Decisions about hysterectomy
Hysterectomy is the surgical removal of the uterus.
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 risk-reducing salpingo-oophorectomy is not universally recommended for BRCA mutation carriers undergoing risk-reducing oophorectomy. However, some considerations may impact the decision to remove the uterus with the ovaries and fallopian tubes. 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 risk-reducing surgery include:
- Uterine cancer risk
Although an increased uterine cancer risk has not been associated with carriers of a BRCA mutation, some stuides have shown that BRCA1 mutation carriers are at an increased risk of a very rare type of uterine cancer called “uterine serous papillary carcinoma.” Women who have taken tamoxifen are also at an increased risk for uterine cancer.
- 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 women who are not at high risk for cancer, 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 women with mutations that increase cancer risk.
- Risk for fallopian tube cancer in the fallopian tube remnant:
Women with mutations that increase ovarian cancer risk are also 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 RRSO, 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 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.
Women who have a mutation that causes Lynch syndrome have an increased risk for uterine cancer; a risk-reducing hysterectomy is recommended.