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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Surgical Oncology · Hereditary Breast and Ovarian Cancer Syndrome

Surgical Options for Risk Reduction

At a Glance

Preventive surgery is a highly effective way to reduce cancer risk for people with Hereditary Breast and Ovarian Cancer syndrome. Options include bilateral mastectomy to prevent breast cancer and ovary removal to prevent ovarian cancer. The ideal timing depends on your specific gene mutation.

For many people with HBOC, surgery is a highly effective way to take control of their health, but it is also a profoundly personal and often emotionally difficult choice. Unlike screening, which aims to catch cancer early, risk-reducing surgeries aim to prevent cancer from ever starting. These decisions involve balancing cancer protection with significant quality-of-life considerations, including changes to your body image, the onset of menopause, and fertility [1][2].

Bilateral Risk-Reducing Mastectomy (BRRM)

A Bilateral Risk-Reducing Mastectomy (BRRM) is the surgical removal of both breasts to prevent breast cancer [1].

  • Effectiveness: This surgery provides the highest level of protection available, reducing the risk of breast cancer by over 90% in BRCA carriers [1][3].
  • Impact on Survival: Studies show that for many BRCA carriers, choosing BRRM is linked to a significant increase in overall survival [1].
  • The Choice: Many patients choose this surgery to eliminate the “scan-to-scan” anxiety that can come with frequent MRIs and mammograms, though it comes with a major emotional and physical recovery period [1].

Risk-Reducing Salpingo-Oophorectomy (RRSO)

An RRSO is the surgical removal of the fallopian tubes and ovaries [4]. This is currently the only proven way to significantly reduce the risk of ovarian cancer, which is difficult to detect through screening [5][6].

Why Timing Matters

The timing for this surgery is different for BRCA1 and BRCA2 carriers because the “risk window” for ovarian cancer starts at different ages for each gene [4][7].

Mutation Recommended Age for RRSO Rationale
BRCA1 35 to 40 years old Ovarian cancer risk begins to rise earlier in BRCA1 carriers [4].
BRCA2 40 to 45 years old Risk tends to rise later; delaying surgery helps avoid the effects of early menopause for a few extra years [4][2].

Waiting too long past these recommended windows can increase the chance of a doctor finding “occult” (hidden) cancer cells during the surgery [8][9].

Managing Surgical Menopause

Removing the ovaries before natural menopause causes surgical menopause, which happens overnight rather than over several years [2]. This can lead to hot flashes, bone density loss, and changes in sexual health [2][10]. Preparing for these emotional and physical changes is just as important as the surgery itself.

Is Hormone Replacement Therapy (HRT) Safe?

Many patients fear that taking hormones will “undo” the cancer protection of the surgery, but research suggests otherwise for those who have not had breast cancer:

  • Safety: For BRCA carriers who have not been diagnosed with breast cancer, short-term use of HRT (until the natural age of menopause, around age 50) does not appear to significantly increase breast cancer risk [11][12][13].
  • Benefits: HRT is highly effective at managing menopausal symptoms and protecting your bones and heart health [14][10].
  • Individual Choice: Your doctor may recommend estrogen-only HRT (if you have also had a hysterectomy) or a combination of hormones [15][16].

A Note on Breast Cancer Risk

While RRSO is primarily done to prevent ovarian cancer, it may also provide some reduction in breast cancer risk for certain patients, especially those with a BRCA2 mutation [5][17]. However, because the data on this is mixed, BRRM remains the most effective surgical option for preventing breast cancer specifically [18][19].

Common questions in this guide

How much does a bilateral mastectomy reduce breast cancer risk?
A bilateral risk-reducing mastectomy can lower your risk of developing breast cancer by more than 90 percent. Many patients choose this option to gain peace of mind and eliminate the anxiety associated with frequent cancer screenings.
When should I have my ovaries removed if I have a BRCA mutation?
The ideal timing depends on your specific gene mutation. It is generally recommended that BRCA1 carriers have their ovaries removed between ages 35 and 40. For BRCA2 carriers, the recommended age is slightly later, typically between 40 and 45.
What happens when my ovaries are removed before natural menopause?
Removing your ovaries early causes immediate surgical menopause, which happens overnight rather than over several years. You may experience sudden symptoms like hot flashes, bone density loss, and changes in sexual health.
Is hormone replacement therapy safe after preventive ovary removal?
For BRCA carriers who have never been diagnosed with breast cancer, short-term hormone replacement therapy is generally considered safe. It effectively manages menopausal symptoms and protects your bone and heart health until the natural age of menopause.
Does removing my ovaries also lower my risk of breast cancer?
While removing your ovaries is primarily done to prevent ovarian cancer, it may also offer some reduction in breast cancer risk for certain patients, particularly BRCA2 carriers. However, a bilateral mastectomy remains the most effective surgical way to prevent breast cancer.

Questions for Your Doctor

5 questions

  • •Given my specific mutation and current age, what is the ideal 'window' for me to have my ovaries and tubes removed?
  • •How much will a bilateral mastectomy reduce my risk of breast cancer compared to relying on screening alone?
  • •If I have my ovaries removed, what is your plan for managing surgical menopause? Can I start HRT immediately?
  • •What type of HRT (estrogen-only vs. combined) is safest for me, and for how long should I take it?
  • •Does removing my ovaries also lower my risk of breast cancer, or should I still consider a mastectomy?

Questions for You

3 questions

  • •Have I completed my family, or do I want to explore options like egg or embryo freezing before considering surgery?
  • •How do I feel about the physical and emotional impact of a mastectomy versus the anxiety of frequent cancer screenings?
  • •Am I prepared for the sudden symptoms of menopause (like hot flashes or bone health changes) if I choose to have my ovaries removed?

References

References (19)
  1. 1

    Time trends, uptake, and oncological effects of risk-reducing surgeries in 3067 Danish BRCA1/2 carriers: a population-based study with matched controls.

    Willert CB, Mellemkjær L, Tolver A, et al.

    Breast cancer research and treatment 2025; (214(3)):355-366 doi:10.1007/s10549-025-07821-4.

    PMID: 40974500
  2. 2

    Impact of risk-reducing salpingo-oophorectomy in premenopausal women.

    Vermeulen RFM, Beurden MV, Korse CM, Kenter GG

    Climacteric : the journal of the International Menopause Society 2017; (20(3)):212-221 doi:10.1080/13697137.2017.1285879.

    PMID: 28509627
  3. 3

    The Role of Risk-Reducing Surgery in Hereditary Breast and Ovarian Cancer.

    Hartmann LC, Lindor NM

    The New England journal of medicine 2016; (374(5)):454-68 doi:10.1056/NEJMra1503523.

    PMID: 26840135
  4. 4

    Age-specific ovarian cancer risks among women with a BRCA1 or BRCA2 mutation.

    Kotsopoulos J, Gronwald J, Karlan B, et al.

    Gynecologic oncology 2018; (150(1)):85-91 doi:10.1016/j.ygyno.2018.05.011.

    PMID: 29793803
  5. 5

    A competing risks model with binary time varying covariates for estimation of breast cancer risks in BRCA1 families.

    Choi YH, Jung H, Buys S, et al.

    Statistical methods in medical research 2021; (30(9)):2165-2183 doi:10.1177/09622802211008945.

    PMID: 34232831
  6. 6

    Effect of Oophorectomy on Survival After Breast Cancer in BRCA1 and BRCA2 Mutation Carriers.

    Metcalfe K, Lynch HT, Foulkes WD, et al.

    JAMA oncology 2015; (1(3)):306-13 doi:10.1001/jamaoncol.2015.0658.

    PMID: 26181175
  7. 7

    Uterine cancer in Jewish Israeli BRCA1/2 mutation carriers.

    Laitman Y, Michaelson-Cohen R, Levi E, et al.

    Cancer 2019; (125(5)):698-703 doi:10.1002/cncr.31842.

    PMID: 30489631
  8. 8

    Retrospective evaluation of risk-reducing salpingo-oophorectomy for BRCA1/2 pathogenic variant carriers among a cohort study in a single institution.

    Kobayashi Y, Hirasawa A, Chiyoda T, et al.

    Japanese journal of clinical oncology 2021; (51(2)):213-217 doi:10.1093/jjco/hyaa173.

    PMID: 33037428
  9. 9

    Retrospective study of a 16 year cohort of BRCA1 and BRCA2 carriers presenting for RRSO: Prevalence of invasive and in-situ carcinoma, with follow-up.

    Blok F, Dasgupta S, Dinjens WNM, et al.

    Gynecologic oncology 2019; (153(2)):326-334 doi:10.1016/j.ygyno.2019.03.003.

    PMID: 30894273
  10. 10

    Sexual activity and functioning after risk-reducing salpingo-oophorectomy: Impact of hormone replacement therapy.

    Johansen N, Liavaag AH, Tanbo TG, et al.

    Gynecologic oncology 2016; (140(1)):101-6.

    PMID: 26597462
  11. 11

    Is hormonal therapy after risk-reducing salpingo-oophorectomy associated with an increased risk of malignancy in pathogenic variant carriers?

    Mills KA, Joshi TV, West L, et al.

    Gynecologic oncology 2020; (157(3)):706-710 doi:10.1016/j.ygyno.2020.02.033.

    PMID: 32143914
  12. 12

    Hormone replacement therapy after risk reducing salpingo-oophorectomy in patients with BRCA1 or BRCA2 mutations; a systematic review of risks and benefits.

    Gordhandas S, Norquist BM, Pennington KP, et al.

    Gynecologic oncology 2019; (153(1)):192-200 doi:10.1016/j.ygyno.2018.12.014.

    PMID: 30661763
  13. 13

    Hormone replacement therapy in BRCA mutation carriers and risk of ovarian, endometrial, and breast cancer: a systematic review.

    Huber D, Seitz S, Kast K, et al.

    Journal of cancer research and clinical oncology 2021; (147(7)):2035-2045 doi:10.1007/s00432-021-03629-z.

    PMID: 33885953
  14. 14

    BRCA carriers after risk-reducing bilateral salpingo-oophorectomy: menopausal hormone therapy knowledge gaps, and the impact of physicians' recommendations.

    Armon S, Miron-Shatz T, Mor P, et al.

    Climacteric : the journal of the International Menopause Society 2023; (26(2)):154-160 doi:10.1080/13697137.2023.2173567.

    PMID: 36866779
  15. 15

    Hormone replacement therapy after prophylactic risk-reducing salpingo-oophorectomy and breast cancer risk in BRCA1 and BRCA2 mutation carriers: A meta-analysis.

    Marchetti C, De Felice F, Boccia S, et al.

    Critical reviews in oncology/hematology 2018; (132()):111-115 doi:10.1016/j.critrevonc.2018.09.018.

    PMID: 30447915
  16. 16

    Safety of hormone replacement therapy following risk-reducing salpingo-oophorectomy: systematic review of literature and guidelines.

    Vermeulen RFM, Korse CM, Kenter GG, et al.

    Climacteric : the journal of the International Menopause Society 2019; (22(4)):352-360 doi:10.1080/13697137.2019.1582622.

    PMID: 30905183
  17. 17

    Bilateral Oophorectomy and Breast Cancer Risk in BRCA1 and BRCA2 Mutation Carriers.

    Kotsopoulos J, Huzarski T, Gronwald J, et al.

    Journal of the National Cancer Institute 2017; (109(1)) doi:10.1093/jnci/djw177.

    PMID: 27601060
  18. 18

    Cost-Effectiveness of Gene-Specific Prevention Strategies for Ovarian and Breast Cancer.

    Wei X, Sun L, Slade E, et al.

    JAMA network open 2024; (7(2)):e2355324 doi:10.1001/jamanetworkopen.2023.55324.

    PMID: 38334999
  19. 19

    Risk reduction and survival benefit of prophylactic surgery in BRCA mutation carriers, a systematic review.

    Ludwig KK, Neuner J, Butler A, et al.

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    PMID: 27649974

This page provides educational information about surgical risk reduction for HBOC. Always consult your genetic counselor or oncologist to discuss your personal risk factors, surgical options, and optimal timing.

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