Elective and Risk Reducing Salpingo-Oophorectomy

Risk reducing implies ovaries are normal during the time of removal

Elective is ovaries are removed at time of another indicated surgery

Menopause- 51 years, estradiol decreases by 90% because of follicular arrest and estrone becomes dominant estrogen.

Estrone produced after menopause comes from peripheral conversion adrenal androstenedione by aromatase primarily in adipose tissues.

Androstenedione levels by ovary decrease 50% because of ovarian reduction, but adrenal androstenedione remains constant.

Factors favor oophorectomy- genetic susceptibility, bilateral ovarian neoplasms, severe endometriosis, PID, postmenopausal status.

Factors protective ovarian cancer- pregnancy, bilateral tubal ligation, oral contraceptives

Women with highest risk are those with HBOC and HNPCC

Inherited mutations or BRCA1 and BRCA2 account for 10-15% of all ovarian carcinoma. Mucinous and borderline ovarian are not suggestive of BRCA1 and BRCA2.

HNPCC inherited mutation in the DNA mismatch repair genes MSH2, MLHI, PMS2, MSH6. Most common types in women are colon endometrial cancer (40-60%) and ovarian (8-10%).

Criteria BRCA testing

Non- Ashkenazi Jewish-

• Two 1^st degree relatives with breast cancer diagnosed younger than 50 years old
• Combination of three 1^st or 2^nd degree relatives
• 1^st degree bilateral breast cancer
• Combination of two or more 1^st or 2^nd degree relatives with ovarian cancer at any age
• Male with breast cancer

Ashkenazi Jew-

• Any 1^st degree relative with breast or ovarian cancer
• Two 2^nd degree relatives on the same side of family with breast or ovarian cancer

Criteria for HNCC

• 3 or more relatives with HNPCC related cancers, colon, endometrium, small bowel, ureter, or renal pelvis
• Two or more successive generations are affected cancer diagnosed in at least one individual who is younger than 50 years
• Familiar adenomyosis polyposis should be excluded in any colorectal cancer

Estrogen replacement postmenopausal women have no increased risk in breast cancer or heart disease up to 7.5 years of use. But increased risk of thromboembolic disease and stroke.

Some studies to date suggest that that testosterone therapy and progestin therapy may be the determining factor in breast cancer risk with with postmenopausal hormone therapy.

Bilateral salpingo-oophorectomy should be offered to women with BRCA1 and BRCA2 mutations after completion of childbearing, preferably by age 40.

Bilateral salpingo-oophorectomy may be indicated for breast cancer survivors who have a high risk of ovarian cancer.

Salpingo-oophorectomy also may be indicated for hormonal therapy of breast cancer. Salpingo-oophorectomy appears to be more effective than tamoxifen alone as an adjuvant therapy in premenopausal women with hormone sensitive breast cancer. Ovarian ablation may be beneficial in women younger than 35 years old who are treated with chemotherapy for hormone sensitive breast cancer.

Estrogen receptor positive metastatic breast cancer is treated first with aggressive hormonal therapy that may include suppressing the ovaries either medically or surgically.