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Preventively Removing Fallopian Tubes First, Ovaries Later Offers Better Quality of Life for Women With BRCA Mutations

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Women with a BRCA1 or BRCA2 gene mutation had better menopause-related quality of life after having surgery to remove the fallopian tubes between ages 40 and 50, and then surgery to remove the ovaries later in life, compared to women who had both the fallopian tubes and ovaries removed when they were in their 40s, according to a Dutch study.

Still, researchers don’t know if having two surgeries to remove the fallopian tubes first and then the ovaries after some time reduces ovarian cancer and breast cancer risk as much as having one surgery to remove the fallopian tubes and the ovaries at the same time.

The research was published online on June 3, 2021, by the journal JAMA Oncology. Read the abstract of “Association of Salpingectomy With Delayed Oophorectomy Versus Salpingo-oophorectomy With Quality of Life in BRCA1/2 Pathogenic Variant Carriers: A Nonrandomized Controlled Trial.”

Surgery to remove the healthy ovaries and fallopian tubes is called prophylactic or risk-reducing salpingo-oophorectomy. Surgery to remove only the healthy fallopian tubes is called prophylactic or risk-reducing salpingectomy. And surgery to remove only the healthy ovaries is called oophorectomy.

Genetic mutations linked to breast and ovarian cancer
Risk-reducing ovary and fallopian tube removal
About the study
What this means for you

Genetic mutations linked to breast and ovarian cancer

Two of the most well-known genes that can mutate and raise the risk of breast and ovarian cancer are BRCA1 and BRCA2. Women who inherit a mutation in either of these genes — from their mothers or fathers — have a much higher-than-average risk of developing breast cancer and ovarian cancer.

The average woman’s risk of developing breast cancer in her lifetime is about 13%. According to the National Cancer Institute (NCI), women with a BRCA1 mutation have between a 55% and 72% lifetime risk of developing breast cancer, and women with a BRCA2 mutation have a 45% to 69% lifetime risk of developing breast cancer.

The average woman’s risk of developing ovarian cancer is 1.22%. Women with a BRCA1 mutation have about a 44% risk of developing ovarian cancer, and women with a BRCA2 mutation have a 17% risk.

Men with these mutations also have an increased risk of developing breast cancer, especially if the BRCA2 gene is affected, and possibly of developing prostate cancer.

About 5% to 10% of breast cancers are thought to be hereditary, meaning the cancer is linked to mutations in genes passed from parent to child.

You are substantially more likely to have a genetic mutation linked to breast cancer if:

  • your mother or blood relatives (grandmothers, sisters, aunts) on either your mother’s or father’s side of the family have been diagnosed with breast cancer before age 50
  • there is both breast cancer and ovarian cancer on the same side of the family or in a single individual
  • you have at least one relative with triple-negative breast cancer
  • there are other cancers in your family in addition to breast, such as prostate, melanoma, pancreatic, stomach, uterine, thyroid, colon, and/or sarcoma
  • women in your family have had cancer in both breasts
  • you are of Ashkenazi Jewish (Eastern European) heritage
  • you are Black and have been diagnosed with breast cancer at age 35 or younger
  • a man in your family has had breast cancer
  • there is a known breast cancer gene mutation in your family

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Risk-reducing ovary and fallopian tube removal

Women who are at high risk for breast cancer and ovarian cancer because they have a BRCA gene mutation may choose to have their healthy fallopian tubes, ovaries, and breasts removed. The ovaries are the body’s main source of the hormones estrogen and progesterone, and the fallopian tubes connect the ovaries to the uterus. Risk-reducing salpingo-oophorectomy surgery means that your doctor removes the ovaries and fallopian tubes before any cancer is detected in them.

It’s important to know that this surgery is a serious choice that can have a considerable impact on your life. Ovary removal takes away your ability to have children and reduces the amount of estrogen your body produces, putting you into immediate menopause at a much younger age. The sudden loss of estrogen can cause a range of menopausal side effects, such as hot flashes, depression, difficulty sleeping, and lessened sex drive. Estrogen loss may also affect bone and heart health.

It’s also important to know that this risk-reducing surgery doesn’t guarantee that cancer won’t develop.

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About the study

Research has shown that the fallopian tubes, rather than the ovaries, is where most high-grade ovarian cancer starts. So researchers came up with the idea of splitting salpingo-oophorectomy surgery into two procedures — the first to remove the fallopian tubes and a second to remove the ovaries some years after — with the aim of avoiding early menopause and its symptoms.

Two earlier studies found that up to 44% of women with a BRCA1 or BRCA2 gene mutation were interested in this alternative risk-reducing surgery.

Still, a study looking at whether having two surgeries to remove the fallopian tubes and the ovaries reduces the risk of ovarian cancer as much as having one surgery to remove the fallopian tubes and the ovaries at the same time would require at least 3,000 participating women and 10 to 15 years of follow-up time.

Before starting such a large and involved trial, researchers conducted this study — called the TUBA study — so they could first see if a procedure to remove only the fallopian tubes would cause fewer menopausal symptoms, giving women better quality of life. The women would have a procedure later in life to remove the ovaries.

The study included 548 Dutch women with either a BRCA1 or BRCA2 gene mutation. The women’s average age was about 37. About half of the women had a BRCA1 mutation and about half had a BRCA2 mutation. None of the women had been diagnosed with ovarian, fallopian tube, or peritoneal cancer (cancer in the thin layer of tissue that lines the abdomen). None of the women had been diagnosed with cancer when they joined the study.

In the Netherlands, doctors recommend risk-reducing surgery to remove both the fallopian tubes and the ovaries between the ages of 35 and 40 for women with a BRCA1 mutation and between the ages of 40 and 45 for women with a BRCA2 mutation.

Between January 2015 and November 2019, the women chose one of two risk-reducing surgeries:

  • 394 women chose to have only their fallopian tubes removed, waiting until later in life to have their ovaries removed
  • 154 women chose to have both their fallopian tubes and ovaries removed at the same time

Hormone replacement therapy (HRT) was recommended for women who had both their fallopian tubes and ovaries removed, as long as it was considered medically safe. Some of the women who chose to have only their fallopian tubes removed also decided to take HRT.

Because HRT eases menopausal symptoms, the researchers analyzed results from women who did and didn’t take HRT separately.

It’s important to know that this study wasn’t randomized. This means the women could freely choose which type of surgery they had. This means that the results could be biased because women more likely to have menopausal symptoms could have chosen one type of surgery and women less likely to have menopausal symptoms could have chosen the other type.

Before surgery, 3 months after surgery, and 1 year after surgery, the women completed the Greene Climacteric Scale, a tool used to measure 21 menopausal symptoms, including hot flashes, night sweats, loss of libido, and muscle and joint pain.

The researchers compared Green Climacteric Scale menopause-related quality of life scores 1 year after surgery for the women who had not taken HRT:

  • 296 women who had only the fallopian tubes removed
  • 40 women who had both the fallopian tubes and the ovaries removed

Compared with scores before surgery, Green Climacteric Scale scores increased by:

  • 0.7 for women who had only the fallopian tubes removed
  • 7.7 for women who had both the fallopian tubes and the ovaries removed

This difference in scores was statistically significant, which means it was likely because of the difference in surgery and not because of chance.

The most commonly reported menopausal symptoms were:

  • hot flashes
  • sudden excitability
  • irritability
  • loss of libido

The researchers also compared Greene Climacteric Scale menopause-related quality of life scores 1 year after surgery for the women who had both the fallopian tubes and ovaries removed and took HRT vs. the women who had only the fallopian tubes removed and either took or didn’t take HRT.

Compared with scores before surgery, Greene Climacteric Scale scores increased by:

  • 0.8 for women who had only the fallopian tubes removed
  • 4.6 for women who had both the fallopian tubes and ovaries removed

This difference also was statistically significant.

“In this nonrandomized controlled trial, patients who underwent risk-reducing salpingectomy reported better menopause-related quality of life and better sexual functioning compared with patients who received risk-reducing salpingo-oophorectomy, with the difference more pronounced in women who did not receive HRT,” the researchers concluded.

They also said a new study, called TUBA-WISP, recently started to see if removing only the fallopian tubes first (and the ovaries later in life) reduces ovarian cancer risk as much as removing both the fallopian tubes and the ovaries at the same time.

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What this means for you

If you have a BRCA1 or BRCA2 gene mutation, the results of this study are encouraging. Still, more research needs to be done before we know if removing only the fallopian tubes when a woman is in her 40s and the ovaries later in life reduces the risk of ovarian cancer and breast cancer as much as removing both the fallopian tubes and ovaries at the same time when a woman is in her 40s.

While improving menopause-related quality of life is hugely important, if removing only the fallopian tubes (and the ovaries later in life) doesn’t offer the same decrease in cancer risk as removing the fallopian tubes and ovaries at the same time, the trade-off may not be worth it.

Stay tuned to Breastcancer.org Research News for the latest information on new ways to reduce cancer risk in people who have genetic mutations linked to a higher risk of breast cancer.

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Written by: Jamie DePolo, senior editor

Reviewed by: Brian Wojciechowski, M.D., medical adviser


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