Risk-Reducing Salpingo-Oophorectomy and the Use of Hormone Replacement Therapy Below the Age of Natural Menopause (Scientific Impact Paper No. 66)
This Scientific Impact Paper details the risk factors for ovarian cancer which determine the indications for and timing of risk-reducing salpingo-oophorectomy. It also outlines the subsequent consequences of premature surgical menopause and the role of hormone replacement therapy – its benefits, risks and limitations.
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This Scientific Impact Paper was developed prior to the emergence of the COVID-19 coronavirus. Please note that the information provided in this paper will be considered for update 3 years after publication, with an intermediate assessment of the need to update 2 years after publication.
This is the first edition of this paper.
Plain language summary
This paper deals with the use of hormone replacement therapy (HRT) after the removal of fallopian tubes and ovaries to prevent ovarian cancer in premenopausal high risk women.
Some women have an alteration in their genetic code, which makes them more likely to develop ovarian cancer. Women with a strong family history of ovarian cancer and/or breast cancer may also be at increased risk of developing ovarian cancer.
Women at increased risk can choose to have an operation to remove the fallopian tubes and ovaries, which is the most effective way to prevent ovarian cancer. This is done after a woman has completed her family.
However, removal of ovaries causes early menopause and leads to hot flushes, sweats, mood changes and bone thinning. It can also cause memory problems and increases the risk of heart disease. It may reduce libido or impair sexual function.
Guidance on how to care for women following preventative surgery who are experiencing early menopause is needed.
HRT is usually advisable for women up to 51 years of age (average age of menopause for women in the UK) who are undergoing early menopause and have not had breast cancer, to minimise the health risks linked to early menopause.
For women with a womb, HRT should include estrogen coupled with progestogen to protect against thickening of the lining of the womb (called endometrial hyperplasia). For women without a womb, only estrogen is given.
For women with a history of receptor-negative breast cancer, the gynaecologist will liaise with an oncology doctor on a case-by-case basis to help to decide if HRT is safe to use.
Whether to undergo surgery to reduce risk or not and its timing can be a complex decision-making process. Women need to be carefully counselled on the pros and cons of both preventative surgery and HRT use so they can make informed decisions and choices.
Declaration of interests (guideline developers)
Professor R Manchanda MRCOG, London: Research grants from Cancer Research UK, The Eve Appeal, Barts Charity, Rosetrees Trust, China Medical Board and the British Gynaecological Cancer Society. Fellowship grant from NHS Innovation Accelerator. Various payment/honoraria from AstraZeneca, GlaxoSmithKline and Merck Sharp & Dohme. Trial Steering Committee (TSC) member on ALDO, PROTECTOR, UKFOCSS, SIGNPOST and PROMISE FS studies. Trial Outcomes Committee member, UKCTOCS. TSC Chair, BRCA Direct. Independent Advisory Committee Scientific Advisor/Chair, Mermaid Project (Denmark). Scientific Advisor, GO Girls and BRCA Umbrella. National Cancer Programme Early Diagnosis Task and Finish Group member.
Dr F Gaba MRCOG, London: Honoraria from AstraZeneca for educational material development.
Dr VS Talaulikar MRCOG, London: Lecture honorarium from Mylan.
Dr J Pundir MRCOG, London: None declared.
Dr S Gessler PhD, University College Hospital Gynaecological Cancer Research Centre: None declared.
Miss MC Davies FRCOG, London: Chief Investigator, POISE study. British Menopause Society Medical Advisory Council elected member.
Professor U Menon FRCOG, London: Research Advisory Panel member at Yorkshire Cancer Research. Data Monitoring Committee Chair on GEM3 trial. Trial Steering Committee member on NOVEL and PROTECTOR. GCP Professional Certification Scheme Steering Committee member, CDSA, THSTI, India. Clinical and Public Health Fellowship Selection Committee member and Early Career Fellowship Selection Committee member, Wellcome Trust DBT India Alliance. Prevention Expert Review Panel, Population Research Committee member, Cancer Research UK. Shares in Abcodia, awarded by University College London.