Hormone replacement therapy counseling at prophylactic bilateral salpingo-oophorectomy in high-risk patients (354)

Abstract

<b>Objectives:</b> Women at high risk for ovarian cancer are advised to undergo bilateral salpingo-oophorectomy (RRSO) prior to natural menopause. Hormone replacement therapy (HRT) mitigates the negative effects of surgical menopause. We sought to understand how high-risk women are counseled about HRT and use patterns of HRT after RRSO. <b>Methods:</b> We performed a chart review of women seen at a high-risk clinic between 2000-2018 who underwent RRSO. Reviewing patient age, surgical details, pathology, documented HRT counseling, and whether HRT was recommended. We then surveyed by mail, online, and by phone all women alive and meeting study criteria (no surgery for ovarian malignancy, surgery not just for ovarian suppression for breast cancer) to determine what they recalled regarding counseling, use of HRT, cancer diagnoses, and depression (PHQ9), anxiety (GAD7), and cancer worry (CWS) scores. Chi-square test and t-test compared categorical and continuous variables, respectively. Logistic regression examined associations between age, history of cancer, surgeries, and reports of HRT discussions and recommendations. <b>Results:</b> A total of 150 women met the survey criteria, with a 60.1% response rate. The median age at the survey was 57.5 years (range: 37-86). RRSO median age was 46 (range: 27-74). Those surveyed included 76 <i>BRCA',</i> 50 <i>BRCA2,</i> 3 <i>BRCA1</i> and <i>BRCA2</i> mutation carriers, and 22 participants with other mutations or strong family histories. Responders and non-responders were alike in RRSO age and mutation status. About 44.4% of respondents recalled discussion about HRT; eight reported recommendations for HRT, 21 against, and 11 other guidance. Among the respondents, 51.5% reported undergoing hysterectomy; 17 (18.9%) respondents took HRT after surgery (64.7% estrogen alone). Five patients stopped HRT, three because a doctor advised, one because she was afraid, and one because she felt she no longer needed it. HRT recommendations were not associated with mastectomy (prophylactic or otherwise), hysterectomy, or cancer history. Younger age at RRSO was associated with receiving HRT counseling (RRSO age 43 if discussed vs 50 not discussed, p<0.01), but not with recommendations about HRT (RRSO age 41 if recommended vs 44 not recommended, p=0.06). RRSO age remained significant in predicting discussion, though other surgeries and cancer history did not. Starting or continuing HRT after RRSO was not indicative of depression or anxiety scores, but those taking HRT after RRSO had higher CWS (CWS > 10 in 82.4% with HRT vs 52.9% without, p=0.03). Eighteen (43.9%) respondents did not remember receiving counseling documented in the chart, while 15 (37.5%) remembered counseling that was not documented. <b>Conclusions:</b> A majority of patients undergoing RRSO did not receive HRT counseling, and nearly 44% did not remember documented HRT counseling. Surgeries and diagnoses that would impact HRT use were not correlated with recommendations. Younger age was correlated with discussion but not a recommendation for HRT. Before RRSO, we propose discussing HRT regardless of the recommendation for or against the use and providing written summaries to which patients and future healthcare providers can refer.