Surgical Removal of Ovaries & Tubes
"Oophorectomy" is the removal of the ovaries to treat or prevent ovarian cancer or other ovarian abnormalities.
“Prophylactic oophorectomy” refers to the removal of healthy ovaries in women who have an elevated risk for ovarian cancer. Women with elevated hereditary risk for ovarian cancer also have an elevated risk for fallopian tube cancer. For this reason, when their ovaries are removed prophylactically, the fallopian tubes must also be removed.
“Bilateral salpingo-oophorectomy” (BSO) refers to the surgical removal of both ovaries and both tubes. In women at increased risk for ovarian cancer, bilateral prophylactic oophorectomy has been shown to be a highly effective tool to lower the risk for both ovarian cancer and breast cancer.
After prophylactic oophorectomy, there is still a small risk for developing cancer of the “peritoneum,” which is the lining of the abdomen. This type of cancer, called “primary peritoneal cancer,” is related to ovarian cancer. Although the risk remains, it is quite small. Currently there is no proven method of preventing or screening for primary peritoneal cancer.
Previously, all ovarian cancers were believed to develop in the lining of the ovary as a result of the constant rupture and repair process during ovulation. New research, however, suggests that many ovarian cancers in BRCA gene mutation carriers may actually start in the distal fallopian tube (part of the tube closest to the ovary), causing researchers to question whether salpingectomy (removal of the fallopian tubes) might reduce ovarian cancer risk.
Current expert guidelines recommend that women with BRCA mutations undergo bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes) between the ages of 35 - 40 or after childbearing is completed. This surgery has been shown through research to improve survival in mutation carriers. However, the surgery also causes immediate surgical menopause, which can be accompanied by short and long-term side effects and health consequences.
New research suggests that some ovarian cancers may actual begin in the fallopian tube research. Some experts have proposed that "interval salpingectomy"—removing the fallopian tubes and leaving the ovaries intact until after natural menopause—might lower risk for ovarian cancer in high-risk women while avoiding the negative side effects and long-term health consequences associated with oophorectomy at a young age. After menopause women would then undergo a second procedure to remove their ovaries.
The decision to undergo prophylactic surgically is highly personal. Confronting your personal cancer risk can be confusing and frustrating. Therefore, it is important to consult with experts in genetics and gynecologic oncology when determining your risk for ovarian cancer and making the risk-management decisions that are best for you.
Research has shown that Risk Reducing Salpingo-Oophorectomy (RRSO) lowers the risk of developing and dying of breast cancer in women who have BRCA mutations.
Lowered risk for developing breast cancer
In 2002, two landmark studies, one by Dr. Noah Kauff at Memorial Sloan Kettering and another by Dr. Timothy Rebbeck, lead investigator of the PROSE study, demonstrated the benefits of removing the ovaries of BRCA carriers. When women’s ovaries and tubes were removed, their breast cancer risk was reduced substantially. Subsequent published studies confirm these results. A meta-analysis (a compilation of results from many similar studies) published in 2008 that looked at 10 separate studies on breast cancer risk reduction in mutation carriers found a 53% reduction of risk for mutation carriers whose ovaries were removed.
Some studies, but not all, suggest that the level of breast cancer risk reduction may differ between BRCA1 and BRCA2 carriers who choose risk-reducing salpingo-oophorectomy (BSO). In 2008, a multi-institutional study reported that women with BRCA2 mutations who removed their ovaries lowered their risk for breast cancer by 72%. Risk reduction was less—about 29%—for women with BRCA1 mutations. The researchers suggest that ovary removal may be more protective for women with BRCA2 mutations because their breast cancers are more likely to be hormone receptor-positive, while breast cancers in BRCA1 mutation carriers are usually hormone receptor-negative.
Lowered risk for dying of breast cancer
Research in 2010 also showed that women with mutations who remove their ovaries lower their risk of dying of breast cancer by 56%.
Age of RRSO and breast cancer risk
Many studies on breast cancer risk reduction in mutation carriers who undergo RRSO have been done on women who removed their ovaries before age 50, the average age of menopause. But some studies have suggested a benefit for breast cancer risk reduction, even in women who undergo RRSO after menopause. A study presented by Dr. Kauff and collegues in 2013 confirmed these results. It followed 199 postmenopausal BRCA mutation carriers and found that risk-reducing salpingo-oophorectomy appeared to confer a 57% reduction in breast cancer risk in women who had undergone menopause before surgery. Although the ovaries stop producing estrogen and progesterone after natural menopause, they continue to produce some hormones, including testosterone, which might explain why RRSO after menopause still has protective effects against breast cancer.
Researchers have studied the reduction of ovarian cancer risk after prophylactic oophorectomy.The amount of risk reduction achieved varies according to how much risk was present prior to surgery.
A prospective, 4-year study of 218 women found BSO lowered ovarian cancer risk substantially. The risk for ovarian or primary peritoneal cancer was 1.4% in the group that had prophylactic oophorectomy, while the risk for either cancer in women who underwent surveillance was 11%.
In another larger but retrospective study, less than 1% of women with BRCA mutations who chose prophylactic oophorectomy developed primary peritoneal cancer (2 of 247 or .08% ) compared with 19.9% (58 of 292) of women who didn’t have surgery ended up with ovarian cancer or primary peritoneal cancer. This represents a 96% risk reduction for ovarian cancer after prophylactic oophorectomy.
A recent study on 122 BRCA positive women undergoing prophylactic oophorectomy found that about 6% of these women had cancer at the time of prophylactic surgery. Of these women, all had cancers originating in their fallopian tube. This study suggests that much of the ovarian cancer in BRCA carriers may begin in the fallopian tubes. It is important to be certain that the surgeon performing prophylactic oophorectomy is familiar with the associated fallopian tube risk in BRCA carriers and that the pathology department that reviews the ovaries performs what is known as "serial sectioning" where they look at many cross sections of the fallopian tubes to be certain that a cancer is not present.
A high-risk woman undergoing prophylactic oophorectomy may have an increased risk for ovarian cancer being found at the time of surgery, even when she shows no signs of ovarian cancer. Therefore the surgeon should follow a special protocol to identify any abnormalities and also be prepared to perform full staging if an ovarian cancer is seen. The specific protocol for prophylactic oophorectomy for high risk women involves
- exploring the pelvic organs for any evidence of cancer
- performing a peritoneal wash (the pelvis is bathed in fluid and the fluid is collected to look for any cancer cells that may be in the abdomen)
- removal of the ovaries and fallopian tubes in their entirety.
Although an experienced gynecologic surgeon can perform an oophorectomy, it is important for a surgeon to be familiar with this high-risk protocol and have experience in prophylactic oophorectomy for high-risk women. Many facilities refer high-risk women to specialists known as gynecologic-oncologists: although these specialists often treat ovarian cancer, they are also trained in spotting abnormalities that might indicate cancer, are familiar with the high-risk protocol which should be followed for prophylactic surgery and can perform full staging if a cancer is found. Some facilities will schedule prophylactic oophorectomy with a gynecologist, but will have a gynecologic-oncologist available in case an abnormality is found. You can find a gynecologic-oncologist near you through the Foundation for Women's Cancer website.
The ovaries and tubes are located within the abdominal cavity. Oophorectomy requires the surgeon be able to make incisions into the abdominal cavity to visualize the ovaries and tubes, look for abnormalities, remove the organs and prevent internal bleeding. There are two general surgical approaches to ovary and tube removal: laparotomy and laparoscopy. Laparotomy involves a large incision in the lower abdomen. It involves a longer recovery, more postoperative pain, a longer hospital stay, and more potential complications than laparoscopy. If a woman is also having her uterus removed (hysterectomy) the surgeon can do that during the same procedure and through the same incision.
In a laparoscopic surgery the surgeon inserts a small camera called a laparoscope, through a small incision in the belly button. With this camera, the surgeon can see the abdominal and pelvic area including the ovaries and the tubes on a monitor. The surgeon then inserts the surgical instruments needed through two or three additional incisions. The ovaries are removed through one of these incisions or through a small incision in the vagina.
Generally speaking, laparoscopic surgery involves less postoperative pain and a shorter recovery than laparotomy and is often performed as an outpatient surgery. However, this type of surgery requires a surgeon who is experienced with laparoscopic techniques. Further, not every woman is a candidate for a laparoscopic procedure. One potential complication of laparoscopic surgery is the need for the surgeon to switch to a laparotomy incision during the procedure. This might occur for many reasons, including the need for better visualization of the pelvis, or controlling bleeding during the procedure.If a laparoscopic surgery must be converted to a laparotomy, the recovery and incision will be that of a laparotomy.
Hysterectomy is the surgical removal of the uterus. Women who have a mutation that causes Hereditary Non-Polyposis Colorectal Cancer (HNPCC) have an increased risk for uterine cancer; a prophylactic hysterectomy and BSO are recommended. Most experts believe the risk for uterine cancer in women with BRCA mutations is similar to women in the general population. For that reason, the removal of the uterus with a prophylactic oophorectomy is not universally recommended for carriers of a BRCA mutation undergoing prophylactic oophorectomy. However, some considerations may impact the decision to remove the uterus with BSO. The issue is complicated: some surgeons feel very strongly one way or the other about this surgery. Considerations that influence the decision to remove the uterus at the time of prophylactic surgery include:
- Consideration of any previous uterine or cervical abnormality:
Hysterectomy is often considered if a woman has had any previous abnormal pap smears or any abnormality of the uterus.
- Considerations about hormone replacement
Typically, if a woman plans to take hormones after oophorectomy, the absence of the uterus impacts what type of hormones are prescribed. There is an increased risk for uterine cancer in women who take estrogen alone compared to estrogen with progesterone. Therefore, women who do not have a hysterectomy and keep their uterus are recommended to take a hormone replacement therapy that includes estrogen plus progesterone. Data from an entirely unrelated population, however, suggests estrogen alone may be safer than estrogen plus progesterone with regard to breast cancer risk, but no one is certain how applicable this information is to the BRCA population.
- Risk for fallopian tube cancer in the fallopian tube remnant:
Women with BRCA mutations are at increased risk for fallopian tube cancer. The fallopian tubes connect the uterus to the ovaries and are attached to both organs. Although gynecologic oncologists remove as much of the fallopian tubes as possible, a small bit remains embedded in uterus. The risk of cancer developing in the residual portion of the fallopian tube is unknown; most medical experts believe it is miniscule compared to the risk for ovarian cancer. This theoretic risk for cancer in the remaining segment of fallopian tube is enough to cause some gynecologic-oncologists to offer hysterectomy along with BSO, although no cases of fallopian tube cancer have been reported from this small remnant.
- Intra-operative risk of hysterectomy:
Removing the uterus involves more surgery than oophorectomy alone. Therefore, there is a slight increase in operative complications and in the risk that a laparoscopic procedure will have to turn into an abdominal surgery with a full incision.
- Longer recovery:
A hysterectomy increases recovery time and hospitalization.
- Insurance coverage:
Because of the surgery, recovery and hospitalization are lengthier; some insurance companies won’t pay for prophylactic hysterectomy unless there is medical necessity.
- Risk for bladder prolapse with hysterectomy:
Although bladder prolapse is commonly cited as a risk with hysterectomy, there is no clear evidence relating hysterectomy to increased vaginal prolapse risk. Study data from the Women’s Health Initiative suggests hysterectomy does not increase the risk for bladder prolapse.
- Possible decrease in sexual experience after hysterectomy:
Hysterectomy has not been proven to lower libido or sexual satisfaction; sometimes, however, health care providers cite this as a potential side effect of the surgery. Although everyone reacts to surgery differently, studies based on women undergoing hysterectomy for non-prophylactic reasons did not show a decrease in libido or sexual satisfaction after hysterectomy.
- Uterine cancer risk
Although an increased uterine cancer risk has not been associated with carriers of a BRCA mutation, one small study of women with a very rare type of uterine cancer called “uterine serous papillary carcinoma” did find a connection with carriers of a BRCA1 mutation.
New research suggests that the fallopian tubes may be the source of many hereditary ovarian cancers. This has led researchers to study if premenopausal women could remove their fallopian tubes and delay ovarian removal until after menopause. Several pieces of evidence point to ovarian cancers starting in the fallopian tubes:
- Researchers established early on that fallopian tube cancer—which is rare in the general population—is more common in women with BRCA mutations.
- Careful examination of the fallopian tubes from research studies such as GOG-0199 led to the discovery of precancerous fallopian tube changes called “serous tubal intraepithelial carcinoma “ (STIC) lesions. These STIC lesions found in fallopian tubes appear to be “precursor” lesions that will develop over time into ovarian cancers. No similar lesions have been found in the ovaries of high-risk women.
- STIC lesions have similar gene profiles as serous ovarian cancers.
- As many as 50% of women with BRCA mutations who have ovarian cancer also have lesions in their fallopian tube.
- Preliminary studies in cancer-prone mice show that removal of fallopian tubes prevents high-grade serous carcinoma of the ovaries—the type that women with BRCA mutations are most likely to get.
Even if the fallopian tubes are the cause of many gynecologic cancers in mutation carriers, researchers caution that there is not enough evidence to suggest that all of these ovarian cancer start in the fallopian tubes. Also removing just the fallopian tubes is not likely to lower the risk for breast cancer. More research is needed to completely understand the role of the fallopian tubes in the development of these cancers.
Before experts can recommend "interval salpingectomy"—removing the fallopian tubes and leaving the ovaries intact until after natural menopause—more research is needed on the safety, efficacy, and acceptability of this procedure for high-risk women.
FORCE conducted an online survey of 204 premenopausal women with BRCA mutations who had neither ovarian cancer or a risk-reducing removal of fallopian tubes and ovaries (salpingo-oophorectomy). Thirty-four percent of women surveyed said they would definitely be interested in a study of salpingectomy; approximately 83% of these women cited the possibility of reducing ovarian cancer risk without menopause as their motivation to participate. On the other hand, approximately 30% of women said they would not be interested in such a study, citing concerns about surgical complications, the possibility of ovarian damage, and potential cost. These findings suggest that there would be enough patient interest in the HBOC community to begin a clinical trial of risk-reducing salpingectomy. The survey results were presented as a poster at the annual conference for the Society of Gynecologic Oncologists.
Still, questions remain about the feasibility of conducting such a study. The Gynecologic Oncology Group, part of the National Cancer Institute’s Clinical Trials Cooperative Group Program approved further development of a study on salpingectomy, which would further examine the fallopian tubes of high-risk women who undergo the procedure and to assess:
- immediate and long term complications of the procedure
- impact of the procedure on ovarian function
- the proportion of women who ultimately undergo completion oophorectomy
- feasibility of conducting a larger trial to determine impact of the procedure on cancer risk.
In the meantime, FORCE and the University of Washington have organized a salpingectomy research registry to follow outcomes on women who have undergone this procedure.
Every surgery has potential risks; some are more serious than others. Some possible risks of oophorectomy and or hysterectomy include:
- intestinal blockage
- injury to internal organs
- anesthesia risks
- menopausal side effects
- possibility that cancer will be found during surgery
It is important to discuss possible surgical risks with your physician. Understand the seriousness and likelihood of these risks prior to surgery.
Disclaimer: Health links are made available for educational purposes only. This information should not be interpreted as medical advice. All health information should be discussed with your health care provider. Please read our full disclaimer for more information.
This site has been made possible by a generous grant from Morphotek.