By Kari Danziger, MS, CGC

Reviewed by Andrea Fishbach, MS, MPH and Miriam Komaromy, MD




Women who are at high risk for developing ovarian cancer have limited screening and prevention options, and in many cases the cancer has spread to other organs by the time it produces symptoms or is detected. This is why some women are willing to consider surgical removal of the ovaries in order to prevent ovarian cancer. Not surprisingly, there are many physiological and emotional issues to be weighed when considering this course of action.

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Why Remove Ovaries Before Ovarian Cancer Develops?

As with other cancers, ovarian cancer is easiest to treat if it is detected at an early stage. However, ovarian cancer has often spread to other parts of the body by the time it produces symptoms or is detected, making treatment difficult. In addition, screening for this type of cancer is both difficult and unreliable. Sometimes current methods fail to detect cancer when it's present, and other times they identify something that appears to be a cancer when it's not. (For these reasons, ovarian cancer screening isn't even recommended for women in the general population.) The mortality rate associated with ovarian cancer is high, primarily because often the disease is not detected until it's in an advanced stage.

Oral contraceptives taken for five years or more can reduce the risk of developing ovarian cancer by 40 percent to 50 percent

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For many women with elevated risk, the 40 to 50 percent risk reduction simply isn't enough. They want to do more — and one of the only remaining options is removing the ovaries (prophylactic oophorectomy). For this reason, many experts, including the National Institutes of Health, suggest that high-risk women consider having their ovaries removed once their child-bearing years are over, or after they reach the age of 35. The average age of ovarian cancer onset is mid- to late-40s in women with a BRCA1 mutation, and early- to mid-50s for women with a BRCA2 mutation. In looking at all women who have been diagnosed with ovarian cancer, the average age of onset is 57.

Prophylactic oophorectomy can also reduce the risk for breast cancer in high-risk women

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The Surgery

The surgical procedure for removing a woman's ovaries is called a prophylactic bilateral salpingo-oophorectomy (BSO). In this procedure a surgeon removes both of a woman's fallopian tubes and ovaries via one of two surgical procedures:

• Laporotomy. In a laporotomy, the surgeon makes a 5 to 11 inch long incision in the abdomen to remove both fallopian tubes and ovaries. This procedure is easier for the surgeon to perform, but involves a longer recovery, more postoperative pain, longer hospital stays, and more potential complications than the laparoscopy. If the woman is also having her uterus removed (hysterectomy) the surgeon can do that during the same procedure.
• Laparoscopy. In a laparoscopy the surgeon inserts a videocamera, or laparoscope, through a small (1/4 inch) incision in the belly button. With this camera, the surgeon can see the pelvic organs on a television monitor in the operating room. The surgeon then inserts other instruments needed for the surgery through two or three additional incisions in or near the pubic hairline. The ovaries are then removed through a small incision in the vagina, or sectioned into smaller pieces and removed through the abdominal openings. Women who undergo a laparoscopy rather than a laporotomy have less postoperative pain, a shorter recovery, and excellent outcomes. However, this type of surgery is very difficult to master so many doctors prefer the laporotomy.

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Issues to Consider

The risks involved in prophylactic oophorectomy include: - Surgical risks - The resulting infertility - Side effects entailed by premature menopause - Psychological and social repercussions

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Surgical Procedures. Ask your doctors not only about the procedures themselves but also about recovery time and the psychological and physiological aftermath of surgery — that is, how you can expect to feel physically and emotionally after the prophylactic surgery is complete.

Residual risk. Although removing the ovaries can reduce your risk of developing ovarian cancer, residual cells that could become cancerous may still remain in the peritoneum — the membranous lining of the abdominal cavity, which surrounds most of a person's internal organs. This type of cancer is called primary peritoneal carcinoma. On a cellular level, it is indistinguishable from ovarian cancer and may occur because of ovarian tissue that remains after surgery or perhaps because the cancer has spread to these cells prior to surgery. Talk with your doctor about the odds of developing this or other types of cancer after surgery.

The reduction in ovarian cancer risk due to prophylactic oophorectomy is likely to be between 50 to 75 percent

Surgically induced menopause. Natural menopause occurs when a woman stops menstruating and her ovaries produce significantly less estrogen. However, menopause also results when the ovaries are removed. The symptoms and risks associated with menopause are largely the same whether its onset is natural or surgically induced. However surgically-induced menopause is much more abrupt, rather than the natural process that occurs over several months or years. As with natural menopause, hormone replacement therapy (HRT) can reduce symptoms such as hot flashes, vaginal dryness, incontinence (involuntary loss of urine), decreased interest in sexual relations, sleep disturbances, and cognitive changes. HRT can also offset the increased risk for osteoporosis that occurs when the body is no longer producing estrogen and many physicians believe that it can also reduce the risks of cardiovascular disease.

However, studies have shown that HRT may increase the risk for breast cancer in women who are already at increased risk for the disease (such as women with BRCA1 and BRCA2 mutations). The increased risk for developing breast cancer depends on the duration of HRT and on whether estrogen and progesterone are both included in the hormone mix. For these reasons, any woman considering prophylactic oophorectomy should consider whether HRT will be an acceptable option for coping with menopausal symptoms.

Psychological impact. Some women choose prophylactic surgery because they want to reduce their risk and anxiety about developing ovarian cancer. Other women — regardless of risk — do not consider prophylactic surgery an acceptable option. Surgical menopause can be interpreted as an abrupt change in life stage from pre- to post-menopausal. Although it is not associated with actual aging, some women experience a psychological shift in perceived life stage as they experience the side effects of menopause including hot flashes and night sweats, as well as possible mood swings. Talk to a counselor or a genetics specialist to thoroughly evaluate your own feelings.

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References

NIH Consensus Conference. (1995). Ovarian cancer. Screening, treatment, and follow-up. NIH Consensus Development Panel on Ovarian Cancer. JAMA. 273(6):491-7.

Struewing JP, Watson P, Easton DF et al. (1995). Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr. 17:33-35.

Piver MS, Jishi MF, Tsukada Y, and Nava G. (1993). Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer. A report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer. 71(9):2751-5.

Nguyen HN, Averette HE and Janicek M. (1994). Ovarian carcinoma. A review of the significance of familial risk factors and the role of prophylactic oophorectomy in cancer prevention. Cancer. 74(2):545-55.

Kerlikowske K, Brown JS and Grady DG. (1992). Should women with familial ovarian cancer undergo prophylactic oophorectomy? Obstet Gynecol. 80(4):700-7.