Pink Hope invited Gynaecological Oncologist, Dr Greg Gard to help our community understand the prevention and detection of ovarian cancer, and the risk-reducing surgery options available to high risk women. You can view the recording of Dr Gard’s presentation and follow up Q&A session at this EduEvening, here.
You might be surprised to learn that a lot of ovarian cancer does not actually present in an ovary, most ovarian cancers arise in the fimbria of the fallopian tube. The fimbria is a section of the fallopian tube that opens to the peritoneal cavity. More on the different types of ovarian cancers is available to read in our latest blog .
Precancerous changes are very rarely identified in the ovary with serious tumours appearing similar to, the normal tubal lining. Precancerous changes are however often identified adjacent to cancer in a fallopian tube. When surgeons first started conducting RRS (risk reducing surgery) on high risk women, in the early 2000’s, microscopic cancers were predominately found in the fallopian tube. It is estimated now that 2% of risk reducing surgeries will uncover microscopic cancers.
Prior to this discovery, screening for ovarian cancer had focused solely on the ovaries, surgeons now know that they were looking in the wrong place. The preventative focus is now on identifying women at an increased risk and performing risk reducing surgery.
What is Risk Reducing Surgery
Until recently, risk reducing surgery was performed as RRSO, Risk Reducing Salpingo-Oophorectomy, which is the removal of both the fallopian tubes and the ovaries. However with the discovery that most ovarian cancers start in the fallopian tubes, surgeons are moving more towards RRESDO, Risk Reducing Early Salpingectomy with Delayed Oophorectomy, meaning an initial surgery to remove the fallopian tubes followed by a later surgery, often around the timing of menopause, to remove the ovaries.
The question that is now being considered, is if the tubes are removed, is the function of the ovary impacted? Very good evidence is now suggesting, that even with the removal of the tubes, ovarian function is preserved and appears to be unaffected. This evidence is being gathered through the study of the levels of Anti-Mullerian Hormone (AMH), a hormone used to measure ovarian reserve.
The IVF community also considers that the removal of the fallopian tubes does not impact a woman’s fertility opportunities, when undergoing IVF. Of course, removal of the fallopian tubes does mean a woman will no longer be able to fall pregnant naturally.
Why remove the fallopian tubes early?
By removing the fallopian tubes early, through RRESDO, you remove the risk of cancer while maintain ovarian function and preventing the onset of premature menopause.
For BRCA1 mutation carriers, it is recommended that this occur between the ages of 35-40, or several years prior to the youngest known ovarian cancer in your family tree. For BRCA2 carriers it is recommended around the age of 45, or a few years before the youngest known ovarian cancer in your family tree.
Menopause is brought on by the reduction in oestrogen and progesterone, hormones that are produced in the ovaries, this is a part of the natural ageing process but when the ovaries are removed, a woman will experience a premature menopause.
The symptoms of surgical menopause are varied and for some women, can be debilitating, they often include:
- Night sweats
- Hot flushes
- Vaginal dryness
- Weight gain
- Impacts on cardiovascular health, bone health and cognitive function
- Loss of libido and changes to a woman’s sexual health
Limitations of RRESDO
Although there is a significant theoretical reduction in risk when choosing to undergo RRESDO, this reduction has yet to be quantified or proven, with studies to-date only reflective of removing both fallopian tubes and the ovaries.
It is important to note that fimbrial tissue from the fallopian tubes is also found on the ovarian surface of around 10% of women. Therefore, the risk is not fully removed for these women when only the fallopian tubes are removed.
RRESDO requires a woman to undergo two operations, which of course means meeting the costs of two operations, and it is important to also consider the risk of complications during both surgeries. Although the surgeries are both uncomplicated, the risk of a complication is not zero and your surgeon will discuss this with you in detail during your consultation.
Hormone Replacement Therapy after RRSO
For a woman without a personal history of breast cancer and a genetic mutation, HRT will be recommended if both the fallopian tubes and ovaries are removed prior to the age of 51. However, HRT will be considered for women who have had a triple negative breast cancer, on a case by case basis.
The removal of ovaries does reduce a woman’s risk of breast cancer substantially so does taking HRT then increase this risk again? Dr Gard advises, yes it will, however it will not take the risk back to the level that it would have been prior to removing the ovaries.
The benefits of HRT will significantly improve the symptoms of surgical menopause, although will not remove the symptoms entirely, there is a proven reduction in osteoporosis and improvements in cardiovascular health, along with anecdotal evidence of improved cognitive function. All of these benefits will lead to an improved quality of life and sexual function.
Sexual Dysfunction after RRSO
Although this is an area of discussion that may bring about a level of discomfort, for both women and their surgeons, it is incredibly important that it is discussed when a woman is considering RRSO.
The impacts of RRSO on sexual function are most often:
- A decreased frequency of sex
- Low libido
- Vaginal dryness
- An inability to reach orgasm.
A study showed that 77% of women experienced some element of sexual dysfunction following RRSO and that up to 30% of these cases were considered to be severe, this study was carried out on a group of women with a very low use of HRT. The figures for women who did use HRT were substantially lower.
So, the good news is, HRT significantly improves sexual function and, as uncomfortable as the conversation might be for you, it is an important one to have with your surgeon.
You can view the recorded EduEvening webinar with Gynaecological Oncologist, Dr Greg Gard here, this article was written following Dr Gard’s presentation.