Ovarian Shutdown or Removal

If you are still getting a regular menstrual period (you are pre-menopausal), most of the estrogen produced in your body is made in your ovaries. If you are pre-menopausal and have hormone-receptor-positive breast cancer, shutting down the ovaries' production of estrogen can be very effective in stopping cancer cell growth. The ovaries can be shut down by taking medicines or by having surgery.

Although the most common hormonal therapy used in pre-menopausal women is tamoxifen, your doctor might also talk to you about ovarian shutdown, depending on your situation.

Here's the difference between the two approaches:

• Tamoxifen blocks estrogen from getting into the estrogen receptors.
• Shutting down or removing the ovaries decreases the amount of estrogen in your body.

Ovarian shutdown or removal may be combined with taking tamoxifen to avoid further estrogen stimulation of cancer cell growth.

How ovarian shutdown or removal works

If you are pre-menopausal and have advanced (metastatic) hormone-receptor-positive breast cancer, your doctor may suggest ovarian shutdown or removal so that you can become post-menopausal.

Shutting down the ovaries with medication and removing them surgically are both very effective ways to reduce or eliminate the main source of estrogen. With less estrogen to "feed" hormone-receptor-positive breast cancer cells, the growth of these cells is controlled or stopped.

If your ovaries are removed, you will go right into menopause instead of having the gradual transition that natural menopause allows. Ovarian shutdown with medication, which happens over a period of months, is a more gradual change. The side effects of ovarian shutdown or removal include hot flashes, vaginal dryness, mood swings, depression, weight gain, and bloating. There are solutions for managing all of these symptoms, however.

Ovarian shutdown or removal are only for pre-menopausal women

Ovarian shutdown or removal are only effective in pre-menopausal women with hormone-receptor-positive breast cancer. Before recommending this treatment approach, your doctor will want to know if you are really in menopause or if your periods might come back.

Some women who are pre-menopausal at diagnosis find that chemotherapy stops their periods. But the menopause caused by chemotherapy may be only temporary. You may get your periods back over time, usually within one year but sometimes about two years later.

If you are already post-menopausal because you have gone through a natural menopause (usually around age 50–52) or because of chemotherapy, you cannot have ovarian shutdown or removal. If it has been more than two years since your last period, your ovaries are no longer developing an egg every month. This means your ovaries are making little to no estrogen, and ovarian shutdown or removal would offer you no benefit.

How does your doctor determine if you are post-menopausal?

Your doctor may test the levels of hormones in your blood to help figure out whether you have gone into menopause forever. The hormones tested are:

• estrogen
• follicle-stimulating hormone (FSH)
• luteinizing hormone (LH)

If your estrogen level is very low and the FSH and LH levels are very high, then you're probably in menopause already and your periods are unlikely to return. Read more about hormone levels and menopause.

Menopause brought on by chemotherapy is most likely to be permanent if:

• You were age 40 or older when you received chemotherapy.
• Your periods have stopped for longer than one year.
• The chemotherapy agents and dose used might have increased your risk of going into menopause forever. Read more about chemotherapy and menopause.

Once you're in menopause, another form of hormonal therapy becomes an option: the aromatase inhibitors, either Arimidex (chemical name: anastrozole), Aromasin (chemical name: exemestane), or Femara (chemical name: letrozole). New research is looking at the role of aromatase inhibitors—which are only used in post-menopausal women—for those women who were pre-menopausal, have gone through ovarian shutdown, and are now post-menopausal.

Three ways to shut down the ovaries

There are three main ways to stop the ovaries from producing estrogen:

1. Medical shutdown. Your doctor may recommend you take medicines that temporarily turn off signals from your brain tell your ovaries to make estrogen. This leads to a major drop in estrogen. The medicines that can make the ovaries shut down include Zoladex (chemical name: goserelin) or Lupron (chemical name: leuprolide). These medicines are given by injection (shots) once a month for several months.
2. Surgical removal. The ovaries can be surgically removed through small incisions (cuts) in the belly, using an instrument called a laparoscope. This is called oophorectomy. Removing the ovaries removes most of the estrogen in your body. However, other tissues, such as your adrenal glands (glands over the kidneys that help control important body functions), will still produce small amounts of estrogen.
3. Radiation shutdown. Low-dose radiation therapy completely shuts down the production of estrogen in the ovaries. This technique, sometimes called ovarian ablation, is rarely used today.

How do you and your doctor decide if ovarian shutdown is right for you?

Deciding on an ovarian shutdown or removal procedure requires a lot of careful thought. If you are still in your thirties and haven't started or finished having a family, fertility may be a big issue for you.

However, if you are in your mid-to-late forties, still menstruating, but have multiple positive lymph nodes, your doctor may recommend several treatments to get your estrogen level down as low as possible. This might include both shutting down or removing the ovaries and taking an aromatase inhibitor. Treatment options will depend on your risk of recurrence.

Women with a known breast cancer gene abnormality (such as BRCA1 or BRCA2) may choose ovary removal to reduce the risk of both breast and ovarian cancer. Breast cancer risk falls by about 50% when the ovaries are removed. The rock-bottom estrogen levels that follow surgery successfully stop breast cell growth, making cancer less likely to develop.

Treatment concerns will depend on how early menopause will affect your quality of life (fertility, hot flashes, etc.) and overall health considerations (such as increased cholesterol and bone loss).

Ovarian removal to reduce risk of ovarian cancer

You may also choose to have your ovaries removed after chemotherapy in order to reduce your risk of ovarian cancer—regardless of your menopausal status.

Before and after menopause, removal of the ovaries reduces the risk of ovarian cancer. Both women with a strong family history of breast cancer and those with a known breast cancer gene abnormality, such as BRCA1 or BRCA2, can benefit from having their ovaries removed.

If your ovaries are removed before menopause, your risk of both breast and ovarian cancer are reduced. If you've had breast cancer, and you went into permanent menopause from chemotherapy, you may still want to have your ovaries removed to reduce your risk of ovarian cancer.

Ovarian cancer risk drops by about 80% when the ovaries are surgically removed. The risk doesn't go down to zero because ovary-like cells that are normally present in the pelvic area could still form a cancer, even after the ovaries are gone.

For cancers linked to abnormal breast cancer genes, the type of abnormal breast cancer gene a woman has seems to influence how much risk reduction she gets from preventive ovary removal. A 2008 study by researchers at Memorial Sloan-Kettering Cancer Center found that in women who had an abnormal BRCA1 gene, removing the ovaries was more beneficial for lowering ovarian cancer risk than lowering breast cancer risk. In women who had an abnormal BRCA2 gene, removing the ovaries was more beneficial for lowering breast cancer risk than ovarian cancer risk.