In a moving New York Times op-ed, Angelina Jolie Pitt revealed today that she had preventive surgery last week to remove her ovaries and fallopian tubes. The news comes two years after she disclosed that she had a preventive double mastectomy, touching off a national conversation about women and cancer risk.
Jolie Pitt carries a mutation in the BRCA1 gene that gives her an 87% chance of developing breast cancer and a 50% chance of developing ovarian cancer. She lost her mother, grandmother, and aunt to cancer.
She opted to have her breasts removed first, since her breast cancer risk was higher than her ovarian cancer risk, but noted that she planned to have further cancer-preventing surgery at some point. "I was readying myself physically and emotionally, discussing options with doctors, researching alternative medicine, and mapping my hormones for estrogen or progesterone replacement," she writes. "But I felt I still had months to make the date."
Then came a cancer scare: Blood tests showed that she had elevated inflammatory markers, a possible indicator of early cancer. Further scans and tests showed no signs of a tumor, but the experience helped solidify Jolie Pitt's resolve: "To my relief, I still had the option of removing my ovaries and fallopian tubes and I chose to do it."
About the surgery
Having surgery to remove the ovaries (known as risk-reducing or prophylactic oophorectomy) can dramatically reduce the odds of developing ovarian cancer in women who carry a BRCA1 gene mutation, a 2014 study found. Removing the ovaries can also lower breast cancer risk by significantly reducing the amount of estrogen and progesterone in your body, since many breast cancers need those hormones to grow.
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Since women with BRCA1 or BRCA2 mutations are also at increased risk of fallopian tube cancer, experts usually recommend removing the fallopian tubes along with the ovaries (a salpingo-oophorectomy, the surgery Jolie Pitt had).
However, as Jolie Pitt notes, removing the ovaries also puts women into early menopause. This can result in not just hot flashes, vaginal dryness, and other uncomfortable side effects of menopause, but also osteoporosis and an increased risk of heart disease.
Jolie Pitt says she now wears a patch containing bio-identical estrogen, and has a progesterone IUD to help protect against uterine cancer. (Estrogen therapy alone can increase the risk of uterine cancer, so progesterone must be given along with it to lower the risk back to normal levels.) Though hormone replacement therapy (HRT) has long been controversial due to a link to increased breast cancer risk, some research suggests that it's safe for women with BRCA1 or BRCA2 mutations to take short-term HRT after a preventive oophorectomy to relieve menopausal symptoms.
Weighing the options
It's important to know that surgery isn't the only option for women who carry a breast cancer gene mutation, as Jolie Pitt emphasizes. Preventive strategies may include taking birth control pills, getting frequent screenings, or having just the fallopian tubes removed but leaving the ovaries. Breastfeeding and having the tubes tied may also reduce ovarian cancer risk in women with BRCA gene mutations, a 2014 review found.
Despite the side effects of the surgery, Jolie Pitt says she's at peace with her decision. "I feel feminine, and grounded in the choices I am making for myself and my family," she writes. "Regardless of the hormone replacements I’m taking, I am now in menopause. I will not be able to have any more children, and I expect some physical changes. But I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared."