Synopsis
Plan gene- and age-specific gynaecological risk-reducing surgery through shared decision making, then prevent and manage the immediate reproductive, menopausal, bone, cardiovascular and psychosexual consequences.
- Risk-reducing surgery is considered only after validated genetic or familial risk assessment, completed reproductive plans and multidisciplinary discussion of the person's age, variant, family history and competing health priorities.
- NICE uses a total lifetime ovarian-cancer risk of at least 5% as the threshold for discussing surgery, but the appropriate operation and timing still depend on the pathogenic variant and individual risk trajectory.
- NICE lists bilateral salpingo-oophorectomy no earlier than 35 for BRCA1, 40 for BRCA2 and 45 for RAD51C, RAD51D, BRIP1 or PALB2 when lifetime ovarian risk is at least 5%; earlier surgery needs individualised assessment.
- For MLH1, MSH2 or MSH6 Lynch syndrome, hysterectomy with bilateral salpingo-oophorectomy is listed no earlier than 35 because both endometrial and ovarian risk are relevant; PMS2 requires a different, personalised discussion.
- Bilateral salpingo-oophorectomy before natural menopause causes immediate irreversible ovarian failure, infertility and loss of endogenous ovarian hormones; consent must cover vasomotor, sexual, bone, cardiovascular and psychological effects.
- Offer HRT until about age 51 after premenopausal risk-reducing bilateral salpingo-oophorectomy when there is no previous breast cancer; use combined HRT when the uterus remains and oestrogen alone after hysterectomy.
- A previous breast cancer does not create a generic prescribing rule: liaise with the breast cancer team before HRT, considering tumour biology, current endocrine treatment, symptom burden and non-hormonal options.
- Salpingectomy with delayed oophorectomy does not yet have equivalent cancer-prevention evidence and NICE restricts this risk-reducing strategy to a clinical trial.
Key red flags
Haemodynamic disturbance, abdominal distension, increasing pain or unexpected vaginal or wound bleeding after surgery requires same-day surgical assessment.
Fever, rigors, offensive discharge, wound erythema or confusion may represent pelvic, urinary or wound sepsis and should not be attributed to normal recovery.
Sudden dyspnoea, pleuritic chest pain, haemoptysis, hypoxia or unilateral leg swelling requires emergency assessment for venous thromboembolism.
New calf swelling, persistent vomiting, inability to pass urine, faeculent vaginal discharge or peritonism raises concern for thrombotic, urinary or bowel injury.
Unexpected invasive or premalignant disease in the prophylactic specimen requires prompt gynaecological oncology review before assuming surgery completed risk management.
Investigation priorities
Confirm the familial cancer syndrome and place the variant alongside cancer diagnoses and ages in relatives.
Management branches
A pathogenic variant or strong family history raises concern about ovarian or endometrial cancer.
- Confirm the laboratory result, relevant organs, personal cancer history, pedigree and calculated ovarian risk through genetics and the familial ovarian cancer MDT.
- Explain gene-specific timing, the operation proposed, residual cancer risk, possible occult findings, fertility loss, recovery and alternatives including the limitations of surveillance.
- Record informed preference after reproductive, menopause and psychological support, and revisit the decision when someone chooses to defer without treating delay as loss of care.