my lungs. When I discontinued tamoxifen, the acne changed to more cystic and increased, had my period 3 times in 5.5 weeks, mood swings, bloating, decreased libido, exhaustion but difficulty sleeping, weight gain (10lbs in 1 week), and hair loss. Diagnosed with too much estrogen and that is what is causing these side effects. Dr said it was a waiting game and eventually it would normalize. I took tamoxifen for only 2.5 months. I stopped it 3 months ago and still experiencing side effects of high estrogen (though they are getting better slowly). I worry that any remaining cancer cells are gorging on the estrogen feast they now have access to. Hysterectomy is coming up and it can't get here fast enough

  • Bosombuddy101
    Bosombuddy101 Member Posts: 182
    edited August 2017

    Lula,

    I'm sorry about your reaction ---it sounds horrific!!! So now you have excess estrogen floating around which the tumor cells can feed on? What a nightmare! I'd be a basket case! I'm trying to schedule an appointment with my gynecologist to see if I can arrange to have my ovaries removed within the next year.

    Thank-you for that very clear and concise explanation as to why estrogen builds up in the body when taking tamoxifen. I've been reading accounts of women who suddenly and unexpectedly develop stage 4 liver mets while on tamoxifen. These are women who were initially diagnosed with IDCIS or stage 1 invasive cancers less than one centimeter. One would expect a favorable prognosis for these women given their initial diagnosis. So why then is everyone so gung ho on this drug??

  • Bosombuddy101
    Bosombuddy101 Member Posts: 182
    edited August 2017

    This is interesting!

    http://onlinelibrary.wiley.com/doi/10.3322/canjcli...

    Early Breast Cancer Trialist Collaborative Group

    Every 5 years in Oxford, England, a meta-analysis, which includes 55 trials with approximately 37,000 patients, is performed comparing outcomes from trials in which patients with early stage breast cancer were randomized to tamoxifen or to placebo.2 After excluding women with ER-negative tumors, the absolute risk reduction for recurrence was 14.9% (P < 0.0001) for patients with node-negative tumors (relative risk reduction of 49%) and 15.2% (P < 0.0001) in those with node-positive disease (relative risk reduction of 43%) after 5 years of tamoxifen, compared with 5 years of placebo. Mortality reduction was also significant, with an absolute reduction of 5.6% and 10.9% (P < 0.0001) in patients with node-negative (relative risk reduction of 25%) and node-positive (relative risk reduction of 28%) tumors, respectively. Five years of tamoxifen was significantly more effective than 2- or 1-year duration. The NSABP B-1423 trial is included in the meta-analysis and initially randomized 2,818 women with node-negative, ER-positive disease to tamoxifen or placebo for 5 years. Many of the patients who initially received 5 years of tamoxifen were rerandomized to a further 5 years of tamoxifen or to no further therapy. This extension trial24revealed no further improvement in outcome by continuing tamoxifen for 10 years. In fact, the most recent analysis of this trial demonstrated a significantly shorter disease-free survival of 78% for patients who received 10 years of tamoxifen, compared with 82% for patients who stopped the drug at 5 years.24 Additionally, overall survival was worse in patients treated for 10 years, compared with patients stopping the drug at 5 years.24 Based on the result of this trial, the National Cancer Institute recommended stopping tamoxifen after 5 years in patients with early stage breast cancer. However, it was not clear that the results of this trial could be applied to patients with node-positive disease.

    The meta-analysis clearly demonstrated that tamoxifen significantly reduced the rate of contralateral breast cancer by 50%.2 The 2000 Oxford Overview Analysis demonstrates that tamoxifen is only effective in decreasing the incidence of contralateral breast cancer if the primary breast cancer was ER-positive [presented at Oxford, United Kingdom, 2000]. The fact that tamoxifen effectively decreases the risk of contralateral breast cancer was a major reason why the drug was subsequently developed as a breast cancer chemopreventive.

    These adjuvant trials identified several serious side effects of tamoxifen, mainly related to its estrogen agonistic effects, including uterine cancer and thromboembolic disease. These side effects of tamoxifen and the fact that many patients with early stage breast cancer develop drug resistance, leading to disease recurrence, opened the door for the development of AIs as adjuvant therapies.



  • dtad
    dtad Member Posts: 2,323
    edited August 2017

    Hi everyone. I'm going to say again that IMO there should be a endocrinologist on our team. Most MOs simply do not know enough about female hormones. Even gynecologists on the team would be beneficial...

  • diannep
    diannep Member Posts: 5
    edited August 2017

    Thank you, bosombuddy for this article. Very informative. My onco wants me on Tamoxifen for 10 years.

  • pupmom
    pupmom Member Posts: 5,068
    edited August 2017

    Wow, I guess I should consider myself either lucky, or part of the vast majority of Tamoxifen users. Only SE, that I know of, was hot flashes. Those are now, after 2 years, pretty much gone.

  • Jilled1965
    Jilled1965 Member Posts: 15
    edited August 2017

    Has anyone else ever had to find a new MO Doc? I am fed up with mine. I had a lumpectomy in July 2016 and rads in Sept-Nov 2016. I had very little trouble with the surgery or rads. Fatigue of course and burns on my skin. I did develop radiation pneumonitis but non symptomatic. They found a small area on my right lung and have done 2 CT scans, due for another in a month. Pulmonary team just wants to keep an eye on it. Through all of this I've been relatively ok, I mean as good as you might expect.

    Then off to the MO for medication. Tamoxifen 20mg a day for 5 years. First 5 weeks no real side effects with the exception of hot flashes and night sweats. A little fatigued but not extreme. Week six, I began having severe GI Issues. Diarrhea for six weeks and no appetite. I dropped 30 lbs in 12 weeks. Since I have a history of GI problems I of course went to my GI doc. He ran all the usual tests and determined it must be just a extrene case of IBS. He prescribed anti spasm medication for IBS and said it should work itself out. 2 weeks later, although the diarrhea had subsided I was nauseated 24/7 and could barely eat. I was really fatigued and extremely disoriented, could not concentrate, which I chalked up to malnutrition and lack of sleep.

    I began thinking, the only thing different is the new Tamoxifen medication. I consulted my MO and he ran a few other tests my GI had not and found nothing. He suggested I stop taking the Tamoxifen and see what happens. I did, and 3 weeks later I was my old self again. All symptoms completely disappeared. On my next visit with my MO he was surprised that it all cleared up as "these are not normal side effects of Tamoxifen". He was so sure Tamoxifen wasn't the culprit he wanted me to start back on it. I asked if a lower dose might be better and he stated no I can't lower the dose.

    3 Weeks after restarting, the stomach issues returned. I began researching on line and indeed Nausea and other GI issues can be a side effect. Really? My MO said it was unusual and doubtful the Tamoxifen was contributing to my misery. After some suggestions from this community I found Teva brand use fillers and dyes that were gluten free and some people gleaned relief switching to this brand. I immediately had my pharmacy switch my brand and began taking the Teva brand. Guess what? No more GI issues!! I relayed this info to my MO and he responded, ok good.

    Four weeks into taking the Teva brand I now have other side effects. Still hot flashes and night sweats but now a host of other issues. Extreme anxiety, agitation, and confusion. I am constantly on edge and can't sit still or concentrate. I asked my MO could this be due to the Tamoxifen? He said that his highly unlikely but let's reduce your dose to 10 mg. (WTH I asked months ago and he said no we can't reduce the dose?)

    The anxiety got so bad I ended up in the ER last week thinking I was having a heart attack before I even began the 10Mg regimen. They kept me overnight and determine there were no heart or lung issues. I asked my MO if this increased anxiety could be the result of the Tamoxifen. He stated it was very unlikely and I should see my GP.

    I saw my GP last Thursday and he said he was not sure why I was feeling this way and was probably just stressed and likely depressed. He prescribed Prozac. I had read Prozac was not good to use with Tamoxifen and told my MO what my GP prescribed. My MO responded, OK. I then told him really? Is Prozac ok to take with Tamoxifen? His answer, Shoot I wasn't thinking, no don't take Prozac. He then prescribed Effexor.

    I now have 10mg Tamoxifen and a slow start of Effexor sitting in my medicine chest. 2 weeks off Tamoxifen now and my anxiety has reduced dramatically. Not before landing me in the ER with the "I think I'm having a heart attack" embarrassment.

    All this leading back to my original question, is it time for a new MO? Do all MOs deny SEs that are out of the norm? I think I need to find one that believes these are side effects and will work with me to figure it out, not make me think I'm just losing my mind. How do you go about finding a new MO?

  • Bosombuddy101
    Bosombuddy101 Member Posts: 182
    edited August 2017

    Jill,

    Your symptoms with Tamoxifen sound so familiar to other women on this site going through hormonal therapy. I'm pretty new to all of this---under what conditions are women prescribed hormonal therapy? Is it true that hormonal therapy is a preventative measure for contralateral breast cancer? Would this mean that hormonal therapy is recommended for women who have undergone a lumpectomy or have positive lymph nodes?

  • Jilled1965
    Jilled1965 Member Posts: 15
    edited August 2017

    Bosombuddy
    I'm not an expert and relatively new to this site myself. I came here after I began having issues after I started taking Tamoxifen. I was tired of my MO telling me my issues weren't related to taking Tamoxifen.

    From what I've read: (copy and paste)

    Tamoxifen may be prescribed in women with ductal carcinoma in situ (DCIS) who have completed surgery and radiation therapy. Tamoxifen may reduce the risk of invasive breast cancer.

  • exercise_guru
    exercise_guru Member Posts: 716
    edited August 2017

    jilled I am not sure what to tell you I share your story mine is very similar. I find the MO's are constantly sure that none of these pills have these side effects even when I take a clinical paper detailing the side effect that I am having. Their goal is to keep you on the medication because Tamoxifen is truly a huge lifesaver in preventing recurrence. I am so glad to hear that the TEVA brand fixed your GI troubles if that doesn't return bless you many times. I had horrible side effects on TEVA and switched to Mylan. now I have different stinky side effects on it. Life is not the same after breast cancer. I have two friends that have died from it and both were young like me with kids so I put up with it.

    BTW this is my 2nd MO and I think they both just patronize me and send me on my way. You could try to find one that specializes on Breast cancer patients. In my area they all kind of do it all and it shows.

  • Jilled1965
    Jilled1965 Member Posts: 15
    edited August 2017

    Thanks Exercise Guru,

    I am researching and trying to find one that specializes in BC. The one I have does it all as you say. Patronized is a good word for how he makes me feel. I at least need someone who believes there is a direct effect caused by the medication. Seriously, I'm off for 5 weeks and return to normal, go back on and the effects return. I'm no Dr. but that alone should prove there's a link.

    Mylan is the first brand I was on that jacked my stomach all to heck. Teva, doesn't bother my stomach but now I'm batshit crazy. I'm glad the switch to Mylan worked for you. I agree it's necessary, but putting up with this is not an option when it's effecting my ability to work or function.

  • Lula73
    Lula73 Member Posts: 1,824
    edited August 2017

    maybe asking the question to your MO differently is the way to go-'

    'Is this a symptom of estrogen deprivation?'

    'Is this a symptom of elevated/excess estrogen in the bloodstream?'

    'Is this a symptom of testosterone dominance?'

    'Is this a symptom of estrogen/testosteronehormone imbalance?'

    All are alternative ways of asking the same question but from different perspectives. Maybe the drug itself isn't causing the symptoms but your body's natural reaction to how the drug works is.

    I gave all my symptoms I was experiencing after discontinuing tamoxifen to the dr. 1/2 way through his eyes were big as saucers and getting bigger with each new symptom. He said "I don't know what's going on." Then I finished the list and he said "it sounds like you've got too much estrogen!" Turns out I had 11 out of 13 symptoms of excess estrogen. And here I was blaming it on the drug when it was really the after effects of my body's response to the action of the drug


  • dtad
    dtad Member Posts: 2,323
    edited August 2017

    Hi everyone. We all deserve to be treated respectfully by any doctor. However a physician dealing with cancer should be especially compassionate. Yes a lot of MOs deny or minimize the SEs of anti hormone treatment. However it is possible to find one who is open to working with you. Just keep trying!

    Lula...I understand what you are saying however IMO its not our responsibility to ask the questions a certain way! We have enough to worry about. A good doc should be able to answer appropriately no matter how we ask. Also a SE is a SE no matter if its directly or indirectly related to the drug. MOs should be able to identify them regardless and work with us to find a solution. Good luck to all navigating this complicated disease.

  • SummerAngel
    SummerAngel Member Posts: 1,006
    edited August 2017

    My MO was wonderful, they do exist! I had severe side effects and he absolutely believed me. He gave his blessing for me to discontinue taking Tamoxifen, as my chances of recurrence are low.

  • Lula73
    Lula73 Member Posts: 1,824
    edited August 2017

    dtad- totally get what you're saying, however we have to remember that doctors are humans too. They have many idiosyncrasies just like everyone else. In fact, many of them were the awkward nerdy kid in school who didn't have much "regular" kid-type interaction. They were not the ones on the football or cheerleading teams, they were not at the "cool kid" parties in high school or college. For many of them their social skills are lacking. They are also very literal and are trained to think critically & clinically, and not in an out of the box manner. I work with doctors everyday and get to see the way they think, interact and work first hand. I realize we're the patient and they're the dr. But if you the patient recognize that sometimes you need to word things different to engage the Dr's thinking process in a different manner and you choose not to do it because you feel the Dr should just know this or do things a certain way there is only 1 person who loses out. It's like going to the dr, sitting on the exam table and when the Dr asks what Brings you in today, you respond with 'you're The Doctor, you tell me.' And in their world there is a difference between Side effects of the medication directly (allergic reaction, nausea, etc) and side effects that are the result of a chain reaction of events from the mechanism of action of the drug (high serum estrogen, acne, mood swings, etc). All I'm saying is remember That they are human too and that there is a gap in how the patient thinks and how her doctor thinks typically on all levels of the spectrum. And for the best care, we sometimes have to work a little more with each other's quirks

  • Trvler
    Trvler Member Posts: 3,159
    edited August 2017

    I agree, Lula. I wish you could have seen my first MO. She was very tall, had black spiked hair and wore high heal black moto boots. She was a lousy doctor and her bedside manner was awful, which is why I fired her.

  • dtad
    dtad Member Posts: 2,323
    edited August 2017

    Lula...got it! Be well

  • CCS648
    CCS648 Member Posts: 41
    edited August 2017

    This is really interesting. I have been on Exemestane (Aromasin) for 2 1/2 years. For the first couple of years, I had horrible joint pain, but stuck it out.

    About 5 months ago, I had some serious stress and started losing weight. I was fine with that, as I had put on about 10 pounds after starting the drug. The stress went away, but the weight loss continued, with low appetite and mild nausea most of the time. I went to my regularly scheduled oncologist appointment around the time I reached 20 pounds of weight loss. He was very grave, examined my abdomen, pronounced that he felt "a mass", and told me to be prepared for a stage IV diagnosis. I first had an MRI, then CT of chest and abdomen, then endoscopy/colonoscopy, ultrasound, and finally PET/CT. Nothing. He told me my problems were not cancer-related (he was essentially saying it was all in my head) and he could do nothing more. (I am not an anxious person. I know when I'm stressed and when I'm not.)

    Then I started having blood pressure and heart rate spikes. I ended up in the hospital with a hypertensive crisis last weekend. After running eight million tests, they told me that my heart is in great shape, and that I actually do not have high blood pressure (it went down after they gave me lots of meds, but then stayed down for a few days without meds.)

    When I saw my PCP last week (now at a weight loss of 30 pounds), she said these are all side effects of the AI. I was skeptical, because I've been on it for 2 1/2 years. She told me that she had patients who suddenly couldn't tolerate it after five years, and even ten. She said that the loss of estrogen, and its effect on the body's systems, are cumulative and the body may suddenly just 'have enough.'

    I really hadn't heard of anyone losing weight on any estrogen-inhibiting drug, so I did a search and came up with this thread. Fascinating.

  • Jilled1965
    Jilled1965 Member Posts: 15
    edited August 2017

    CCS, well now you have. I lost 30 lbs in 3 months due to digestive issues and constant nausea. I changed brands and that helped the GI issues. However now I'm having extreme anxiety levels. At least that's all I can fathom they are. I too had a battery of tests because I literally thought I was having a heart attack. After no heart issues were found my GP put me on anti anxiety meds. I am NOT an anxious person. A week and a half later, off Tamoxifen for nearly 3 weeks I still have rapid heart beats, lightheadedness and get dizzy. I'm suddenly having bouts of weepyness as well. My brain is returning to normal which is nice but will be short lived. I'm heading out for a 4 day road trip vacation. Nearly postponed AGAIN, because I'm not feeling myself. However, I have canceled 4 work and 2 personal trips since these NOT SE's started. I need a taste of normalcy. Once I return I will restart the Tamoxifen at a lower dose and use the Effexor and say goodbye to my brain, ability to think rationally and problem solve. My work is really suffering but thankfully I have a caring and understanding boss.

    Surgery and Rads went well and I thought "hey, I got this" I never realized the hormone therapy would put my life on hold for five years! Four more to go.

  • MexicoHeather
    MexicoHeather Member Posts: 365
    edited August 2017

    Jill. God bless you. I fired my oncologist and I have an appt. with another in October. I'm taking all my SEs to the urogynocologist. I'm going to get a hysterectomy first, then we'll see.

    I an taking more xanax than when I was in treatment. I'm not depressed, I just want doctors to listen.


  • Sabina1974
    Sabina1974 Member Posts: 39
    edited March 2018

    Hi everyone


    I have been on tamoxifen for nearly a year now. I recently got hormonal blood tests done and estradiol is 1697 which is completely abnormal. They have now said to stop taking the tamoxifen and have referred me to another Dr to see about having my ovaries removed. I am terrified to think something else is going on. Thanks everyonr

  • edwards750
    edwards750 Member Posts: 3,761
    edited March 2018

    Oh Sabina I hope your tests go okay. I know you are scared. At least whatever it is they are addressing it now instead of later.

    Keep us posted.

    Diane

  • Sabina1974
    Sabina1974 Member Posts: 39
    edited March 2018

    Hi Diane


    I had a pelvic ultrasound yesterday and waiting on results. I have decided I want my ovaries out that level of oestrogen is off the charts. Just wondering did anybody else have anything similar.


    Sabina

  • bluepearl
    bluepearl Member Posts: 961
    edited March 2018

    ALWAYS CHECK THE DATE OF THE ARTICLE/RESEARCH, IT MAKES A BIG DIFFERENCE.

  • Bosombuddy101
    Bosombuddy101 Member Posts: 182
    edited March 2018

    Sabina, how incredibly stressful! I hope the doctors figure out what to do fast. Most women probably wouldn't even know that their hormone levels are through the roof because doctors discourage hormone testing. Did your MO recommend the test? This was and is my biggest fear, treating a hormone receptor positive cancer with a drug that could potentially increase my circulating estrogen levels and cause the cancer cells to grow out of control and metastasize. Tamoxifen doesn't work for everyone and I don't think they have a way of knowing who it does work for. We're all given the same treatment, same dosage regardless of what happens.

  • gb2115
    gb2115 Member Posts: 1,894
    edited March 2018

    I was under the impression that Tamoxifen works by blocking estrogen receptors, but ends up increasing estrogen levels in the process. So they go up (which is where the risk of uterine cancer comes from), but then the receptors are blocked. I don't know why people keep saying that tamoxifen lowers estrogen, because it doesn't.

  • klvans
    klvans Member Posts: 258
    edited March 2018

    Do AI's lower estrogen or do they just block receptors as Tamoxifen does?


  • MelissaDallas
    MelissaDallas Member Posts: 7,268
    edited March 2018

    Oversimplified, AIs prevent the conversion of androgens to estrogen.

  • Sabina1974
    Sabina1974 Member Posts: 39
    edited March 2018

    Hi Bosombuddy

    So stressful yes they requested bloods because I had a very small bleed, just once about 3 weeks ago. So of course when saw the level that high my oncologist said to stop taking it. So I think ovaries out and possibly uterus as well. Well if they have told me to stop taking it then it must be of concern to them. I have read though it can still work against cancer cells!!

    Sabina



  • Patsfan12
    Patsfan12 Member Posts: 6
    edited March 2018

    I have a slightly different question for you...I've been taking Tamoxifen for about 3 weeks now and am having constant back, shoulder and muscle pain. Motrin doesn't touch it, a massage didn't help and stretching and yoga (which I hate but am trying anyway) haven't seemed to make much of a difference. Saw my doctor today and he said that it was an unusual symptom and he's hoping it will go away in time. I can't find much on this particular side effect on my internet searches so just wondering if anyone else has experienced anything like this?

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