Ovarian Cancer: Surgery to Reduce Risk

Surgery to Lower Ovarian Cancer Risk

This section covers the following topics:

Note that when we use the terms "female" and "women" we are referring to people assigned female at birth. 

Removal of the ovaries and tubes

Experts believe that most ovarian cancers begin in the fallopian tubes. For this reason, surgical removal of the ovaries also includes removing the fallopian tubes as well. Surgery to remove the fallopian tubes and ovaries is called salpingo-oophorectomy.

What is risk-reducing salpingo-oophorectomy?

Risk-reducing salpingo-oophorectomy (RRSO) refers to the removal of the healthy ovaries and fallopian tubes to reduce a person's risk of developing cancer. Decades of research on RRSO in high-risk individuals has shown that:

• It is an effective way to lower the risk for ovarian and fallopian tube cancer. It does not completely eliminate the risk for these cancers. There is a remaining risk for primary peritoneal cancer even after the ovaries and tubes have been removed, but this risk is very small. 
• it can lower the risk for death in high-risk women.
• It may also lower the risk for breast cancer in certain high-risk women. 

What is risk-reducing salpingectomy?

• Salpingectomy involves removal of the fallopian tubes only. Research suggests that the fallopian tubes may be the source of many ovarian cancers. This has led researchers to study if it is safe to remove the fallopian tubes only before menopause and delay removal of the ovaries until after menopause. Studies looking at salpingectomy to lower risk are currently enrolling people. Until these studies are completed, experts cannot say for certain that salpingectomy lowers the ovarian cancer risk in high-risk people. 

Laparoscopic surgery

In the past, risk-reducing removal of the ovaries and tubes were performed using open surgery (also known as a laparotomy). This involves one long incision in the lower abdomen to remove the ovaries and fallopian tubes, (and for those undergoing hysterectomy, the uterus). Today, risk-reducing removal of the ovaries and tube can usually be performed by laparascopic surgery. Laparoscopic surgery involves a small incision made in the abdomen to insert a flexible scope with a camera, which is used to see the ovaries and tubes. Addition small incisions are made to insert surgical instruments needed to remove the ovaries and tubes.

In general, people who have surgery by laparoscopy may heal quicker and spend a shorter time in the hospital than people who have open surgery.

Hysterectomy during risk-reducing salpingo-oophorectomy

Hysterectomy can be performed at the same time as RRSO, especially for people who have an increased risk for both ovarian and endometrial cancer. Mutations in some of the Lynch syndrome genes increase the risk for both cancers. Although the overall risk is not increased, some studies have shown that inherited BRCA1 or BRCA2 mutations may increase the risk of a very rare but aggressive type of cancer called “uterine serous papillary carcinoma.” Medications like tamoxifen and progesterone may also increase the risk for uterine cancer.

People who have increased risk for ovarian cancer and average risk for endometrial cancer may still choose to remove their uterus at the same time that they undergo risk-reducing removal of their ovaries and fallopian tubes. Factors that may affect the decision to remove or spare the uterus at the time of risk-reducing salpingo-oophorectomy include:

• 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:
  Women who plan to take hormone replacement after RRSO may consider hysterectomy in order to simplify hormone replacement. There is an increased risk for uterine cancer in women who take estrogen alone compared to estrogen with progesterone. Women who have hysterectomy can take estrogen without progesterone. Estrogen alone may have fewer side effects than estrogen with progesterone. See our section on Surgical Menopause for more information. 
• 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.
• Insurance coverage:
  Because of the surgery, recovery and hospitalization are lengthier; some insurance companies won’t pay for hysterectomy unless there is medical necessity.
• Possible long term effects of hysterectomy:
  Hysterectomy may increase the risk for some of the long term health issues which may be associated RRSO. 

Surgical risks and recovery

Every surgery has risks; some are more serious than others. Some RRSO risks can affect recovery or long term health 

• Infection
• Delayed healing
• Blood loss
• Blood clots
• Pain (post-operative and long term pain syndromes)
• Surgical menopause and related health issues (see our section on Side Effects of Menopause for more information)
• Injury to internal organs
• Bladder incontinence
• Sexual side effects

It is important for people to discuss possible surgical risks with a surgeon to understand the seriousness and likelihood of these risks before making the decision to have risk-reducing surgery.

Average recovery time after RRSO is about 1-2 weeks. Recovery after open surgery is longer, up to 6 weeks. 

Who should have risk-reducing removal of the ovaries and tubes?

The National Comprehensive Cancer Network (NCCN), is an organization of cancer experts that creates guidelines on cancer care and updates them yearly. NCCN's guidelines include recommendations for risk-reducing salpingo-oophorectomy based on an individual's gene mutation and situation. Each gene has a slightly different recommendation, click on the links for each gene for the full risk-management recommendation.