Ovarian ablation and breast cancer

Ovarian ablation and ovarian suppression are different ways of stopping the ovaries from working. They reduce the amount of the hormone oestrogen in your body. Oestrogen can encourage breast cancer cells to grow.

These treatments are only suitable if you have oestrogen-receptive (ER) positive breast cancer and have not been through menopause. They help to reduce the risk of primary breast cancer coming back after surgery or of getting a new breast cancer. They also help to control breast cancer that has come back (secondary breast cancer).

The different ways to stop the ovaries producing oestrogen are:

  • Surgery to remove the ovaries
  • Hormonal therapy drugs which ‘shut down’ (suppress) the ovaries
  • Radiotherapy, which uses high-energy x-rays, to stop the ovaries working – this isn’t commonly done.

The side effects are similar to menopause symptoms. If the ovaries are removed with surgery side effects can be more intense than natural menopause.

Surgery or radiotherapy to the ovaries will cause infertility. Your breast nurse can give you advice about managing the side effects and coping with your feelings.

Ovarian ablation and breast cancer

Ovarian ablation and ovarian suppression are medical terms used to describe different ways of stopping the ovaries from working. We use the term ovarian ablation to cover all of these methods.

Ovarian ablation is only suitable if:

  • you have not yet had the menopause (you are pre-menopausal)
  • you have oestrogen receptor positive (ER positive) breast cancer.

This is because ER positive breast cancer is the type of cancer that responds to hormonal therapy treatment.

Hormones are made by the body and help control how cells grow and what they do in the body. The hormone oestrogen can stimulate breast cancer cells to grow in women with ER positive breast cancer.

Before menopause, most of the oestrogen in the body is made by the ovaries. Ovarian ablation stops the ovaries producing oestrogen and lowers oestrogen levels in the body. It can be used to treat women with primary breast cancer or breast cancer that has spread to other parts of the body (secondary breast cancer).

The ovaries and their surrounding structures
The ovaries and their surrounding structures

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Ovarian ablation can be used:

  • after surgery, to reduce the risk of the cancer coming back
  • to reduce the risk of developing a new breast cancer
  • to shrink and control breast cancer that has spread.

You might be offered ovarian ablation in combination with the hormonal therapy drug tamoxifen.

Ovarian ablation may be offered as an option if you don’t want to have chemotherapy after surgery. Chemotherapy may be given after surgery to reduce the risk of breast cancer coming back. It can also bring on an early menopause.


Types of ovarian ablation

There are three different ways to stop the ovaries producing oestrogen:

  • surgery to remove the ovaries
  • hormonal therapy to 'shut down' the ovaries (ovarian suppression)
  • radiotherapy to stop the ovaries working.


Surgery

An operation to remove the ovaries is called an oophorectomy. It’s usually carried out under a general anaesthetic. The fallopian tubes are usually removed at the same time.

Removing the ovaries produces an immediate and permanent menopause. This means you won’t have any more periods and you may get menopausal symptoms very shortly after the operation.

Keyhole surgery

The operation is often done using keyhole (laparoscopic) surgery. The surgeon makes up to four small cuts (incisions) in the skin and muscle in the tummy area (abdomen). They then insert a long, thin, flexible tube called a laparoscope through one of the cuts. The tube has a tiny light and camera on the end and is connected to a video camera. The inside of your abdomen can be seen on a screen. During the operation, carbon dioxide gas is passed into the abdominal cavity. This makes the tummy swell so that it’s easier for the surgeon to see the ovaries. The gas is released through the cuts at the end of the operation.

To remove the ovaries, your surgeon uses instruments that are attached to the laparoscope and inserted into the other cuts. Afterwards, the cuts are closed with stitches (usually self-dissolving) and covered with a small dressing. You may be in hospital for a day or two, and recovery is usually quick.

Open surgery

Sometimes it’s not possible to remove the ovaries with keyhole surgery. Instead, you’ll have one long incision made below the bikini line. You’ll usually be in hospital for a few days after this operation to fully recover.


Hormonal therapy

Hormonal therapies are drugs that work by lowering or blocking the effects of oestrogen on breast cancer cells.

Your doctor may recommend drugs called LHRH blockers that stop the brain producing a hormone called luteinising hormone. Luteinising hormone stimulates the ovaries to make oestrogen. LHRH blockers cause a temporary menopause by shutting down or suppressing the ovaries (ovarian suppression) from producing oestrogen. Oestrogen levels usually drop within three weeks of starting treatment and remain like this as long as treatment continues.

The drug most commonly used is called goserelin (Zoladex®). Another drug called leuprorelin (Prostap®) may also be used. Zoladex is given as an injection under the skin (subcutaneously) into the tummy every 28 days. You'll usually have the first injection given to you at a clinic appointment. After this it can usually be given to you by your practice nurse, community nurse or GP.

You may have one, or sometimes two, more periods after your treatment starts before it takes effect.

Zoladex or Prostap are usually given for two years, but can be given for longer in some situations. You and your doctor can talk about the length of treatment that's right for you.

After treatment your ovaries may start to work again and your periods may come back. This usually happens within six months. If you want the option of having children after breast cancer, this treatment may be suitable. Whether or not your periods come back depends on how close you were to your natural menopause when you started treatment. If you were close, your periods may not come back afterwards.

Although your periods usually stop during treatment, the drugs are not a contraceptive, so you'll need to use effective contraception to make sure you don't get pregnant. Your breast care nurse or doctor can give you further advice.


Radiotherapy

Radiotherapy uses high-energy x-rays and can be given to the ovaries to stop them working and producing oestrogen. This way of stopping the ovaries working isn’t commonly used.

You can have the radiotherapy over a few days as an outpatient. The side effects can include diarrhoea and feeling sick, but your doctor can prescribe medicine to control this. You may also feel tired. The side effects go away shortly after treatment is over.

It is rare for radiotherapy in ovarian ablation to cause any long-term effects because the dose used is very low.

Radiotherapy to the ovaries causes a permanent menopause. This doesn’t happen straight away and your periods may carry on for up to three months after radiotherapy. It’s important to use reliable contraception until you are sure your periods have stopped completely, as you may still become pregnant. Your breast care nurse or doctor can give you further advice.


Infertility

Having your ovaries removed or having radiotherapy to your ovaries means you won’t be able to have children. This can be distressing, especially if you were hoping to have children or add to your family. Some women find it helpful to talk through their feelings with a professional counsellor. Your breast care nurse or doctor can give you support and advice. There are also organisations that can help.


Coping with menopausal symptoms

Women whose ovaries are removed will have an early menopause straight away. The symptoms of this can start suddenly and may be more intense than the symptoms of a natural menopause.

Ovarian ablation using hormonal therapy or radiotherapy happens over a period of weeks or months and is a more gradual change.

The menopause can cause symptoms such as:

  • hot flushes
  • dry skin
  • vaginal dryness
  • lowered sex drive
  • psychological effects.

These symptoms can vary from being mild to severe. This can be difficult for women to cope with, especially when they’re already dealing with breast cancer and its treatments.


Long-term effects

Oestrogen helps keep bones strong. A lack of it over a long period increases the risk of osteoporosis (thinning of the bones). You may have your bone health (density) checked by having a bone scan called a DEXA scan. Your doctor can prescribe bone strengthening drugs if needed.

Doing regular exercise, healthy eating and giving up smoking can help keep your bones healthy. These measures also help protect your heart and reduce the risk of other illnesses. Your doctor and breast care nurse can give you information and advice about the risk of long-term problems after ovarian ablation.

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