What are the treatment options post bilateral oophorectomy (removal of ovaries)?

Treatment Post Bilateral Oophorectomy

For premenopausal women undergoing bilateral oophorectomy for benign indications or cancer risk reduction, hormone replacement therapy (HRT) should be initiated and continued until the natural age of menopause (approximately age 51) unless contraindicated by estrogen receptor-positive breast cancer. 1

Context-Specific Treatment Pathways

For Cancer Patients (Ovarian/Tubal/Peritoneal Cancer)

Following bilateral salpingo-oophorectomy as part of cancer treatment, the primary post-surgical treatment is platinum-based combination chemotherapy for 6-8 cycles (or 3 cycles for stage I disease, excluding stage IA grade 1). 2 This represents the standard of care for all patients except those with stage IA grade 1 tumors. 2

• Surgical staging must be complete before initiating chemotherapy, including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, appendectomy, lymph node assessment, and peritoneal biopsies. 2, 3
• If initial surgery was incomplete, restaging laparotomy should be performed as soon as possible before chemotherapy. 2
• HRT is generally not recommended in the context of active ovarian cancer treatment due to the hormone-sensitive nature of some tumors.

For Risk-Reducing Surgery (BRCA1/BRCA2, Lynch Syndrome, High-Risk Patients)

This is where HRT becomes critically important and should be strongly recommended:

HRT regimen specifications:

• For women with intact uterus: Combined estrogen plus progestogen to prevent endometrial hyperplasia 1
• For women who had concurrent hysterectomy: Estrogen-only therapy 1
• Duration: Continue until age 51 (average natural menopause age) 1
• Breast cancer considerations: Research demonstrates that HRT in premenopausal women after risk-reducing surgery does not increase breast cancer risk, even in BRCA1/BRCA2 carriers 1

For Benign Indications (Endometriosis, Benign Masses, etc.)

The treatment approach mirrors risk-reducing surgery:

HRT is strongly recommended to mitigate the substantial health risks of premature ovarian failure, which include:

• Increased cardiovascular disease mortality (coronary heart disease accounts for 350,000 deaths annually vs. 14,800 from ovarian cancer) 4
• Increased risk of dementia (potentially 100,000 cases annually attributable to bilateral oophorectomy) 4
• Increased risk of Parkinsonism, cognitive impairment, depression, anxiety 4, 5
• Increased risk of osteoporosis and hip fractures 4, 5
• Decline in sexual function and psychological wellbeing 5

Combined estrogen-testosterone replacement should be considered following bilateral oophorectomy, as this has been shown to reduce the incidence of post-oophorectomy depression more effectively than estrogen alone. 6 The depletion of endogenous androgens from oophorectomy significantly affects mood and sexual function. 6

Absolute Contraindications to HRT

Estrogen receptor-positive breast cancer history is the primary absolute contraindication to HRT. 1 In these cases:

• Liaise with oncology on a case-by-case basis
• Consider non-hormonal alternatives (see below)

For estrogen receptor-negative breast cancer history: Decisions should be made collaboratively with oncology, as HRT may be considered safe in select cases. 1

Alternative Therapies When HRT is Contraindicated

When HRT cannot be used, the following options are available (though less effective than HRT): 1

• Behavioral therapy for vasomotor symptoms 1
• Non-hormonal medications (specific agents not detailed in guidelines but may include SSRIs, gabapentin, clonidine) 1
• Raloxifene (selective estrogen receptor modulator) may be considered for bone protection, as it acts as an estrogen agonist in bone while being an antagonist in breast and uterine tissue 7
• Lifestyle modifications: Regular exercise, healthy lifestyle, avoiding symptom triggers 1

Critical Monitoring and Follow-Up

Regular endocrinologic monitoring following hysterectomy with oophorectomy is essential to detect the need for estrogen replacement, as the cyclical nature of hormone-related depressed states often remains unrecognized in the absence of menstruation. 6

• Monitor for vasomotor symptoms (hot flushes, night sweats)
• Assess mood changes, cognitive function
• Screen for cardiovascular risk factors
• Monitor bone density
• Evaluate sexual function and quality of life

Common Pitfalls to Avoid

• Failing to initiate HRT in premenopausal women without breast cancer contraindications—this is the most significant error, as observational studies suggest bilateral oophorectomy may do more harm than good when ovaries are removed without hormone replacement 4, 8
• Discontinuing HRT before age 51 in women who underwent premenopausal oophorectomy 1
• Missing the diagnosis of hormone deficiency after hysterectomy with ovarian conservation, as premature ovarian failure can occur even when ovaries are retained 6
• Prescribing progestogen unnecessarily in women without a uterus, which can have depressant effects on mood 6
• Failing to consider testosterone replacement in addition to estrogen, particularly for mood and sexual function 6