“There is more than one way to deal with any health issue. The most important thing is to learn about the options and choose what is right for you personally.” (Photo: Getty Images)
Two years after Angelina Jolie Pitt made waves with her choice to undergo a preventive double mastectomy, the mother of six is discussing another major health decision in The New York Times: a laparoscopic bilateral salpingo-oophorectomy to remove her ovaries and fallopian tubes.
Jolie Pitt lost her mother, aunt, and grandmother to cancer and tested positive for a mutation in the BRCA1 gene. Doctors gave her an estimated 87 percent chance of developing breast cancer and a 50 percent chance of developing ovarian cancer. After undergoing her double mastectomy, she wrote a piece in The New York Times to let women know they have options. After this second surgery, she is doing the same.
Now, after the procedure, Jolie Pitt is in forced menopause, just before age 39.
"The biggest thing for a woman who is premenopausal undergoing surgery is that it puts you into menopause overnight," says Susan K. Boolbol, MD, FACS, chief in the Division of Breast Surgery at Mount Sinai Beth Israel and an associate professor of surgery at Icahn School of Medicine at Mount Sinai. Jolie Pitt can likely expect, or is experiencing, menopause’s hallmark hot flashes, night sweats, vaginal dryness and mood changes.
But it’s not all bad. Jolie Pitt’s surgery, and her candor about the difficult choice she made, will open up a discussion for women about taking better charge of their reproductive health.
Lindsay Avner, the founder of Bright Pink, an organization to help educate women on their breast and ovarian health, says it’s important — and potentially lifesaving — that Jolie Pitt is speaking out about her decision. “It’s so fantastic,” she tells Yahoo Health. “It’s one of those moments where you know so many lives will be saved today as a result of this.”
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At 22, Avner tested positive for the same BRCA1 gene mutation as Jolie Pitt. At 23, she was the youngest person in the country to undergo a preventive mastectomy. At 24, she started Bright Pink to encourage women to learn their family histories of cancer and understand their breast and ovarian options.
The organization also has more than 40 communities around the country for women dealing with an increased risk of breast and ovarian cancers, including outreach groups and one-on-one peer support called PinkPal.
“I remember vividly when Angelina’s first op-ed piece was published,” she says. “It was amazing, because it forced people to ask a really important question: What is my family history? There is a low risk of having this mutation, but we want people to opt in to the conversation about cancer risk instead of opting out.”
Bright Pink just launched its new Assess Your Risk tool, which evaluates relative risk of cancer based on 19 questions with regard to factors like family history, exercise, BMI, and onset of menstruation. You can take the questionnaire to determine if you have increased odds of developing cancer.
Avner is now 32 — and plans to have her ovaries and fallopian tubes removed at age 35. “The recommendations are 35, or 40 at the latest or if you’re still having children,” she says. “You don’t want to rush your life, but we have this opportunity to intervene.
“It takes time to process, but the good outweighs the bad,” Avner says. “Ovarian cancer is the deadliest cancer. Two-thirds of women diagnosed will die from it. This is not a disease you want to tempt fate with.”
Jolie Pitt’s journey to having her ovaries and fallopian tubes removed began two weeks ago, when she had her CA-125 protein levels checked. Testing these levels is a way to monitor ovarian cancer; due to her family history, she has them analyzed each year. Although the amount of CA-125 in her blood was normal, doctors saw that she had higher-than-average levels of several other inflammatory markers. Taken together, they told her those markers might indicate early cancer, she explains in the Times piece.
Since the CA-125 test will miss early-stage ovarian cancer in 50 to 75 percent of cases, Jolie Pitt met with a surgeon immediately to check her ovaries and discuss options. Although her ultrasound and physical exam looked fine, her PET/CT came back clear, and she tested negative for any tumors, a small chance of early-stage cancer still existed for Jolie Pitt. Because of this, she chose to have surgery to remove her ovaries and fallopian tubes.
“I did not do this solely because I carry the BRCA1 gene mutation, and I want other women to hear this,” Jolie Pitt writes. “A positive BRCA1 test does not mean a leap to surgery. I have spoken to many doctors, surgeons and naturopaths. There are other options. Some women take birth control pills or rely on alternative medicines combined with frequent checks. There is more than one way to deal with any health issue. The most important thing is to learn about the options and choose what is right for you personally.”
The option made sense for Jolie Pitt for two reasons: She has the BRCA1 gene mutation, and three women in her family died of cancer. “My doctors indicated I should have preventive surgery about a decade before the earliest onset of cancer in my female relatives,” she writes. “My mother’s ovarian cancer was diagnosed when she was 49. I’m 39.”
Now, post-surgery, Jolie Pitt wears a patch containing bio-identical estrogen and had a progesterone IUD inserted into the uterus to keep her hormones balanced and help reduce the risk of uterine cancer.
Boolbol says these steps will help reduce some of the menopausal discomfort for Jolie. “Vaginal dryness and atrophy are common for many women, and the progesterone IUD should decrease those symptoms,” she says. “The other major symptom is hot flashes. Wearing the patch will give the body back some of those missing hormones.”
However, Boolbol says this form of hormone-replacement therapy is only ideal for a woman who is undergoing early menopause. “We don’t want to promote hormone replacement for every woman due to risks,” she says. “But it’s not really hormone replacement for her. Her ovaries were removed, and her body is not supposed to be going through menopause yet. This should decrease her symptoms.
"Talk to your doctor if you have a family history of breast or ovarian cancer — and subtract a decade from the time of your relative’s diagnosis. If your mom was diagnosed with ovarian or breast cancer at age 31, for instance, then you should inquire about prevention measures and testing for the BRCA1 or -2 gene mutation at age 21.
"Angelina Jolie’s big message, which is really important, is options and information," says Boolbol. "The more information you have, the better decisions you can make." She applauds Jolie for opening up this discussion. "Many women are more aware now," Boolbol says. "Surgery isn’t right for everyone, but there are options — it’s all about education. Knowledge is power, and we should try to make sure every woman has this baseline knowledge.”
Even if you take all the precautionary steps to ward off these cancers, risks will still exist. The tragedy is if a woman never knows how her relative risk, or how these diseases progress, when prevention tactics might help her.
“It is not possible to remove all risk, and the fact is I remain prone to cancer,” Jolie Pitt writes in the Times. “I will look for natural ways to strengthen my immune system. I feel feminine, and grounded in the choices I am making for myself and my family. I know my children will never have to say, ‘Mom died of ovarian cancer.’”