Hormone Replacement Therapy after Prophylactic Adnexectomy

In France, the National Collective Statement from the INSERM [1] recommends a prophylactic adnexectomy (PA) in women having an increased ovarian cancer risk due to mutations in BRCA1 or BRCA2 either at 40 years of age or at 35 years of age if the woman has decided she no longer wants children. PA can reduce the risks of ovarian cancer by more than 90% and breast cancer by more than 50%. However, the lack of oestrogen production caused by PA has numerous consequences. These are more pronounced in young women and include hot flushes, vaginal dryness, sexual troubles, joint stiffness and in the long term osteoporosis. Recent data from the large randomised American WHI Study [2, 3] have led the medical community to re-evaluate the benefits and risks of hormone replacement therapy (HRT) and to modify their prescription practices. As data on the HRT products used in France are not available, French agencies have recommended that in the general population HRT should be used at the lowest dose and for the shortest duration possible, and then only for menopausal problems [4]. Currently, many women in France are reluctant to use HRT because of the results of these studies. Gynaecologists also are reluctant to prescribe HRT due to the risk of legal proceedings in cases of cancer. This reluctance is much greater for women with increased risk of breast cancer. Although the Markov Model for predisposed women shows a favourable benefit/risk ratio for short-term HRT prescription, this analysis was carried out without precise data for the effect of HRT on predisposed women [5]. Moreover, breast cancer in women undergoing HRT may be falsely attributed to HRT due to the high incidence of breast cancer associated with BRCA1/2 mutations. We have observed that PA is relatively well accepted in peri-menopausal women (for example after chemotherapy), although some young women still refuse or delay PA despite there being a high incidence of ovarian cancers in their family.