Study: Hormone therapy and breast cancer risk after ovary removal in women with a BRCA1 mutation

The National Comprehensive Cancer Network (NCCN) provides guidelines for the management of gynecologic cancer risk in people with BRCA1 and BRCA2 mutations. 

Prevention

• Risk-reducing removal of ovaries and fallopian tubes, (known as risk-reducing salpingo-oophorectomy or RRSO) is recommended between ages 35-40 for BRCA1 and 40-45 for BRCA2 and upon completion of childbearing.
  • Research shows that removing the ovaries can increase survival for women with BRCA1 or BRCA2 mutations. 
  • Women should talk with their doctors about the effects of early menopause and options for managing them.
• Women should talk with their doctors about the risks and benefits of keeping or removing their uterus (hysterectomy), including:
  • Women with a BRCA1 or BRCA2 mutation have an increased risk for a rare form of aggressive uterine cancer; hysterectomy removes this risk. 
  • For women considering hormone replacement after surgery, the presence or absence of a uterus can affect the choice of hormones used.
    • Estrogen-only hormone replacement is less likely to increase the risk for breast cancer, although it increases the risk for uterine cancer. Women who still have their uterus are typically given hormone replacement with both estrogen and progesterone.
    • Adding progesterone to estrogen hormone replacement can protect against uterine cancer. However, the combination of these hormones may increase the risk for breast cancer more than estrogen alone. 
  • A medical history of fibroids or other uterine or cervical issues may justify a hysterectomy. 
• Oral contraceptives (birth control pills) have been shown to lower the risk for ovarian cancer in women with BRCA mutations. Research on the effect of oral contraceptives on breast cancer risk has been mixed. Women should discuss the benefits and risks of oral contraceptives for lowering ovarian cancer risk with their doctors. 
• Removal of the fallopian tubes only (salpingectomy) is being studied as an option for lowering risk in high-risk women who are not ready to remove their ovaries. Studies on the effects of salpingectomy are ongoing. Whether salpingectomy lowers the risk for ovarian cancer in high-risk women remains unknown. 
  • Consider enrolling in a research study looking at this procedure to lower cancer risk.

Screening

• There are no proven benefits to routine ovarian cancer screening using transvaginal and a CA-125 blood test. These tests are not currently recommended.
• After RRSO, a very small risk remains for a related cancer known as primary peritoneal cancer (PPC). There is no effective screening for PPC after RRSO
• Women should be aware of the symptoms of gynecologic cancer and report abnormalities to their doctors, particularly if they persist for several weeks and are a change from normal.  These symptoms can include:
  • pelvic or abdominal pain
  • bloating or distended belly
  • difficulty eating
  • feeling full sooner than normal
  • increased urination or pressure to urinate 

Updated: 01/29/2025

The National Comprehensive Cancer Network (NCCN) provides the following guidelines for the management of gynecologic cancer risk in people with inherited mutations that are linked to endometrial or ovarian cancer. We recommend that you speak with a genetics expert who can look at your personal and family history of cancer and help you to determine the best risk management plan. 

BRIP1, RAD51C or RAD51D mutation

• Recommend risk-reducing salpingo-oophorectomy between the ages of 45-50.

Lynch syndrome

• Be aware of endometrial and ovarian cancer symptoms.
• Consider endometrial biopsy every 1-2 years beginning at ages 30-35.
• For postmenopausal women, consider transvaginal ultrasound after discussion with your doctor. 
• Consider risk-reducing hysterectomy; discuss risk-reducing removal of ovaries and fallopian tubes with your doctor (EPCAM, MLH1, MSH2 and MSH6).
• Discuss the benefits and risks of oral contraceptives.

PTEN mutation

• Be aware of endometrial cancer symptoms.
• Consider endometrial biopsy every 1-2 years beginning at age 35.
• For postmenopausal women, consider transvaginal ultrasound after a discussion with your doctor. 
• Consider risk-reducing hysterectomy. 

Updated: 02/23/2023

The National Comprehensive Cancer Network (NCCN) has cancer risk management guidelines for people with inherited mutations linked to cancer. The NCCN panel's guidelines on risk management for women at high risk for ovarian cancer states: 

• Some research shows that hormone replacement after RRSO does not negate the reduction in breast cancer risk associated with the surgery. However, the panel cautions those considering hormone replacement to consider the limitations of the existing research when making this decision.
• Individuals who undergo hysterectomy at the time of RRSO are candidates for estrogen-only hormone replacement therapy, which has been associated with a lower risk for breast cancer compared with combined estrogen and progesterone therapy. Individuals with an intact uterus are not candidates for estrogen-only therapy due to the increased risk of endometrial cancer. 

The North American Menopause Society is a professional society of experts in the field of menopause.

• In 2017, the organization released a position statement on hormone replacement therapy, which includes the following: 
  • Menopause symptoms and a variety of diseases are more likely to occur in women who have surgical menopause from ovary removal. These symptoms can have a major effect on quality of life and potential adverse effects on the cardiovascular system, bone, mood, sexual health and cognition, which have been shown in observational studies to be lessened by estrogen therapy. 
  • Unless contraindications are present, estrogen therapy for women who have removed both ovaries is indicated to reduce their risk of sexual side effects, bone loss, heart disease and cognitive decline. For women who retain their uterus, endometrial protection (progesterone) is indicated.
• Specific to women with BRCA1 or BRCA2 mutations who have removed their ovaries to lower their cancer risk:
  • For women with BRCA1 or BRCA2 mutations who have not been diagnosed with breast cancer, some evidence suggests that hormone therapy after oophorectomy does not further increase the risk for breast cancer.
  • Considerations should be made regarding the benefits of estrogen to prevent health risks caused by surgical menopause.
  • Considerations should be made (based on limited data) about hormone therapy until age 52, with discussions about longer use based on the individual patient.
• In 2018, the organization released a joint position statement with the International Society for the Study of Women's Sexual Health regarding the management of genitourinary syndrome of menopause (GSM) in women who have or are at high risk for breast cancer, including the following:
  • People with or at high risk for breast cancer should discuss treatment options for GSM with their healthcare providers, using a shared decision-making approach. 
  • For women diagnosed with breast cancer:
    • Vaginal moisturizers and lubricants are recommended as initial treatment options. 
    • Local (vaginal) hormone treatment may be considered when nonhormonal options do not work. Local therapy should be individualized, taking into account the risk of disease recurrence and severity of vaginal symptoms. 
    • Intravaginal estrogens in women on tamoxifen may be less of a concern than intravaginal estrogens in women on aromatase inhibitors. 
  • For high-risk women without breast cancer who have undergone RRSO, vaginal hormone therapy is likely to be safe. 

Updated: 08/13/2024

The following resources can help you locate an expert near you or via telehealth. 

Finding menopause experts

• The Menopause Society has a tool to help you find a qualified menopause expert in your area. 

Related experts

Other experts may manage some symptoms of menopause. People experiencing menopause symptoms may benefit from a consultation with the following experts:

Sexual health experts

• The Sexual Medicine Society of North America has a search tool to find experts in your area who provide sexual health care services.
• The American Association of Sexuality Educators, Counselors and Therapists maintains a tool to help people find a sexual health expert near them. 

Acupuncture experts

• The National Certification Commission for Acupuncture and Oriental Medicine has a searchable directory of licensed acupuncturists.

Sleep experts

• The American Academy of Sleep Medicine maintains the public-facing website sleepeducation.org, which includes a section on finding a sleep center by location. 

Bone density experts

• The Bone Health and Osteoporosis Foundation has a searchable database for finding experts. 

Other ways to find experts

• Register for the FORCE Message Boards and post on the Find a Specialist board to connect with other people who share your situation. 
• National Cancer Institute (NCI)-designated comprehensive cancer centers have specialists to manage the symptoms and side effects of cancer prevention or treatment. 

Updated: 09/11/2024