Most of the media comments about Angelina Jolie’s decision to remove her ovaries have been along the lines of, “What a difficult decision!” or “Was it too radical?”
I’ve got news for you: Every day I see women who are BRCA positive. Knowing they have a gene mutation that guarantees almost a 50 percent chance of developing ovarian cancer does not make for a difficult decision. Most of them can’t get on my surgery schedule fast enough.
The decisions that BRCA-positive women must make once they opt for ovary removal are far more complex, including whether to go on hormone therapy.
When Should I Have My Ovaries Removed?
The most appropriate time to remove ovaries to prevent cancer is when pregnancy is no longer desired, but before cancer can occur. Hereditary cancers occur at a younger age than sporadic ovarian cancer. Statistically, age 35 is the point at which the most ovarian cancers can be prevented by surgical intervention. Many women, Angelina Jolie for one, prefer to hold off.
The Tubes Too?
Yes! We now know that the majority of ovarian cancers originate from the fallopian tubes. Removal of the tubes reduces ovarian cancer risk not only in BRCA-positive women, but also in every woman. In fact, women who are at risk but not ready or willing to remove their ovaries should consider tubal removal.
What About My Uterus?
The advantage of keeping the uterus is that there is still the ability to carry a pregnancy, albeit with someone else’s egg. The disadvantage of keeping the uterus is that there is always the possibility of uterine cancer.
Now just to be clear, women who have a BRCA mutation are NOT at increased risk of developing uterine cancer. However, if someone does not undergo mastectomy, they are often advised to take tamoxifen to protect their breasts. And tamoxifen increases the risk of uterine cancer. In addition, women who have post-menopause estrogen therapy must also use a progestin to protect the lining of their uterus, and that often creates problems.
Most experts believe the greater good is to undergo a prophylactic hysterectomy at the time of ovary removal. The additional surgery requires only an extra 20 to 30 minutes. And since the uterus is also removed laparoscopically, recovery time is no greater than if just the ovaries are removed.
Will Hormone Therapy Affect My Cancer Risk?
You may be thinking that it would be better to face the risk of ovarian cancer than go through early surgical menopause. However, when ovaries are removed at a young age, hormone therapy is not a problem because it’s not the hormones that create the risk for cancer but the ovarian tissue. Just as it is fine for a young woman with a BRCA mutation to take birth control pills if she still has her ovaries, it is fine to use hormone therapy to alleviate menopause symptoms. The real decision is determining which hormone therapy is best.
First, consider estrogen.
Despite the media hysteria, estrogen is not poison and estrogen does NOT increase the risk of breast cancer. You read that right. In the Women’s Health Initiative (WHI) study, in the estrogen-only group of women who had a hysterectomy, there was an 18 percent decrease in breast cancer. It is now clear that the modest increase that is sometimes seen in breast cancer in women who take hormone therapy is due to the progestin, not the estrogen. In addition, many women who undergo prophylactic removal of their tubes and ovaries also have a prophylactic mastectomy, essentially eliminating any concerns about breast cancer.
As far as the choice of estrogen, an FDA-approved, commercially produced plant-derived transdermal product (patch, spray, or gel) estrogen like Jolie chose has advantages over oral estrogens or compounded hormones. Further details regarding the specifics of estrogen choices are in my book, Sex Rx.
The Progestin Problem
If a woman is taking estrogen and still has her uterus, it is well established that she needs a progestin as well, because there is an increased risk of uterine cancer if you take estrogen only.
Because breast cancer risk increases if a progestin is taken along with estrogen, this presents a real dilemma for those women who, unlike Angelina Jolie, have not had a mastectomy but still need to protect their uterus.
In addition, many women don’t tolerate progestins and experience bloating, depression, and irregular bleeding.
One non-progestin alternative is to take the oral estrogen pill that is combined with a unique selective estrogen receptor modulator (SERM), bazedoxefene (Duavee), which blocks estrogen pathways in the uterine lining.
Another other option is to do what Jolie did, and that is to place a progestin IUD in your uterus. While standard in Europe, this is not yet FDA-approved here and is therefore an “off-label” practice. It is still a good idea and one I recommend to my patients as well. The disadvantage is that the IUD must be replaced every five to seven years as long as estrogen therapy is continued. For those women on a more limited budget than Jolie, cost is a consideration because an IUD is not covered by insurance after menopause.
If your uterus has been removed, there is no reason to take a progestin.
Breast and Ovarian Cancer in the Spotlight
Each year 22,000 American women are diagnosed with ovarian cancer. Of those, 5 percent to 10 percent are carriers of a BRCA mutation that is responsible for their cancer. Half a million women in the United States have this gene mutation, but more than 90 percent of women who are at very high risk for developing breast or ovarian cancer don’t even know it.
So kudos to Angelina Jolie for increasing awareness and going public with the other tough decisions she made.
Lauren Streicher, MD is the author of Sex Rx: Hormones, Health and Your Best Sex Ever and the definitive consumer publication on hysterectomy and alternatives, The Essential Guide to Hysterectomy. Connect with her on Twitter and Facebook.
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