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Suggest treatment for elevated estrogen levels

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Posted on Mon, 18 Sep 2017
Question: My 46 year old wife had stage 1A invasive ductal breast cancer (low grade) around 4-5 years ago, and is still currently on daily Tamoxifen. When she was initially diagnosed, she had a bilateral mastectomy, negative lymph nodes (she had radiation but no chemotherapy). Her cancer was found to be estrogen positive (ER+). She is BRCA-. She even had an Oncotype DX and a Mammaprint Test, both which stated low risk.

Her last physical exam by her doctor a few months ago was unremarkable. She had routine blood tests which were all normal except her serum estrogen level was very high, 797 pg/mL. I am pasting her serum estrogen result: 797 pg/mL .

FOR REFERENCE SERUM ESTROGEN:
Prepubertal <40
Female Cycle:
1-10 Days 61 - 394
11-20 Days 122 - 437
21-30 Days 156 - 350
Post-Menopausal <40
HMG Treatment for Ovulation
Induction: 400 - 800

Her tumor markers CA 15-3 (breast cancer tumor marker) and CA-125 (ovarian cancer tumor marker) and other labs including C-reactive protein and sedimentation rate, WBC, etc were all completely normal. We have never tested her serum estrogen level before, but it was actually accidentally ordered, and it is very elevated.

My question is: Why is the serum estrogen level so high? Is it the result of the Tamoxifen? And if so, does this indicate that the Tamoxifen isn't working anymore or isn't effective (ie. developed resistance)?
In your opinion, is she at higher risk of a recurrence? What are your suggestions?
Additional information for you is that she is not menopausal, she is 46 years old, so she is not eligible to take medications such as Arimidex. Basically, should we be worried about these results, and what should we do going forward? Thank you
doctor
Answered by Dr. Deepak Sundriyal (48 minutes later)
Brief Answer:
Hello. It is due to her premenopausal.status

Detailed Answer:
Hello dear. I have gone through the details.

So, as she is premenopausal or perimenopausal to be more precise, and since Tamoxifen has blocked the action of estrogen, the high level of estrogen is expected.

She has received 5 years of tamoxifen and now i will advise her to switch over to gonadotropin releasing hormone agonist to block the production of estrogen and then the more effective agent like Arimidex can be used for another 5 years.

There is no need to worry

Feel free to ask further
Thanks and regards


Above answer was peer-reviewed by : Dr. Arnab Banerjee
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Follow up: Dr. Deepak Sundriyal (4 hours later)
First of all, I'd like to thank you for your great response. I read about gonadotropin releasing hormone agonist, and it has many side effects. Do you think this is very necessary, or simply a precautionary suggestion? I agree with you, that once she is "menopausal" she should switch to Arimidex.

With regards to her high serum estrogen level, you said this high level could be attributed to her being "premenopausal/perimenopausal"? But isn't her level still very very high, even for that? Or do you think it could still be within normal range, given the fact she is on tamoxifen. When I googled this, some papers state that high serum estrogen levels may be indicative of Tamoxifen resistance. Do you agree with this, or is this not really common consensus?

Bottom line, you don't think I should be too worried, right? What if she simply just continued doing what she's doing now (ie. daily Tamoxifen, routine 6 months doctor checkups, annual lab test), and not change anything, would that also be reasonable? Thank you Dr. Sundriyal.
doctor
Answered by Dr. Deepak Sundriyal (7 hours later)
Brief Answer:
Hello.gnrh is beneficial

Detailed Answer:
Hello once again
So as the latest recommendations stand up, adding arimidex after 3 years of tamoxifen will add up to survival and currently the best strategy.
Gnrh jave initial.side effects but they wear off with time very soon and are really beneficial.
Frankly.speaking, i hvnt come.across that high estrogen levels suggest resistance nor do our nccn guidelines recommend estrogen check during tamoxifen. Only, when we are planning to switch to arimidex, then it is necessary to.check if patient bas turned post menopausal.or not. If not, then we make her postenopausal.by adding gnrh.
There is actually no reason to worry.
Enjoy your life.
Thanks and regards
Above answer was peer-reviewed by : Dr. Kampana
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Dr. Deepak Sundriyal

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Practicing since :2005

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Suggest treatment for elevated estrogen levels

Brief Answer: Hello. It is due to her premenopausal.status Detailed Answer: Hello dear. I have gone through the details. So, as she is premenopausal or perimenopausal to be more precise, and since Tamoxifen has blocked the action of estrogen, the high level of estrogen is expected. She has received 5 years of tamoxifen and now i will advise her to switch over to gonadotropin releasing hormone agonist to block the production of estrogen and then the more effective agent like Arimidex can be used for another 5 years. There is no need to worry Feel free to ask further Thanks and regards