Is there a role for hysterectomy in BRCA1/2 mutation carriers?

The only known risk reduction procedure for ovarian cancer in BRCA1/2 carriers is removal the ovaries and fallopian tubes. Hysterectomy is not routinely recommended as part of this procedure, nor are there any national guidelines that recommend hysterectomy. However, some BRCA1/2 mutation carriers choose to undergo hysterectomy at the time of salpingo-oophorectomy to enable them to take unopposed estrogen hormone replacement therapy to manage menopause symptoms. Unopposed estrogen hormone replacement therapy is taking estrogen without progesterone.

The rationale for possible hysterectomy in this setting is as follows:

1. Estrogen therapy alone incurs a lower risk of breast cancer than when estrogen is combined with progestin.

2. However, unopposed estrogen therapy in women who have a uterus, increases the risk of endometrial cancer.

It is therefore important to have at least a discussion about these options preoperatively to determine whether the benefits associated with having a hysterectomy are large enough to outweigh the risks associated with more extensive surgery.

Women who choose not to have hysterectomy may first use non hormonal options for menopausal symptoms and osteoporosis prevention. For those who cannot adequately manage their symptoms with non hormonal medications, hormone replacement therapy may be used for a limited duration of time in order to potentially lower, but not eliminate, an increased risk of hormone replacement therapy associated breast cancer.