DEAR MAYO CLINIC:

I have the BRCA1 mutation ("breast cancer gene"), which I know increases my risk of getting breast cancer as well as ovarian cancer.

A gynecologist recommends I have my ovaries removed as soon as I'm done having children, but another doctor suggests waiting until I'm closer to 40 (I'm 32 now).

Are there pros and cons of each option, or is one doctor right?

ANSWER:

For women like you who have an inherited mutation in the BRCA1 or BRCA2 gene -- genes linked to both breast and ovarian cancer -- surgical removal of the ovaries can significantly reduce cancer risk.

Because BRCA1 puts you at a higher risk of developing ovarian cancer earlier than BRCA2 does, Mayo Clinic recommends that a woman in your situation have her ovaries removed at age 35. For women with BRCA2, the Mayo Clinic recommendation is age 45 for ovary removal.

The decision whether to have this surgery, however, should not be based on age alone. Many factors need to be considered.

The ovaries -- the small, almond-shaped organs on each side of the uterus -- contain eggs and secrete hormones that control a woman's reproductive cycle.

Removing the ovaries greatly reduces the chance of developing ovarian cancer. It also reduces the amount of estrogen and progesterone in the body, which can halt or slow breast cancers that need these hormones to grow.

If you have a BRCA mutation, surgical removal of healthy ovaries (prophylactic oophorectomy) reduces your risk of breast cancer by about 50 percent if the procedure is done prior to menopause. The risk of ovarian cancer decreases by about 94 percent.

Yet, the side effects are substantial.

After the procedure, you won't be able to become pregnant. And, when the ovaries are removed prior to menopause, early menopause results. This can cause hot flashes, vaginal dryness, changes in sexual function, sleep disturbance and, for some women, cognitive changes.

Prophylactic oopherectomy also can increase the risk for osteoporosis, because removing the ovaries reduces the protective effect that estrogen has on bones.

In addition, studies have found that women whose ovaries are removed before menopause have an increased long-term risk of anxiety, depression, memory problems, and Parkinson's disease and related conditions known as parkinsonism.

To protect against these conditions, research findings suggest that younger women who have surgically-induced menopause may benefit from low-dose hormone therapy until age 45 or 50. However, hormone therapy isn't appropriate for women who have had breast cancer and is controversial in women at high risk for breast cancer.

Discuss the pros and cons of hormone therapy with your care team as you make decisions.

If you're not sure about prophylactic oophorectomy, there are alternatives.

You can forego surgery and instead keep a close watch on your situation. This might entail having clinical breast exams every six months and mammograms every year to check for breast cancer, as well as other breast imaging, such as magnetic resonance imaging (MRI), as recommended by your doctor.

You might also need to have blood screening and pelvic ultrasounds every six months to one year to check for ovarian cancer, although the effectiveness of such screening is unclear.

Another possible option is medication that has a known preventive effect on cancer (chemoprevention), such as tamoxifen for breast cancer or birth control pills for ovarian cancer.

Estrogen-suppressing medication to slow or stop production of estrogen by the ovaries is also an alternative.

These medications reduce breast cancer risk, but they may not affect the risk of ovarian cancer.

Tubal ligation -- surgically cutting or sealing the fallopian tubes -- can reduce the risk of ovarian cancer.

Researchers have found that tubal ligation lowers ovarian cancer risk by about 60 percent in women with BRCA1 mutations. No benefit has been shown in women with BRCA2 mutations.

The decision to have prophylactic oophorectomy is difficult.

There is no one right or wrong answer.

It comes down to a personal choice, made ideally with input from a genetic counselor, a breast health specialist and a gynecologic oncologist.

Determining whether the surgery is right for you -- and when -- depends on your situation and how aggressive you want to be in cancer prevention efforts.

-- Bobbie Gostout, M.D., Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota.

Medical Edge from Mayo Clinic is an educational resource and doesn't replace regular medical care.

To submit a question, write to: medicaledge@mayo.edu, or Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207.

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