This information is for women who have been offered ovarian ablation, as part of their breast cancer treatment. Ovarian ablation or ovarian suppression are terms used to describe different ways of stopping the ovaries from working. We use the term ovarian ablation to cover all the different methods.

Ovarian ablation is a way of stopping the ovaries from producing the hormone oestrogen.

In women with oestrogen receptor positive (ER+ve) breast cancer, oestrogen can stimulate the breast cancer cells to grow. Stopping the ovaries from producing oestrogen means there is less of the hormone available in the body. For premenopausal women, research has shown that ovarian ablation after surgery and radiotherapy can:

• reduce the risk of the cancer coming back
• increase chances of survival
• reduce the risk of the cancer spreading.

Ovarian ablation is only suitable for women who have an oestrogen receptor positive breast cancer, who haven’t reached their menopause (change of life). It can be used to treat women with primary or secondary breast cancer.

There are three different ways to stop the ovaries from producing oestrogen:

• surgery to remove the ovaries
• hormone manipulation
• radiotherapy to the ovaries.

Surgery

Surgery to remove the ovaries is known as an oophorectomy. Doctors may also recommend removing the fallopian tubes (salpingo-oophorectomy). The operation is usually done using laparoscopic or keyhole techniques. This involves using a laparoscope – which is a thin, flexible tube with a light and magnifying lens at the tip. It enables the surgeon to look into the abdomen.

The surgery usually involves a general anaesthetic. Two or three small cuts are made into the skin and muscle of the abdomen to allow the laparoscope and other instruments to be inserted. Most women will be in hospital one or two days.

For some women it may not be possible to remove the ovaries using laproscopic surgery. In this situation, a short incision is made below the bikini line. Again a general anaesthetic is used, but this procedure usually requires a slightly longer stay in hospital.

Removing the ovaries with surgery produces an immediate and permanent menopause. This means that periods will stop straight away.

Hormonal therapy

Your doctor may suggest that you take drugs (injections) which temporarily ‘switch-off’ the signals from your brain that tell your ovaries to make oestrogen. This leads to a drop in oestrogen similar to that which happens after surgical removal of the ovaries. The level of oestrogen usually drops within about three weeks of starting treatment and stays down as long as treatment is continued. The main drug that is used to shut down (suppress) the ovaries is called goserelin (Zoladex®).

Zoladex is an injection which is given under the skin (subcutaneous) into the tummy. It is given every 28 days. The first injection is usually given in the outpatients department of the hospital. After that, your practice or community nurse, or your GP, can give you the injections.

Zoladex temporarily stops the ovaries from working. Once treatment is stopped, the ovaries will start working again – usually within six months depending on how near a woman is to her natural menopause. For example, if a woman is near the menopause when she begins Zoladex, her periods may not return when the treatment stops.

Zoladex is often given for between two and five years. Your doctor will discuss the length of treatment that they feel is right for you.

Although periods usually stop while you are having treatment, Zoladex is not a contraceptive and women need to ensure that they use effective contraception until their periods stop. It might be helpful to discuss this with your doctor.

Radiotherapy

Radiotherapy uses high energy x-rays to stop the ovaries from working. This technique is not often used in the UK any more.

Radiotherapy is given over a period of a few days as an outpatient. The side effects can include tiredness, diarrhoea, feeling sick and abdominal discomfort. These are temporary and will clear up quickly. Your doctor can prescribe medicine to treat any that are troublesome.

Sometimes radiotherapy can cause late side effects months or years after treatment, but because the dose of radiotherapy used in ovarian ablation is very low, this is rare.

Radiation therapy permanently shuts down the production of oestrogen in the ovaries. However this doesn’t happen straight away, as it does with surgery. Periods usually stop about three months after the radiotherapy is given.

It’s important, if appropriate, that you use reliable contraception until your periods stop completely as you may still become pregnant.

Ovarian ablation will mean you can no longer have children. This may be temporary if you are taking Zoladex. Infertility can be very distressing, especially if you were hoping to have children or add to your family. You might mourn the loss of your fertility – even if you didn't plan on having children in the future.

Some women feel a strong sense of femininity connected to their ovaries and other reproductive organs. You might fear that you'll somehow be less of a woman if your ovaries are no longer there. It can really help to talk about your feelings. Your breast care nurse can give support and advice, or you can contact a support organisation.

Women whose ovaries are removed will have an early menopause straight away. The symptoms of this can start suddenly and may be more intense than one that happens naturally.

Ovarian ablation using hormonal therapy or radiotherapy happens over a period of months and is a more gradual change.

The menopause can cause symptoms such as hot flushes, dry skin, vaginal dryness, lowered sex drive and psychological effects. Women can have one or more of these symptoms and they can range from being mild to severe. This can be difficult for women to cope with, especially when they’re already dealing with breast cancer and its treatments.

The most common symptoms, and ways of dealing with some of them, are described below.

Hot flushes

Hot flushes are the most common menopausal symptom. There are a range of medicines that your doctor can prescribe to try to reduce the severity and number of flushes and sweats. Wearing thin layers of cotton clothing which can easily be removed, and sleeping in a well ventilated room with a window open (or using an electric fan), can help. Some women may also find complementary therapies helpful.

Dry skin

A little baby oil, or a few drops of bath oil in the bath, helps to moisturise the skin. Some women find zinc, vitamin B, and linseed oil supplements helpful.

Vaginal dryness

A low level of oestrogen in the body causes vaginal dryness, and sometimes itching. Lubricating gels can help to counteract the dryness and these are available from a chemist or can be prescribed by your doctor. Your doctor or nurse can discuss this with you.

Loss of sex drive (libido)

Many women find their sex drive is lower while having treatment with Zoladex. This normally continues for as long as the treatment is given. Using surgery or radiotherapy to stop the ovaries from working can also affect a woman’s sex drive.

Psychological effects

You may feel very emotional or anxious without really knowing why. You may also have mood swings, poor concentration and a lack of confidence. These symptoms may be quite distressing for you and your partner, if you have one. It can often help to talk about how you are feeling and a number of organisations provide support for women going through an early menopause.

Early menopause may increase the risk of developing weakened bones (osteoporosis) which can break more easily. The chance of developing heart problems may also be higher. These happen because oestrogen helps to keep bones strong and to protect the heart. There are effective medicines which help strengthen bones and ones which protect the heart.

Your doctor and breast care nurse can give you more information and advice about your risk of developing long-term problems after ovarian ablation. Let them know if you’re worried about any of these risks.

This section has been compiled using information from a number of reliable sources, including:

• Sainsbury R. Ovarian ablation in the adjuvant treatment of premenopausal and perimenopausal breast cancer. British Journal of Surgery. 2003. 90: 517-26.
• Early Breast Cancer Trialists' Collaborative Group. Ovarian ablation for early breast cancer. www.chochrane.org (April 2007).