Risk-Reducing Surgery and Treatment of Menopausal Symptoms in BRCA Mutation Carriers (and Other Risk Women)

Women with a life expectancy ≥10 years and no diagnosis/history of breast cancer who are considered to be at increased risk for breast cancer should receive counseling to decrease breast cancer risk, considering lifestyle factors, therapy with risk reduction agents, and risk reduction surgery (in BRCA1/2 mutation carriers).Bilateral risk-reducing mastectomy decreases the risk of developing breast cancer by at least 90%; it should be proposed to carefully selected women at high risk for breast cancer considering BRCA1/2 or other genetic mutations and previous history of LCIS. In current practice, atypical hyperplasia is not an indication for prophylactic mastectomy.Bilateral risk-reducing salpingo-oophorectomy decreases the risk of developing ovarian and fallopian cancer by 85–95% and breast cancer by 50% in BRCA1/2 mutation carriers when performed in premenopausal age. Peritoneal washing should be performed at surgery, and pathologic assessment should include fine sectioning of the ovaries and fallopian tubes. The additional benefit of concurrent hysterectomy is not clear at the time. In women with no personal history of breast cancer, short-term HRT use does not negate the protective effect of RRSO on subsequent breast cancer risk, and it should be offered until the time of expected natural menopause.