Prophylactic bilateral salpingo-oophorectomies (BSO) by the age of 35 years is recommended for this patient. Patients with BRCA1/2 mutations are at increased risk for ovarian cancer. The lifetime risk is 35% to 46% in BRCA1 mutation carriers and 13% to 23% in BRCA2 carriers. National guidelines recommend risk-reducing BSO in women who carry deleterious BRCA1/2 mutations between ages 35 and 40 years, once childbearing is complete. A recent registry data analysis of almost 6000 women with BRCA1 or BRCA2 mutations proposed that risk-reducing BSO be done by age 35 years in women with BRCA1 mutations due to a 4% risk of ovarian cancer between ages 35 and 40 years. Women with BRCA2 mutations in this registry data did not develop ovarian cancers until after age 40 years and had an ovarian cancer risk under 1% if BSO was deferred to age 50 years.

Also shown was an 80% reduction in the risk of ovarian, tubal, or peritoneal cancer after prophylactic BSO and a 77% reduction in all-cause mortality. Previous studies have demonstrated a 48% reduction in breast cancer in BRCA1/2 carriers who underwent prophylactic oophorectomy while premenopausal.

Hormone replacement can safely be given to healthy BRCA1/2 carriers after BSO for relief of menopausal symptoms and preservation of bone health if nonhormonal options are not effective. Limited studies have not demonstrated an increased risk of breast cancer with hormone replacement therapy when stopped prior to the normal age of menopause.

At age 33 years, this patient will have two years to pursue further childbearing and still be able to have BSO by age 35 years. It is not necessary to recommend immediate BSO. In the study mentioned above, there was a 0.5% risk of ovarian cancer between the ages of 30 and 34 years and only one occult ovarian cancer found at prophylactic BSO during these ages.

Semi-annual transvaginal ultrasound and serum CA-125 monitoring is recommended for BRCA1/2 mutation carriers starting at age 30 years, but the evidence shows very limited effectiveness of such screening. Prophylactic BSO is the only method that has been shown to decrease ovarian cancer mortality in women at high risk for ovarian cancer.