What worked

Things started working when I was able to talk to a provider who had some experience with SERMs. They acknowledged that spironolactone wasn’t working for me, and prescribed leuprolide injections. They also said they had no experience with raloxifene, but had used tamoxifen, a different SERM, in a previous patient. This turned out to be a lucky coincidence for me, because on tamoxifen, I definitely did notice some estrogenic effects, but not in my breasts.

Over the course of a few months, I worked up to my current regimen: 0.3 mg estradiol per day (as transdermal patches), 20 mg tamoxifen per day (orally), 1 mg finasteride per day (orally), and a 22.5 mg depot injection of leuprolide acetate every three months. With this regimen, I have been seeing fat redistribution from a masculine to a more feminine (or gender neutral) pattern, softer facial features, much diminished acne, lower libido, and an improved psychological well-being overall.

Unfortunately, my provider initially gave me an insufficient dose of leuprolide (roughly half of the above), which meant that my testosterone levels were all over the place, because due to the way GnRH agonists work, they cause a spike in testosterone whenever their effect sets in or wears off. But with the 22.5 mg doses, I finally saw my testosterone levels consistently drop, and my libido came significantly down. On this current regimen, my testosterone levels are now around 30 ng/dL (around 4 pg/mL free testosterone). In contrast, on spironolactone or the lower dose of leuprolide, my measured testosterone never went below 100 ng/dL.

Remarkably, I have not observed any breast growth since starting tamoxifen, even though I gradually increased my estradiol dose to three times the dose that had given me breast growth before (either without SERMs or in combination with raloxifene). On my current regimen, my estradiol levels are between 200 and 300 pg/mL.

While everybody is different and I can only provide an “anecdote” based on my own experience, these results seem quite significant, and I hope it might inspire some more research.