Friday, October 28, 2011

Removal of Ovaries and Early Menopause

In pre-menopausal women, most of the estrogen in the body is made by the ovaries. Because estrogen makes hormone-receptor-positive breast cancers grow, reducing the amount of estrogen in the body or blocking its action can help shrink hormone-receptor-positive breast cancers and reduce the risk of hormone-receptor-positive breast cancers coming back (recurring).

In some cases, the ovaries may be surgically removed to treat hormone-receptor-positive breast cancer or as a risk-reduction measure for women at very high risk of breast cancer. This is called prophylactic or protective ovary removal, or prophylactic oophorectomy. Removing the ovaries is one way to permanently stop the ovaries from producing estrogen. Medicines also can be used to temporarily stop the ovaries from making estrogen (called medical shutdown). Ovarian shutdown with medication or surgical removal is only for pre-menopausal women.

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Medical shutdown of the ovaries

Medicines can be used to temporarily stop the ovaries from making estrogen. Two of the most common ovarian shutdown medicines are:
  • Zoladex (chemical name: goserelin)
  • Lupron (chemical name: leuprolide)

Zoladex and Lupron are both luteinizing hormone-releasing hormone (LHRH) agonists. These medicines work by telling the brain to stop the ovaries from making estrogen. The medicines are given as injections once a month for several months or every few months. Once you stop taking the medicine, the ovaries begin functioning again. The time it takes for the ovaries to recover can vary from woman to woman.

Women who want to bear children after breast cancer treatment may prefer medical shutdown of the ovaries over surgical ovary removal.

Deciding to have your ovaries shut down with medicine or surgically removed requires a lot of careful thought and discussion with your doctor. Tell your doctor about any fertility concerns you may have. Together you can weigh the benefits and the risks against each other and decide on the best option for you and your unique situation.

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In an oophorectomy, a surgeon removes both your ovaries — the almond-shaped organs on each side of your uterus. Your ovaries contain eggs and secrete the hormones that control your reproductive cycle. Removing your ovaries greatly reduces the amount of the hormones estrogen and progesterone circulating in your body. This can halt or slow breast cancers that need these hormones to grow.

Women with BRCA gene mutations usually also may have their fallopian tubes removed at the same time (salpingo-oophorectomy), since they have an increased risk of fallopian tube cancer as well.

Who can consider prophylactic oophorectomy?

Prophylactic oophorectomy is usually reserved for women with a significantly increased risk of breast cancer and ovarian cancer due to an inherited mutation in the BRCA1 or BRCA2 gene — two genes linked to breast cancer, ovarian cancer and other cancers. High-risk women age 35 and older who have completed childbearing are the best candidates for this surgery.

Prophylactic oophorectomy may also be recommended if you have a strong family history of breast cancer and ovarian cancer but no known genetic alteration. It might also be recommended if you have a strong likelihood of carrying the gene mutation based on your family history but choose not to proceed with genetic testing.

How much can oophorectomy reduce the risk of cancer?

If you have a BRCA mutation, a prophylactic oophorectomy can reduce your:
  • Breast cancer risk by up to 50 percent in premenopausal women. As an example, if a woman with a high risk of breast cancer had a 60 percent chance of being diagnosed with breast cancer at some point in her lifetime, oophorectomy could reduce her risk to 30 percent. Put another way, for every 100 women just like her, 60 could be expected to be diagnosed with breast cancer without oophorectomy. And 30 would be expected to be diagnosed with breast cancer after oophorectomy.
  • Ovarian cancer risk by 80 to 90 percent. As an example, if a woman with a high risk of ovarian cancer had a 30 percent chance of being diagnosed with ovarian cancer at some point in her lifetime, oophorectomy could reduce her risk to 6 percent, assuming an 80 percent risk reduction. Put another way, for every 100 women just like her, 30 could be expected to be diagnosed with ovarian cancer without oophorectomy. And six would be expected to be diagnosed with ovarian cancer after oophorectomy.

In studies, the risk of breast cancer and ovarian cancer varies. And your individual risk of breast cancer and ovarian cancer varies depending on many factors, including your family history, your lifestyle choices and other strategies you're using to reduce your risk of cancer. For some women, oophorectomy may offer great reduction in risk. For other women, the risks of surgery and the potential side effects may not be worth the reduction in cancer risk.

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What are the risks of oophorectomy?

Oophorectomy is a generally safe procedure that carries a small risk of complications, including infection, intestinal blockage and injury to internal organs. The risk of complications depends on how the procedure is performed.

But more concerning are the complications that can come from losing the hormones supplied by your ovaries. In women who have yet to undergo menopause, oophorectomy causes early menopause. Early menopause carries many risks, including:
  • Bone thinning (osteoporosis). Removing your ovaries reduces the amount of bone-building estrogen your body produces. This may increase your risk of a broken bone.
  • Discomforts of menopause. Hot flashes, vaginal dryness, sexual problems, sleep disturbance and sometimes cognitive changes are problems for some women during menopause. Removing your ovaries doesn't mean you'll immediately have these problems, but it does mean that any menopausal symptoms you develop will occur earlier and are more likely to reduce your quality of life than if they occurred during natural menopause.
  • Increased risk of heart disease. Your risk of high cholesterol and heart disease may increase if you have your ovaries removed.
  • Lingering risk of cancer. Prophylactic oophorectomy doesn't completely eliminate your risk of breast cancer or ovarian cancer. A type of cancer that looks and acts identical to ovarian cancer can develop after the ovaries and fallopian tubes are removed. The risk of this type of cancer, called primary peritoneal cancer, is low — much lower than the lifetime risk of ovarian cancer if the ovaries remain intact.

Prophylactic oophorectomy might relieve much of your anxiety about developing either disease, but this type of surgery can also take an emotional toll on you. Even if you didn't plan on having children, you might mourn the loss of your fertility. Or you may, like some, have a strong sense of femininity tied to your fertility and reproductive cycle.

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Do women have to take post-menopausal hormone therapy after oophorectomy?

Use of low-dose hormone therapy after oophorectomy is controversial. While studies have shown that use of hormone therapy after menopause may increase a woman's risk of breast cancer, other studies suggest early menopause can cause its own serious risks.

Women who undergo prophylactic oophorectomy and don't use hormone therapy up to age 45 have a higher rate of premature death, cancer, heart disease and neurological diseases. It's not clear that the higher rates of these diseases are due to low estrogen levels caused by oophorectomy, but doctors typically recommend that younger women who have surgically induced menopause consider taking low-dose hormone therapy for a short time and stopping by age 45 or 50.

Prophylactic oophorectomy may also increase your risk of memory loss and dementia. But studies show this risk may be reduced with the use of hormone therapy after surgery.

It isn't entirely clear what effect hormone therapy might have on your cancer risk. Several studies have found that short-term hormone therapy doesn't increase the risk of breast cancer in women with BRCA mutations who have undergone prophylactic oophorectomy. Ask your doctor about your particular situation. If you decide to take low-dose estrogen, plan to discontinue this treatment after age 50.

You may opt to have your uterus removed during your oophorectomy surgery, so that you can take a type of hormone therapy (estrogen only hormone therapy) that may be safer for women with a high risk of breast cancer. Discuss the benefits and risks of hysterectomy with your surgeon.

Differences Between Natural and Surgical Menopause

Natural menopause begins when the ovaries cease to produce an egg every four weeks, menstruation ceases and the woman is no longer able to bear children. Postmenopausal begins after menstruation has ceased for 12 months. For intact women, this process usually happens on average between the ages of 35 and 51. The ovaries reduce their production of estrogen and progesterone and physical changes and side effects occur that coincide with natural aging. In contrast, surgical menopause causes an immediate plunge into postmenopause after the ovaries are removed. Note that if you've had your ovaries removed after menopause, you won't be in surgical menopause and you won't feel any hormonal differences in your body. If you've had your ovaries removed before you've reached natural menopause, you'll wake up from your surgery in postmenopause.

Once the ovaries are removed, your body immediately stops producing estrogen and progesterone. Your follicle stimulating hormone (FSH) will skyrocket in an attempt to make contact with ovaries that no longer exist. Unlike women who go through menopause naturally, women wake up after a bilateral oophorectomy in immediate estrogen withdrawal. It's that sudden: One day you have a normal menstrual cycle, the next day you have none whatsoever. This can cause you to become, understandably, more depressed, and you'll also feel the physical symptoms of estrogen loss far more intensely than a woman in natural menopause.

Symptoms can include:
  • Hot flashes, flushes, night sweats and/or cold flashes, clammy feeling
  • Bouts of rapid heart beat
  • Irritability
  • Mood swings, sudden tears
  • Trouble sleeping through the night (with or without night sweats)
  • Loss of libido
  • Vaginal dryness
  • Crashing fatigue
  • Anxiety, feeling ill at ease
  • Feelings of dread, apprehension, doom
  • Difficulty concentrating, disorientation, mental confusion
  • Memory lapses
  • Itchy, crawly skin
  • Headache change: increase or decrease
  • Depression
  • Electric shock sensation under the skin and in the head
  • Tingling in the extremities
  • Osteoporosis
  • Changes in fingernails: softer, crack or break easier

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Fortunately, you most likely won't experience all of these symptoms, and the ones you do have will vary in degree and duration. The great news is that nature offers you alternatives to the damaging effects of convential horomone replacement therapy. Soy isoflavones are phytochemicals (naturally occurring plant chemicals) in soy products. Some isoflavones, such as genistein and daidzein, exert mild estrogenic effects and are thus called phytoestrogens. Structurally similiar to estrogen, soy isoflavones have the capacity to bind to empty estrogen receptors and relieve hormonally based symptoms of menopause such as hot flashes. It is this ability to decrease hormone reception that also seems to be the mechanism by which phytoestrogens such as soy isoflavones prevent hormone-dependent cancers.

In addition to the physiological changes that occur during hysterectomy, there can also be emotional and psychosocial changes after the surgery. The natural, gradual transition from peri- into post-menopause normally gives the woman an opportunity to gradually adjust to her biological and emotional changes and to ease into the second part of her life. Women undergoing surgical menopause don't have the luxury of easing into it over time. Rather, the woman is faced with both the challenge and opportunity to establish a new hormonal balance and make the mental adjustments necessary to not only deal with the shock of surgery, but also to establish a relationship with her new and different body/self.

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