Should women with a BRCA gene mutation be advised to have a hysterectomy after they have completed childbearing?
Your Question: Should women with a BRCA gene mutation be advised to have a hysterectomy after they have completed childbearing?
Our Response: Risk-reducing bilateral salpingo-oophorectomy for women with a germline mutation in the BRCA1/2 genes has been shown to be effective in preventing ovarian and fallopian tube cancer and is recommended by multiple professional organizations. Conversely, hysterectomy performed at the same time as removal of the tubes and ovaries remains controversial. Multiple studies have produced conflicting results concerning the presence of increased risk of uterine cancer in women with BRCA mutations. Some studies suggest an increased risk of uterine serous carcinoma, specifically in women with a BRCA1 mutation. However, this association has not been reproduced in other investigations. Currently, there is a paucity of guidelines on hysterectomy at the time of risk reduction surgery by leading organizations, including the National Comprehensive Cancer Network.
Determination of the appropriateness of hysterectomy during prophylactic procedures should include a thoughtful evaluation of the potential risks and benefits for each patient. The additional risk of a hysterectomy includes the inherent surgical risks of urinary tract injury, bowel injury, bleeding, and infection. Benefits include avoidance of progesterone for hormone replacement in pre-menopausal woman following oophorectomy and correction of concurrent pathology (if present) including uterine fibroid, abnormal uterine bleeding, or pelvic organ prolapse.
All women should receive thorough, individualized counseling regarding the risks and potential benefits of concurrent hysterectomy. This allows for the execution of a shared decision-making model; recommendations may evolve as new information about the actual risk of uterine cancer in patients with BRCA mutation becomes available.
James Woods |