Risk Management
Oophorectomy
Overview
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 substantially 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. Although effective, some consider oophorectomy a drastic way to lower cancer risk. 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. For more information see our section on primary peritoneal cancer.
Oophorectomy has been shown to be the most effective method for lowering risk for ovarian cancer in high-risk women. If performed before menopause, oophorectomy also lowers the risk for breast cancer in high-risk women. However, oophorectomy leads to early menopause, and women need to be counseled about the menopausal symptoms that they will likely experience.In post-menopausal women, oophorectomy is less likely to trigger new menopausal symptoms. For more information, please see our section on surgical menopause.
The decision to surgically remove the ovaries is highly personal. Confronting your personal cancer risk can be confusing and frustrating. If you are a high-risk woman trying to choose the best risk-management option, you need a clear sense of your own personal risk and an understanding of the potential benefits, risks, and side effects of prophylactic surgery. Therefore, it is important to consult with a cancer genetics specialist when determining your risk for ovarian cancer and making the risk-management decisions that are best for you. Stay in contact with a genetics expert for updates on current knowledge.
Sometimes it helps to speak with other women who have faced these choices. Learn more about talking with other high-risk women in the FORCE Community section of our website.
Breast cancer risk reduction
Researchers have examined the reduction of breast cancer risk after prophylactic oophorectomy in carriers of BRCA mutations. One prospective study demonstrated a 60% reduction in breast cancer risk after oophorectomy when performed in premenopausal women with BRCA mutations. This risk reduction remained even in women who took hormones after prophylactic oophorectomy. Another study followed premenopausal women who carried a BRCA mutation prospectively to determine breast cancer incidence in women who chose oophorectomy compared with women who chose surveillance. The two year study demonstrated a 60% risk reduction in breast cancer risk. Recently the researchers published results from four year follow-up of the same study. They found a 70% reduction in risk for breast cancer in women who chose oophorectomy.
Ovarian cancer risk reduction
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. For more information visit our section on ovarian cancer risk.
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.
Choice of surgeons
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 website for the Society of Gynecologic Oncologists.
Laparoscopy vs. laparotomy
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.
Decisions about hysterectomy
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. For more information, see our section on surgical menopause. - 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. For more information, see our section on uterine cancer risk.
Surgical risks
Every surgery has potential risks; some are more serious than others. Some possible risks of oophorectomy and or hysterectomy include:
- infection
- intestinal blockage
- bleeding
- injury to internal organs
- anesthesia risks
- menopausal side effects
- possiblity 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.
Clinical trials
ClinicalTrials.gov
This site, produced by the U.S. National Library of Medicine (NLM), provides patients, family members, and members of the public easy and free access to information on clinical studies for a wide range of diseases and conditions.
Other websites
Fertile Hope
Fertile Hope is a nonprofit organization providing information and support
for cancer patients whose medical treatments may affect their fertility.
The website provides a wide range of information as well as links to organizations,
selected health care providers, and other resources.
Hyster Sisters
Hyster Sisters is an online support site for women facing hysterectomy or gynecologic surgery.
North American Menopause Society
NAMS is a scientific organization devoted to promoting women's health and quality of life through an understanding of menopause.
Women’s Cancer Network
Sponsored by the Gynecologic Cancer Foundation, the Women’s Cancer Network has excellent overviews about ovarian cancer and links to finding a gynecologic-oncologist.
Further reading - books
Dr. Susan Love’s Menopause and Hormone Book, by Susan Love
I'm Not in the Mood : What Every Woman Should Know About Improving Her Libido, by Judith Reichman
Ovarian Cancer: Your Guide to Taking Control, by Kristine Conner and Lauren Langford
Restore Yourself : A Woman's Guide to Reviving Her Sexual Desire and Passion for Life, by James A. Simon, M.D., and Victoria Houston
Further reading - articles (advanced reading)
Primary
Fallopian Tube Malignancies in BRCA-Positive Women Undergoing Surgery for
Ovarian Cancer Risk Reduction
Michael J. Callahan, Christopher P. Crum,
Fabiola Medeiros, David W. Kindelberger, Julia A. Elvin, Judy E. Garber,
Colleen M. Feltmate, Ross S. Berkowitz, Michael G. Muto. Journal
of Clinical Oncology. Volume 25, No. 25: p. 3985-3990, September 2007.
Effect
of Short-Term Hormone Replacement Therapy on Breast Cancer Risk Reduction
After Bilateral Prophylactic oophorectomy in BRCA1 and BRCA2 mutation carriers:
The PROSE Study Group
Timothy R. Rebbeck, Tara Friebel, Theresa Wagner,
Henry T. Lynch, Judy E. Garber, Mary B. Daly, Claudine Isaacs, Olufunmilayo
I. Olopade, Susan L. Neuhausen, Laura van 't Veer, Rosalind Eeles , D.
Gareth Evans, Gail Tomlinson, Ellen Matloff, Steven A. Narod, Andrea Eisen,
Susan Domchek, Katrina Armstrong, and Barbara L. Weber. Journal
of Clinical Oncology, (Published on-line ahead of print).,October 2005.
The
effect of total hysterectomy on specific sexual sensations
Martha
F. Goetsch. American Journal of Obstetrics
and Gynecology, Volume
196, Issue 6: p. 1922-1927, June 2005.
Four
year follow-up of outcomes following risk-reducing salpingo-oophorectomy
in BRCA mutation carriers
Y. Kemel, N. D. Kauff, M. E. Robson, D. J.
Goldfrank, E. Wadsworth, T. Diiorio, J. Boyd, C. A. Hudis, R. R. Barakat,
K. Offit. American Society of Clinical Oncologists. (abstract # 1013),
May 2005. (Annual conference proceedings abstract)
Risk-reducing salpingo-oophorectomy
in BRCA mutation carriers: Role of serial sectioning in the detection of
occult malignancy
C. Bethan Powell, Eric Kenley, Lee-may Chen, Beth
Crawford, Jane McLennan, Charles Zaloudek, Miriam Komaromy, Mary Beattie,
John Ziegler. Journal of Clinical Oncology, Volume 23, Number 1:p. 127-132,
January 2005.
BRCA
germline mutations in Jewish women with uterine serous papillary carcinoma
Ofer
Lavie, Gila Hornreich, Alon Ben-Arie, Gad Rennert, Yoram Cohen, Rehuven
Keidar, Shlomi Sagi, Efrat Levy Lahad, Ron Auslander and Uzi Beller. Gynecologic
Oncology, Volume 92, Number 2: p. 521-524, February 2004.
Genetic
testing for a BRCA1 mutation: Prophylactic surgery and screening behavior
in women 2 years post testing
Jeffrey R. Botkin, Ken R. Smith, Robert
T. Croyle, Bonnie J. Baty, Jean E. Wylie, Debra Dutson, Anna Chan, Heidi
A. Hamann, Caryn Lerman, Jamie McDonald, Vickie Venne, John H. Ward, Elaine
Lyon. American Journal of Medical Genetics. Volume 118A, Issue 3: p. 201-209,
February 2003.
Effect of prevention
strategies on survival and quality-adjusted survival of women with BRCA1/2
mutations: An updated decision analysis
Victor R. Grann, Judith S.
Jacobson, Dustin Thomason, Dawn Hershman, Daniel F. Heitjan, Alfred I.
Neugut. Journal of Clinical Oncology. Volume 20, Issue 10: p. 2520-2529,
May 2002.
Risk-reducing
salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation
Noah
D. Kauff, M.D., Jaya M. Satagopan, Ph.D., Mark E. Robson, M.D., Lauren
Scheuer, M.S., Martee Hensley, M.D., Clifford A. Hudis, M.D., Nathan A.
Ellis, Ph.D., Jeff Boyd, Ph.D., Patrick I. Borgen, M.D., Richard R. Barakat,
M.D., Larry Norton, M.D., Mercedes Castiel, M.D., Khedoudja Nafa, Ph.D.,
and Kenneth Offit, M.D., M.P.H. New England
Journal of Medicine. Volume
346: p. 1609-1615, May 2002.
Prophylactic
oophorectomy in carriers of BRCA1 or BRCA2 mutations
Timothy R. Rebbeck,
Ph.D., Henry T. Lynch, M.D., Susan L. Neuhausen, Ph.D., Steven A. Narod,
M.D., Laura van't Veer, Ph.D., Judy E. Garber, M.D., M.P.H., Gareth Evans,
M.D., Claudine Isaacs, M.D., Mary B. Daly, M.D., Ph.D., Ellen Matloff,
M.S., Olufunmilayo I. Olopade, M.D., Barbara L. Weber, M.D. New
England Journal of Medicine. Volume 346: p. 1616-1622, May 2002. (Note: a
review of the above two articles on oophorectomy and breast and ovarian
cancer risk appears in the same issue of the New England Journal of Medicine.)
Outcome of preventive
surgery and screening for breast and ovarian cancer in BRCA mutation carriers
Lauren
Scheuer, Noah Kauff, Mark Robson, Bridget Kelly, Richard Barakat, Jaya
Satagopan, Nathan Ellis, Martee Hensley, Jeff Boyd, Patrick Borgen, Larry
Norton, Kenneth Offit. Journal of Clinical Oncology. Volume 20, Issue 5:
p. 1260-1268, March 2002.
Natural hormone replacement
therapy: What it is and what consumers really want
Dana Reed-Kane,
PharmD, FIACP, FACA. International Journal of
Pharmaceutical Compounding.
Volume 5, Number 5: p. 332-335. September/October 2001.
Tubal
ligation and risk of ovarian cancer in carriers of Brca1 or BRCA2 mutations:
A case-control study
Steven A Narod, Ping Sun, Parviz Ghadirian, Henry
Lynch, Claudine Isaacs, Judy Garber, Barbara Weber, Beth Karlan, David
Fishman, Barry Rosen, Nadine Tung, Susan L Neuhausen. Lancet. Volume 12,
Issue 357(9267): p. 1467-70, May 2001.