Prophylactic oophorectomy: Removing your ovaries to reduce your risk of breast and ovarian cancer

Your doctor has determined that you carry a mutation in breast cancer gene BRCA1 or BRCA2. A mutation to either of these genes significantly increases your risk of breast and ovarian cancer. Your heart freezes at the thought of preventive mastectomy — the surgical removal of your breasts to prevent breast cancer. Do other preventive care options exist?

Yes, in fact, they do. One is called preventive (prophylactic) oophorectomy — the surgical removal of your ovaries. Although the procedure is usually performed to reduce your risk of ovarian cancer, if performed before you reach menopause it also reduces your risk of breast cancer.

But the surgery isn't for everyone. Before considering such a severe approach to breast and ovarian cancer prevention, talk with a genetic counselor to assess your risk. From there, weigh the pros and cons of the surgery and understand the implications that the surgery will have for you.

What is preventive oophorectomy, and what does it have to do with breast cancer?

Oophorectomy refers to the surgical removal of your ovaries. Removing your ovaries greatly reduces the amount of circulating estrogen in your body. This can halt or slow breast cancers that depend on estrogen to grow.

How much of an impact can this have on your risk of breast and ovarian cancer? A significant one. Prophylactic oophorectomy reduces your risk of breast cancer by about 50 percent if you're premenopausal, and it reduces your risk of ovarian cancer by up to 95 percent — no matter what your menopausal status.

Oophorectomy vs. mastectomy

You might think that preventive mastectomy would be the best way to lower your risk of breast cancer. And the procedure does reduce your risk of breast cancer to a much greater extent than does prophylactic oophorectomy. However, you might choose prophylactic oophorectomy over mastectomy because oophorectomy protects against both breast and ovarian cancer, rather than just breast cancer. Having a BRCA1 or BRCA2 gene mutation puts you at risk of both diseases.

You might also opt for prophylactic oophorectomy because ovarian cancer is much more difficult than is breast cancer to detect and treat at an early stage. Preventive mastectomy by itself offers no protection against ovarian cancer.

Oophorectomy also may seem appealing if you're concerned about how you'll look if you have your breasts removed. The downside, though, is that you'll experience premature menopause.

You attain the greatest risk reduction for ovarian and breast cancer by having both procedures.

Who is prophylactic oophorectomy recommended for?

Prophylactic oophorectomy is usually recommended if you're at increased risk of breast cancer and ovarian cancer due to an inherited mutation in the BRCA1 or BRCA2 genes — two genes linked to breast cancer, ovarian cancer and other cancers. High-risk women age 35 and older who have completed their families are the best candidates for this surgery.

If you have a BRCA1 or BRCA2 gene alteration, your risk of ovarian cancer is much higher than it is for the general population — and your risk of breast cancer is even higher. But because ovarian cancer is much more difficult to detect at an early stage than is breast cancer, it's more likely to be deadly.

Because BRCA1 carriers are at risk of developing ovarian cancer at an earlier age than are BRCA2 carriers, they usually have the procedure at an earlier age — between ages 35 and 40. Carriers of a BRCA2 alteration can usually delay the procedure until age 45. In either case, you may be able to postpone having prophylactic oophorectomy until you've finished having children.

Prophylactic oophorectomy may also be recommended if you have a strong family history of breast cancer and ovarian cancer but no known genetic alteration. It might also be recommended if you have a strong likelihood of carrying the gene mutation based on your family history but choose not to proceed with genetic testing.

Assessing your cancer risk

Whether or not prophylactic oophorectomy is your best choice hinges upon your risk of developing breast or ovarian cancer. Your level of risk depends on your personal medical history, your family history and your genes.

You might be considered at high risk of breast and ovarian cancer and a candidate for prophylactic oophorectomy if you have a known mutation in the BRCA1 or BRCA2 genes. You might also be a candidate if you have certain combinations of the following risk factors:

• A personal history of breast cancer diagnosed before menopause
• A known mutation of the breast cancer genes — BRCA1 or BRCA2 — in your family
• A first-degree relative, such as your mother, sister or daughter, with onset of breast cancer before age 50
• A family member diagnosed with ovarian cancer before age 50
• A family history of ovarian cancer in two or more relatives
• A male family member with breast cancer
• Ashkenazi Jewish ancestry

If one or more of these factors apply to you, consider making an appointment with a genetic counselor. A genetic counselor can chart your family history, provide an assessment of your cancer risk based on your family history and discuss with you the merits of genetic testing in your particular situation. The genetic counselor will help you understand your individual risk to aid in your decisions about prophylactic surgery. You may also want to meet with a breast health specialist and gynecologic surgeon to discuss other options.

The surgical procedure

Prophylactic oophorectomy can be performed using a minimally invasive technique known as laparoscopic oophorectomy. With the laparoscopic approach, a surgeon makes three or four small incisions in your lower abdomen rather than a full abdominal incision and uses special surgical instruments to perform the procedure. Usually, if your ovaries are removed, your doctor will recommend also removing the fallopian tubes (salpingo-oophorectomy) because they're also susceptible to cancer if you're at high risk. If your surgery is done laparoscopically, you'll probably be able to go home the same day as the procedure.

During the procedure, your doctor carefully explores the inside of your pelvis and abdomen to check for signs of cancer. This might dictate how much tissue and which organs are removed.

Your uterus may also be removed at the time your ovaries and fallopian tubes are removed. If you're at increased risk of uterine cancer, your doctor will likely recommend surgery to remove your uterus (hysterectomy) at the time of your prophylactic oophorectomy. The advantages and disadvantages of hysterectomy represent a highly individual choice. Factors that may influence your decision include prior or current use of tamoxifen, pressures to return to work or physical activity, and individual risk factors for uterine cancer, such as obesity.

If you choose to also have a hysterectomy, your doctor may suggest one of several possible approaches, including:

• Total abdominal hysterectomy with salpingo-oophorectomy
• Laparoscopically assisted vaginal hysterectomy with salpingo-oophorectomy
• Vaginal hysterectomy with salpingo-oophorectomy

If you have a hysterectomy along with prophylactic oophorectomy, the surgery will be more complicated and will require a hospital stay.

Risks of surgery

Any surgery carries with it the potential for complications. With laparoscopic oophorectomy, rare complications include infection, intestinal blockage and injury to internal organs.

However, the biggest risks of surgery aren't from the surgical procedure itself but from the loss of hormone function in premenopausal women. If you haven't already gone through menopause, prophylactic oophorectomy will cause you to go into early menopause. You then face these health risks:

• Osteoporosis. Although circulating estrogen may help some breast cancers grow, the estrogen your body makes has a protective effect on your bones. Removal of your ovaries if you're premenopausal means you lose the protective effect of estrogen and increase your risk of the bone-thinning disease osteoporosis. You may need to take a bone-building medication to prevent or treat osteoporosis.
• Discomforts of menopause. Hot flashes, vaginal dryness, sexual problems, sleep disturbance and sometimes cognitive changes are problems that some women experience during menopause. Removing your ovaries doesn't mean you'll experience such common menopausal signs and symptoms, but the risk is greater that some of these discomforts could impact your quality of life. Ask your doctor about non-hormonal alternatives, such as healthy lifestyle options, for managing bothersome menopausal signs and symptoms.
• Cancer. Although prophylactic oophorectomy can reduce your cancer risk a great deal, the surgery doesn't completely eliminate your risk of breast or ovarian cancer. Also, because it's possible that some ovarian cells or tissue may remain in your abdomen or pelvis (peritoneum) after an oophorectomy, you could still develop cancer in those cells. This risk is small but still present.

Alternatives to oophorectomy

As you consider prophylactic oophorectomy, be aware that there are alternatives. For instance, you can bypass surgery altogether and instead keep a close watch on your situation. This might entail having clinical breast exams every six months and mammograms every year to check for breast cancer, as well as other breast imaging, such as magnetic resonance imaging (MRI), upon your doctor's discretion. You might also need to have blood screening and pelvic ultrasounds to check for ovarian cancer.

It's also possible that you may qualify for medication that has a known preventive effect on cancer (chemoprevention), such as tamoxifen for breast cancer or birth control pills for ovarian cancer.

Emotional effects of prophylactic oophorectomy

If you have a high risk of breast and ovarian cancer, prophylactic oophorectomy might make you feel better about your future because it can significantly reduce your risk. You might spend less time worrying about your health after the surgery.

However, this type of surgery also can take a toll emotionally. You might mourn the loss of your fertility — even if you didn't plan on having children in the future. You may have concerns over taking hormone therapy, especially in light of the associated health risks reported in recent years. Or you may, like some, have a strong sense of femininity tied to your ovaries and other reproductive organs. You might fear that you'll somehow be less of a woman.

The decision to have prophylactic oophorectomy is a difficult one. There's no clearly right or wrong answer. It comes down to a personal choice that merits advice from a genetic counselor along with discussions with a breast health specialist or gynecologic surgeon. Whether it's right for you — and when it might be right for you — depends on your individual risk of cancer and how aggressive you want to be in your cancer prevention efforts.