A BRCA1 or BRCA2 mutation carries a high lifetime risk of ovarian and tubal cancer. Preventive removal of the ovaries and tubes — bilateral salpingo-oophorectomy — is today the most effective way to reduce that risk. What remains is to decide when to consider it, how it is performed, and how to manage the menopause it causes.
If you carry a BRCA mutation and are considering risk-reducing surgery, Dr Zeitoun reviews your oncogenetics file and imaging, and plans the procedure by laparoscopy at Clinique Hartmann in Neuilly.
The decision rests on a confirmed mutation and genetic counselling; the case is discussed at a multidisciplinary team meeting.
Risk-reducing salpingo-oophorectomy — the preventive removal of the ovaries and fallopian tubes — is the main risk-reducing operation offered to women carrying a BRCA1 or BRCA2 mutation. It is often abbreviated RRSO.
Its goal is clear: by removing the ovaries and tubes before disease appears, the risk of cancer is strongly reduced. It is an important decision, affecting fertility, and — before natural menopause — causing a surgical menopause that must be anticipated.
This article explains at what age surgery is advised depending on the gene, why the tubes are also removed, how the laparoscopy is performed, and how to manage the induced menopause. It is part of the broader BRCA preventive surgery approach, whose breast component is prophylactic mastectomy, and follows NCCN and national guidelines.
If you carry a BRCA mutation and are considering risk-reducing surgery, Dr Zeitoun sees you in consultation, reviews your oncogenetics file and your imaging, and plans the procedure by laparoscopy at Clinique Hartmann in Neuilly.
Before discussing age and timing, a few landmarks: what the operation removes, and why the tubes matter as much as the ovaries.
It was long thought that "ovarian" cancers always started in the ovary. We now know that a large share of the most common ovarian cancers in BRCA women — high-grade serous carcinomas — actually begin in the fimbria of the fallopian tube (the fringed end of the tube, right next to the ovary).
That is why preventive surgery systematically removes both ovaries and both tubes: this is bilateral salpingo-oophorectomy. Removing the ovaries alone would leave a possible starting point for the disease in place.
Key point: RRSO concerns the ovaries and tubes. It does not remove the uterus, which is taken out only in specific situations. It is risk-reducing surgery: it strongly lowers the risk without bringing it entirely to zero, because the peritoneum remains in place.
The advised age depends on the mutated gene, because BRCA1-related ovarian cancers occur on average earlier than BRCA2-related ones. It also always takes into account your family history and your life plans.
Surgery is never an emergency: it is prepared. Four elements frame the decision.
A BRCA1 or BRCA2 mutation documented by genetic testing, within an oncogenetic counselling setting.
The family context of breast and ovarian cancers refines the advised age and the relative urgency.
RRSO causes permanent infertility: it is discussed when you no longer plan a pregnancy.
Understanding and planning the surgical menopause is an integral part of the decision.
What if a wish for pregnancy persists? Surgery can be deferred, combining surveillance and, sometimes, fertility preservation. Dr Zeitoun does not perform assisted reproduction: this is organised with a reproductive medicine team. To understand the whole hereditary strategy, see also hereditary breast-ovary risk.
Bilateral salpingo-oophorectomy is, to date, the most effective measure to reduce the risk of ovarian and tubal cancer in BRCA women. Here is what it provides — and its limits, stated honestly.
Reduction of about 80% in the risk of ovarian and tubal cancer — up to about 90% in some series. This is the central benefit, and it comes with a reduction in overall mortality.
A reduction of about 50% in breast cancer risk was long described before menopause, but recent studies question it. Breast prevention relies mainly on surveillance and, sometimes, prophylactic mastectomy.
Because the peritoneum — the thin membrane lining the inside of the abdomen — is not removed, a very small risk of cancer there remains. Surgery therefore strongly lowers the risk without removing it entirely.
The removed ovaries and tubes are fully examined in pathology, following a dedicated protocol, so as not to miss an early lesion.
Sources for the figures cited: ovarian/tubal risk reduction — Rebbeck, JNCI 2009; Domchek, JAMA 2010; Finch, JCO 2014. Breast risk — Eisen, JCO 2005; Kauff, JCO 2008; recent nuance: Kotsopoulos, JNCI 2017.
Why not surveillance alone? Today no test reliably detects ovarian cancer early — neither pelvic ultrasound nor CA-125 (a marker measured in the blood). Surveillance can accompany a waiting period, but it does not replace the benefit of risk-reducing surgery. By contrast, for an isolated benign ovarian mass, the logic is different.
Whether you have already chosen preventive surgery or would like a second opinion before deciding, Dr Zeitoun reviews your oncogenetics file, explains the procedure and the management of menopause, and operates by laparoscopy at Clinique Hartmann.
Genetic counselling is provided by an oncogeneticist; hormonal management is coordinated with your gynaecologist, GP or midwife.
RRSO is a planned operation, performed by laparoscopy under general anaesthesia. It is prepared in advance and usually proceeds simply.
Before surgery, several steps secure the decision and the management of the menopause to come.
Confirmation of the mutation and genetic counselling: this is the foundation of the indication. The case is discussed at a multidisciplinary team meeting.
Pelvic ultrasound, sometimes MRI, and blood tests. CA-125 (a marker measured in the blood) may be measured, knowing it cannot provide reliable screening on its own.
Information about surgical menopause, baseline bone assessment (bone density scan) and a management plan decided before surgery.
A mandatory anaesthetic consultation, and a detailed written estimate provided before surgery.
The operation is performed through a few small incisions, under video control. After inspecting the abdominal and pelvic cavity, the ovaries and tubes are freed and removed close to their vascular pedicle.
The specimens are extracted in a sealed retrieval bag, without contact with the wall, then sent for a complete pathological examination. The operation lasts between 30 and 45 minutes.
In some cases it can also be performed by vNOTES: surgery through the natural route (via the vagina), camera-assisted, which avoids any abdominal scar.
Hospital stay & recovery: RRSO is performed as a day case only (home the same day) at Clinique Hartmann. Pain is moderate, relieved by simple painkillers, and a return to usual activities is generally within one to two weeks. This surgery is part of the wider range of procedures described in ovary and tube surgery.
What if analysis reveals an early lesion? This is rare but possible. In that case, the file is reviewed at a multidisciplinary team meeting and care follows the recommendations for ovarian cancer. This is precisely the value of systematic analysis: to detect as early as possible.
Performed before natural menopause, removing both ovaries causes immediate menopause, often more marked than spontaneous menopause. It is a central part of the decision — and one that is supported, not simply endured.
Symptoms can appear soon after surgery. Their intensity varies greatly from one woman to another.
In a BRCA woman without a history of breast cancer, hormone replacement therapy is usually possible up to the age of natural menopause (around 50-51 years), to ease symptoms and protect bone and heart. Transdermal estrogen is often preferred.
The decision is individualised and made with your gynaecologist, GP or midwife, and the oncologist if needed. In case of a history of breast cancer, HRT is generally contraindicated, and alternatives are used instead.
When HRT is not indicated, options exist for hot flushes (certain non-hormonal treatments), along with local treatments for intimate comfort.
Follow-up bone density scans, adequate calcium and vitamin D, and regular physical activity to limit the risk of early osteoporosis.
Monitoring of the lipid profile and blood pressure, healthy lifestyle, within an overall follow-up of early menopause.
Adapting to early menopause deserves support: sleep, mood, sexuality and body image are part of care.
Who does what: Dr Zeitoun sets the surgical indication and performs the operation. Hormonal management and menopause follow-up are coordinated with your gynaecologist, GP and/or midwife, as a team — so that a preventive decision never translates into a menopause endured without support.
Follow-up has two aims: to support the induced menopause, and to maintain surveillance of the other risks linked to the mutation — first and foremost the breast.
After surgery, follow-up supports the menopause and maintains surveillance of the other risks. The goal: to live with peace of mind, with spaced-out appointments and a clear point of contact for your questions.
An appointment checks healing, discusses the pathology result and takes stock of the first menopausal symptoms.
The BRCA mutation also carries breast cancer risk: close breast surveillance (examination, mammography, ultrasound and breast MRI as recommended) continues after RRSO.
Follow-up of bone density and the cardiovascular work-up, with adjustment of menopause treatment if needed.
Follow-up is shared between the surgeon, the gynaecologist and the oncogeneticist, for consistent management of the whole hereditary risk.
The breast component does not stop there. For some BRCA women, the reflection extends to prophylactic mastectomy and, where relevant, breast care. These decisions are separate from RRSO and are made at their own pace.
From the first consultation to follow-up, a clear, shared and unhurried path.
Every step is built with you: review of your oncogenetics file and imaging, full information, choice of timing and early planning of the menopause. Dr Zeitoun sets the indication and coordinates the whole pathway.
Review of the oncogenetics file and imaging, clinical examination, analysis of the context (age, mutation, life plans).
Choice of timing, full information, anticipated planning of the menopause. Discussion at the MDT.
Laparoscopy planned at Clinique Hartmann, prior anaesthetic consultation, written estimate provided in advance.
Review, pathology result explained, management of menopause and continued breast surveillance.
It is the preventive removal of both ovaries and both fallopian tubes (bilateral salpingo-oophorectomy), by laparoscopy, in a woman carrying a BRCA1 or BRCA2 mutation. It strongly reduces the risk of ovarian, tubal and peritoneal cancer. The tubes are removed systematically because many so-called ovarian cancers in fact begin in the tube.
As a general rule, from 40 years for a BRCA1 mutation, and it may be deferred to 45 years for a BRCA2 mutation (later cancers), once the family plan is complete. The age is always individualised according to family history and mutation type.
Because a large proportion of the most common ovarian cancers actually start in the fimbria of the fallopian tube — the fringed end of the tube, right next to the ovary. Removing the ovaries and the tubes therefore offers more complete protection than removing the ovaries alone.
It reduces the risk of ovarian and tubal cancer by about 80% (up to about 90% in some series) in BRCA carriers and lowers overall mortality. Because the peritoneum (the membrane lining the inside of the abdomen) is not removed, a very small risk of cancer there remains.
Yes, if performed before natural menopause: removing both ovaries causes immediate surgical menopause, often more marked than spontaneous menopause. Its management (hormone therapy, bone and cardiovascular prevention) should be anticipated before surgery.
In a BRCA woman without a history of breast cancer, HRT is usually possible up to the age of natural menopause (around 50-51 years), preferably with transdermal estrogen. The decision is individualised, made with the gynaecologist and, if needed, the oncologist. In case of a history of breast cancer, HRT is generally contraindicated.
RRSO is performed by laparoscopy (or by vNOTES, the vaginal route assisted by a camera), under general anaesthesia, in 30 to 45 minutes. The ovaries and tubes are removed in a retrieval bag and analysed. It is performed as a day case only (home the same day), with a return to usual activities within one to two weeks.
No, removal of the uterus is not systematic. Standard risk-reducing surgery concerns only the ovaries and tubes. Removing the uterus is discussed only in specific situations and is a shared decision.
A breast benefit was long described when surgery is performed before menopause, but its magnitude is now debated. Breast cancer risk reduction relies mainly on close surveillance and, in some cases, prophylactic mastectomy, which is a separate approach.
RRSO causes permanent infertility: it is offered only once childbearing is complete. When a pregnancy plan persists, the strategy combines surveillance and sometimes fertility preservation, and surgery is deferred. Dr Zeitoun does not perform assisted reproduction and refers to specialist teams.
Yes. The decision is based on a confirmed BRCA mutation and genetic counselling. The oncogenetic consultation clarifies the risk, the advised age and supports the decision. The case is also discussed at a multidisciplinary team meeting.
Risk-reducing surgery in a BRCA woman is a medically justified procedure, covered by French health insurance. I charge fees above the standard tariff (sector 2, non-OPTAM), explained in consultation and set out in a written estimate provided before surgery.
To place risk-reducing salpingo-oophorectomy within the whole BRCA prevention approach.
The overall risk-reducing strategy for BRCA1 and BRCA2 women: breast and ovary, surveillance and surgery.
Breast componentPreventive breast removal in high-risk women: indications, techniques and reconstruction.
Full guideAll laparoscopic procedures on the ovary and tube: cysts, salpingo-oophorectomy, preventive surgery.
Gynaecological cancerDiagnosis, oncological surgery and MDT pathway when an ovarian lesion is malignant.
Hereditary riskUnderstanding hereditary predisposition, the role of BRCA genes and the management options.
Benign conditionWhen should an ovarian cyst be monitored, and when does it need surgery? Laparoscopy and preservation.
Confirmed BRCA1 or BRCA2 mutation, reflection on the right time, or a need for a second opinion before deciding: Dr Jérémie Zeitoun sees patients at his practice in the 8th arrondissement of Paris and operates at Clinique Hartmann in Neuilly-sur-Seine. Please bring your oncogenetics report and your imaging.
Genetic counselling is provided by oncogenetics; hormonal management is coordinated with your gynaecologist, GP or midwife.