Prophylactic oophorectomy: Preventing cancer by surgically removing your ovaries

If you have a mutation in breast cancer gene BRCA1 or BRCA2, you're at significantly increased risk of breast and ovarian cancers. Preventive (prophylactic) mastectomy — the surgical removal of your breasts to reduce your risk of breast cancer — is one possible option. Another is preventive (prophylactic) oophorectomy, or the surgical removal of the ovaries. Although the procedure is usually performed to reduce ovarian cancer risk, having an oophorectomy before you reach menopause also reduces your risk of breast cancer.

Before you consider such a drastic approach to breast and ovarian cancer prevention, talk with a genetic counselor. A breast health specialist and a gynecologic oncologist can help to further assess your risk. From there, weigh the pros and cons of the surgery and understand all its implications.

Oophorectomy vs. mastectomy

You might think that preventive mastectomy would be the most likely way to lower your risk of breast cancer — and it does reduce breast cancer risk 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 you see ovarian cancer as a greater threat than breast cancer. In fact, ovarian cancer is more difficult to detect and treat at an early stage than is breast cancer, so it's more likely to be deadly. 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. And taking estrogen — an effective treatment for menopausal symptoms — is controversial for women at high risk of breast cancer.

Some women decide to go ahead with one procedure initially and then years later may decide to follow through with the other procedure. The decision to pursue one or both procedures depends on your individual situation. If you think you may be at high risk of breast or ovarian cancer, seek genetic counseling. A genetic counselor can perform a risk assessment, give you information on the limitations, risk and benefits of genetic testing, and discuss your surgical options, as well as preventive drug therapy (chemoprevention) options.

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

Who is prophylactic oophorectomy recommended for?

Prophylactic oophorectomy is usually recommended if you're at greatly increased risk of breast cancer and ovarian cancer due to an inherited mutation in the BRCA1 or BRCA2 gene — 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.

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, be certain that your childbearing is complete before you arrange for surgery. Your doctor can help you understand and manage your risk in the meantime.

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.

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 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.

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.

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, but a hysterectomy alone will not reduce your risk of breast or ovarian cancer. Whether to have a hysterectomy often comes down to individual preferences. Factors that may influence the 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.

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 every six months to one year to check for ovarian cancer, although the effectiveness of such screening is unclear.

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.

Another alternative is estrogen-suppressing medication to slow or stop the production of estrogen by your ovaries. The effects of estrogen-suppressing medication are potentially reversible — all you have to do is stop taking it. Estrogen-suppressing medications reduce breast cancer risk, but they may not affect your risk of ovarian cancer.

Tubal ligation — cutting or sealing your fallopian tubes, typically for birth control — may reduce your risk of ovarian cancer as well. Researchers have found that tubal ligation lowers the risk of ovarian cancer by about 60 percent in women with BRCA1 mutations, although no benefit has been demonstrated in women with BRCA2 mutations. While prophylactic oophorectomy offers far greater risk reduction, you may prefer the less drastic option of tubal ligation, particularly if you're in your late 20s to mid-30s and you've finished having children.