When to consider gynaecological surgery

22 Aug 2021

When thinking about risk-reducing gynaecological surgery, it is important to know what’s involved and who can help you gather your facts. Your Family Cancer Clinic team can advise you about your level of risk and what age that increases. You can then make a plan by talking to a surgeon with expertise in gynaecological cancer risk management.

It’s helpful to speak with a psychologist about how you’re feeling about the pros and cons. Talking with other women who have faced similar questions can also help. If you wish to complete your family when risk-reducing surgery is also being recommended, it might be helpful to talk with a fertility specialist.

  • Risk-reducing bilateral salpingo-oophorectomy

Risk-reducing bilateral salpingo-oophorectomy (RR-SO) is the surgical removal of both fallopian tubes, and ovaries before an ovarian cancer has occurred. Both types of tissue are at increased risk in women with a family history of ovarian cancer or an ovarian cancer risk gene mutation.

RR-SO is the most effective way to reduce risk in these tissues, to levels of less than 5%. There is no effective way to screen for ovarian or fallopian tube cancer. Risk-reducing surgery is usually recommended at around age 40 years, as risk before then is low. Sometimes, removal of the uterus (hysterectomy) may be done at the same time. This might be considered in specific situations, for example, if you have uterine problems that are causing symptoms. 

Uterine cancer risk is not increased by a family history of breast or ovarian cancer or a breast-ovarian cancer gene mutation. Adding hysterectomy to the RR-SO makes this a bigger operation with some increased risk of complications and longer recovery time.

Removal of the Fallopian tubes alone (salpingectomies) is not an adequate long term cancer risk reduction treatment. If you have had your Fallopian tubes removed and have a high ovarian cancer risk (because of a family history of ovarian cancer or a mutation), you may still be advised to have her ovaries removed.

  • What about side effects of a risk-reducing salpingo-oophorectomy?

Once the ovaries are removed, there is only a small amount of oestrogen still made outside the ovaries, in other tissues. This means that you will be in menopause, but it is not possible to predict who will have symptoms and who will not. It is important to know that there are options to manage symptoms, including hormone replacement. So far, it seems that HRT used for a few years in a woman who has had RR-SO before age 50 does not increase breast cancer risk. 

Advice on HRT may vary with the woman’s level of breast risk, whether she has had breast risk-reducing surgery, the type of HRT and the number of years it is used. HRT can help manage symptoms of menopause, in particular, hot flushes. Other benefits of HRT include protection against osteoporosis. There are other medications that can assist with symptoms and there are specialist menopause clinics and other resources (such as jeanhailes.org.au).

You can still have a healthy, vigorous life after risk-reducing gynaecological surgery, but it is important to know how you can deal with any side effects if they happen.

  • How is the surgery done?

In most cases, the surgery can be performed using laparoscopic (keyhole) surgery. This involves three to four small (1-2cm) incisions (cuts) in the abdomen skin (tummy) which are closed with a stitch or surgical tape. This form of surgery usually involves staying in hospital overnight and going home the next day.

In some situations, an open operation through a larger incision (laparotomy) will be recommended. Your surgeon will discuss this with you prior to the surgery. After the surgery, there will be some pain in the abdominal (tummy) wall, that may feel like a torn muscle. Less commonly, there is pain in the shoulder which is because of the abdominal lining being irritated, but this will usually go within 24 hours. For most women, any pain is usually well controlled with regular paracetamol and an anti-inflammatory medication such as ibuprofen for 2 to 5 days.

Occasionally a stronger pain medication such as codeine or oxycodone may be required for one to two days. If you have severe pain that is not controlled by these types of medication, contact your surgeon or the hospital, so they can investigate the cause and manage it. 

You should be mobile and able to do your normal living activities when you leave the hospital. You will be unable to do strenuous activity such as heavy lifting, driving or going to the gym for about one week. You can usually resume light gym activity and return to work after about seven to 10 days, but you will need to be guided by your surgeon.

Recovery time will be longer if your operation was not done laparoscopically.

  • What about follow up?

A follow-up appointment is usually arranged for about six weeks after surgery. Before discharge from hospital, make sure you confirm with your surgeon when and how the pathology results from your operation will be given to you. The tissue that is removed is sent to a laboratory after surgery to make sure that no ovarian cancer was already present (which is very uncommon). It is important the tissue is checked carefully by an expert pathologist.