Helping you make the decision about risk-reducing ovarian surgery

Risk-reducing Surgery

Questions in this section:

What is risk-reducing hysterectomy (RRH)?

Risk-reducing hysterectomy (RRH for short) is an operation to remove a healthy womb (uterus) to reduce the risk of endometrial cancer. The aim of the surgery is to remove the endometrial tissue before cancer develops. A total hysterectomy also includes removal of the cervix, which is part of the womb (uterus). This means it also reduces your risk of cervical cancer, although you should note that you are not at increased risk for this cancer. You can have RRH on its own or with risk-reducing bilateral salpingo-oophorectomy to reduce your ovarian cancer risk as well.

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What is risk-reducing bilateral salpingo-oophorectomy (RRSO)?

Risk-reducing bilateral salpingo-oophorectomy (RRSO for short) is an operation to remove healthy ovaries and fallopian tubes to reduce the cancer risk. The word ‘salpingo-oophorectomy’ means surgical removal of the fallopian tubes (salpinges) and ovaries. The term ‘bilateral’ in this context describes the fact that the ovaries and fallopian tubes on both sides of the body are removed. The aim of the operation is to remove these tissues before cancer develops.

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What are the main advantages of RRH plus RRSO?

  1. This operation will reduce your endometrial, cervical, ovarian and fallopian tube cancer risk, as these are completely removed during surgery.
  2. For some women, not having to worry about endometrial and ovarian cancer anymore comes as a great relief.
  3. Even though Lynch women are not thought to be at higher risk for breast cancer, RRSO before the natural menopause could reduce the risk of breast cancer. This is true for the vast majority of women whether at higher risk or not.
  4. Having the surgery will also prevent other, non-cancer related problems happening with the uterus/womb and ovaries, such as cysts, which can cause some discomfort and pain.
  5. You will no longer have to go to get smear tests as part of the screening for cervical cancer.

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What are the main disadvantages of RRH plus RRSO?

  1. You will no longer be able to become pregnant once you have had surgery, therefore it is important that you have considered your plans for a family before making a final decision.
  2. After the operation you will immediately enter the menopause and may start to experience the typical menopausal symptoms, including hot flushes, mood swings, night sweats and vaginal dryness (Please see The Menopause for more details). Furthermore, you may be at increased risk of bone thinning, cardiovascular (heart and blood vessel) disease and memory changes. These effects may be effectively treated with hormone replacement therapy (Please see Hormone Replacement for more details), however not all women can take hormone replacement and this should be discussed before having surgery
  3. Your desire for sex is likely to decrease and due to some menopausal symptoms, such as vaginal dryness, you may enjoy sex less as intercourse can be painful. Again, hormone replacement may counteract these effects.
  4. Your desire for sex is likely to decrease.
  5. There is a small risk of complications during and after surgery.

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What are the main advantages of this operation?

  1. This operation will reduce your ovarian and fallopian tube cancer risk, as these are completely removed during surgery.
  2. For some women, not having to worry about ovarian cancer anymore comes as a great relief.
  3. For the vast majority of women having RRSO before the natural menopause could also reduce the risk of breast cancer.
  4. Having the surgery will also prevent other, non-cancer related problems happening with the ovaries, such as cysts, which can cause some discomfort and pain.

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What are the main disadvantages of this operation?

  1. You will no longer be able to become pregnant once you have had surgery, therefore it is important that you have considered your plans for a family before making a final decision.
  2. After the operation you will immediately enter the menopause and may start to experience the typical menopausal symptoms, including hot flushes, mood swings, night sweats and vaginal dryness (Please see The Menopause for more details). Furthermore, you may be at increased risk of bone thinning, cardiovascular (heart and blood vessel) disease and memory changes. These effects may be effectively treated with hormone replacement therapy (Please see Hormone Replacement for more details), however not all women can take hormone replacement and this should be discussed before having surgery
  3. Your desire for sex is likely to decrease and due to some menopausal symptoms, such as vaginal dryness, you may enjoy sex less as intercourse can be painful. Again, hormone replacement may counteract these effects.
  4. Your desire for sex is likely to decrease.
  5. There is a small risk of complications during and after surgery.

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How much would my risk be reduced by surgery?

Your ovarian-type cancer risk would be greatly reduced by surgery. It will fall from a risk of 39 16 in every 100 women like you to about 2 in every 100 women like you.

Graph of BRCA1 ovarian cancer risk and reudction achieved through surgeryGraph of BRCA1 ovarian cancer risk and reudction achieved through surgery
Graph of BRCA2 ovarian cancer risk and reudction achieved through surgeryGraph of BRCA2 ovarian cancer risk and reudction achieved through surgery

This graph shows how many out of 100 women with a BRCA1 BRCA2 faulty gene will develop ovarian cancer over their life time and the effect of surgery on this number.

By age 70 years about 39 16 of 100 women with BRCA1 BRCA2will have developed ovarian cancer (Light line). If women have surgery when they are 4050 4550, then the number of women who develop ovarian cancer stops rising (Dark line).

Graph created with data produced by Chen et al. (2007)

Studies have shown that women with a faulty BRCA1 BRCA2 gene profit most from surgery when they have it at age 40before or at age 45, so that the risk does not start to rise steeply. However, having surgery later is still useful if you decide to delay.

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What is my risk after surgery?

After surgery your risk of ovarian and fallopian tube cancer endometrial, cervical, ovarian and fallopian tube cancer is greatly reduced, however, there is a rare type of cancer which may still develop after surgery that is very similar to ovarian cancer. This is called primary peritoneal cancer and develops in the lining of the abdomen and pelvis. Unfortunately, the peritoneum cannot routinely be removed during RRSO. Your risk of primary peritoneal cancer depends on whether or not you have a faulty gene. The highest risk for primary peritoneal cancer is in women with a BRCA1 faulty gene. Their risk is about 2 in every 100 women, which is similar to the risk of ovarian cancer in the general population. For women who do not have a BRCA1 faulty gene the risk of primary peritoneal cancer after surgery is much lower than 2 in 100.Your primary peritoneal cancer risk after surgery is about 2 in 100, which is similar to lower than 2 in 100, which is lower than the risk of ovarian cancer in the general population. Your risk of breast cancer will also be reduced by about half if you have surgery before the natural menopause.Your primary peritoneal cancer risk after surgery is lower than 2 in 100, which is lower than the risk of ovarian cancer in the general population.

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What does the surgery involve?

Most often the operation is done as keyhole surgery (laparoscopy). This involves 3 or 4 small (about 1cm) cuts, usually one cut is close to your belly button and 2-3 just below the bikini line, so they are not visible. Keyhole surgery itself usually takes less than 2 hours.

In some cases it may not be possible to do keyhole surgery, because of previous surgery on your tummy or because of your weight. Then surgeons use the more traditional open surgery. This means a longer cut , usually along the bikini line. Sometimes a surgeon might have to convert to an open operation when doing keyhole surgery because of complications or old scar tissue. This happens in about 1 of every 100 keyhole operations.

Pictogram of 94 and 5 and 1 woman out of 100

Type of procedure in 100 women who have the operation

This figure shows how many of 100 women will have keyhole surgery , open surgery and planned keyhole which is converted to open surgery.

94 of 100 women will have planned keyhole surgery (white figures). Five of 100 women will have planned open surgery (light teal figures). One of 100 women will have planned keyhole surgery which is converted to open surgery (dark figure).

RRH plus RRSO can be done as laparoscopic (keyhole), vaginal or abdominal surgery. The type of surgery you will be offered depends on your personal medical history.

Most often the operation is done as keyhole surgery (laparoscopic hysterectomy plus RRSO). This involves 3 or 4 small (about 1cm) cuts. Usually one cut is close to your belly button and 2-3 just below the bikini line, so they are not visible. This operation can take about an hour and a half.

During vaginal hysterectomy plus RRSO, surgical instruments are inserted through the vagina, so that no cut is needed for the instruments. The uterus and cervix are then removed through a cut just above the vagina. This operation takes less than an hour.

Abdominal hysterectomy plus RRSO is an 'open' operation and involves a cut (several inches) in the tummy, either horizontally just above the bikini line or vertically from your belly button down to the bikini line. This operation takes less than an hour.

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How long does it take to recover?

75 of 100 patients who have keyhole surgery leave the hospital the day after surgery.80 of 100 patients who have keyhole or vaginal surgery leave the hospital by the third day after surgery. They are usually back to normal activity about 4 weeks 6-8 weeks after surgery. If you have open surgery you are likely to stay in hospital a bit longer. Usually patients leave the hospital about 5 days after open surgery and are back to normal in about 6 weeks. About 60 of 100 patients who have open surgery leave the hospital by the fourth day. After surgery you are not allowed to do any heavy lifting for a few weeks. You may also have to refrain from driving until you can comfortably wear a seatbelt and make an emergency stop without pain.

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What are the complications of RRH with RRSO?

There is a risk of complications linked to RRH with RRSO. The risk of complications depends on the type of procedure you are having. Minor complications can include wound or urinary tract infections and usually have no long-term effects on your health. More serious complications might happen during surgery and can include damage to blood vessels, the bowel or the bladder. If you are having keyhole surgery this might mean that the surgeon has to convert to an open surgery to repair the damage.

There are a number of other rare complications that might happen and your surgeon will go through those with you if you wish before you go in for surgery.

Please note that the majority of women do not experience any complications at all.

Studies have found different risks of complications. The pictures below show approximately how many out of 100 women have some kind of complication with the different procedures:

Pictogram of 3 of 100 women

Studies found that 4 to 19 of every 100 women who have laparoscopic surgery will have a complication. 81 to 96 women will not.

Pictogram of 5 out of 100 women

Studies found that 5 to 23 of every 100 women who have vaginal surgery will have a complication. 77 to 95 women will not.

Pictogram of 9 out of 100 women

Studies found that 9 to 17 of every 100 women who have abdominal surgery will have a complication. 83 to 91 women will not.

As with any surgery, there is a very small risk of death. However, this is highly unlikely. The risk may be greater in women with health problems before surgery.

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Do I need to have my womb removed as well?

No, normally it is not necessary that you have your womb removed at the same time as having RRSO, unless you know that you have Lynch Syndrome or you have other problems with your womb and have been told by a doctor that removing the womb would help you with those problems. However, you may choose to have your womb removed at the time of RRSO, as it may affect the type of hormone replacement you would be given (see Hormone Replacement). You should discuss this with your doctor.

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What are the complications of RRSO?

There is a small risk of complications linked to RRSO. About 4 in every 100 people will experience some complication. Minor complications can include wound or urinary tract infections and usually have no long-term effects on your health. More serious complications might happen during surgery and can include damage to blood vessels, the bowel or the bladder. If you are having keyhole surgery this might mean that the surgeon has to convert to open surgery to repair the damage. There are a number of other rare complications that might happen and your surgeon will go through those with you if you wish before you go in for surgery.

Please note that about 96 of every 100 women do not experience any complications at all.

Pictogram of 4 out of 100 women

Complications in 100 women who have the operation

This figure shows how many of 100 women will experience complications during or after surgery.

4 of 100 women will experience some kind of complication either during or after surgery. 96 of 100 women will not experience any complications.

As with any surgery, there is a very small risk of death. However, this is highly unlikely. The risk may be greater in women with health problems before surgery.

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Could cancer be found during the surgery?

Yes, although this is rare. Once your uterus/womb, ovaries and fallopian tubes have been removed they will be checked thoroughly for any signs of cancer. There is a chance that cancer may be discovered during this check. This happens in up to 4 out of every 100 operations in women with a BRCA faulty gene. in the highest risk patients. For others the chances of finding cancer during the surgery are much lower.

If cancer is found during the surgery, you will be informed as soon as possible and might have to undergo further tests, treatment and surveillance. If you were planning to start HRT and cancer is found during the operation, you might be unable to take HRT; however this depends on the type of cancer that is found.

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How would RRSO affect my life?

In the short-term, if you decide to go for surgery, you will have to take time off work and will not be able to do some of the things you might usually do, such as driving or heavy lifting. Therefore you may need help with everyday tasks. During recovery you may also feel some pain and discomfort and you may be more tired than usual. However most women recover fully within 4 to 6 weeks.

In the longer term there are a number of things you should consider. After surgery you may feel less worried about ovarian cancer. However you may feel differently about your body and you may loose interest in sex. You will also no longer be able to become pregnant and you will enter the menopause if you have not gone through it yet (Please see The Menopause). You may opt to take hormone replacement (Please see Hormone Replacement). These factors may affect your life after surgery and should be considered carefully before making a decision.

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How would surgery affect my life?

In the short-term, if you decide to go for surgery, you will have to take time off work and will not be able to do some of the things you might usually do, such as driving and heavy lifting. Therefore you may need help with everyday tasks. During recovery you may also feel some pain and discomfort and you may be more tired than usual. However most women recover fully within 6 to 8 weeks.

In the longer term there are a number of things you should consider. After surgery you may feel less worried about endometrial and ovarian cancer. However you may feel differently about your body and you may loose interest in sex. You will also no longer be able to become pregnant and you will enter the menopause if you have not gone through it yet (Please see The Menopause). You may opt to take hormone replacement (Please see Hormone Replacement). These factors may affect your life after surgery and should be considered carefully before making a decision.

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