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DEAR MAYO CLINIC: I am 42 years old and have a BRCA1 gene mutation. I’ll have a prophylactic oophorectomy later this year. I have had a prophylactic mastectomy as well, and am considering hormone replacement therapy. How soon after surgery would I need to start taking hormones? What are the risks if I decide against hormone replacement?
ANSWER: For a woman carrying a BRCA mutation without a personal history of cancer, hormone replacement therapy, or HT, is usually recommended from the time your ovaries are removed until you turn 50. Beyond that age, the risks of continuing HT for a BRCA mutation carrier are not fully known. So HT is usually stopped around age 50. Going without any hormone therapy after prophylactic oophorectomy may increase the likelihood of some significant health risks, including problems that could affect your bones, heart and brain.
A mutation in the BRCA1 gene significantly raises your risk of breast and ovarian cancer. Surgery done in an effort to prevent cancer by removing the breasts, called prophylactic mastectomy, and removing the ovaries, called prophylactic oophorectomy, often can dramatically lower those cancer risks.
The surgeries, however, pose their own health risks. Because your ovaries make most of your body’s estrogen — one of the hormones that regulates your menstrual cycles — removing your ovaries triggers menopause. That means after your surgery, you are likely to have menopause symptoms, such as hot flashes, night sweats and vaginal dryness.
When menopause happens before age 50, which is considered the average age for it, research suggests the risk goes up for bone thinning, heart disease, parkinsonism, anxiety, depression and dementia. After your ovaries are removed, HT during your 40s may provide some protection against these health risks.
Hormone replacement therapy involves taking medications containing female hormones to replace the ones your body no longer makes after menopause. Estrogen typically is prescribed along with the hormone progesterone or a medication similar to progesterone called progestin. This is because estrogen alone, when not balanced by progesterone, can stimulate growth of the uterine lining, increasing the risk of uterine cancer. If you have your uterus removed, you won’t need progesterone.
To get the best protective effect, you will likely need systemic HT. That means the hormones are delivered to your entire body. Along with reducing your risk for heart, bone and brain problems, systemic HT often effectively decreases hot flashes, night sweats and vaginal symptoms of menopause. Hormone replacement therapy comes in a variety of forms, including pills, skin patches, gels, creams, sprays and a vaginal ring. Talk to your doctor about which is best for you.
It is important to note that if you have already had breast cancer, HT is not appropriate for you at any age. That’s because HT can increase the risk that certain kinds of breast cancer could come back.
Research is currently underway to see if surgically removing only the fallopian tubes, a procedure called salpingectomy, could be a viable alternative to prophylactic oophorectomy for women who have a BRCA gene mutation. Studies have found that a relatively high percentage of ovarian cancers begin in the fallopian tubes. Removing the fallopian tubes before cancer begins may be an effective way to prevent ovarian cancer while avoiding the side effects of ovary removal. This is still under investigation and is not standard care at this time. However, talk to your surgeon about your options before you have surgery.
Hormone replacement therapy can be a complicated topic. It is important that you fully understand the risks and benefits in your situation before you move forward. Talk with your doctor about his or her recommendations based on your medical history, as well as your individual circumstances. Ask questions and get the information you need to feel comfortable making a well-informed decision. — Myra Wick, M.D., Ph.D., Obstetrics and Gynecology, and Mary Marnach, M.D., Women’s Health Clinic, Mayo Clinic, Rochester, Minn.