Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Organisation of services

Commissioners and service providers in all settings (primary care, genetics services, gynaecology oncology and familial ovarian cancer multidisciplinary services)

1.1.1

Commissioners and service providers should ensure that there are referral pathways to genetics services and gynaecology oncology multidisciplinary services for people at risk of having a pathogenic variant associated with ovarian cancer. Such pathways can be facilitated by providing, for example:

1.1.2

Commissioners and service providers should raise awareness of which groups of people may be at risk of having a pathogenic variant associated with ovarian cancer.

1.1.3

Commissioners and service providers should ensure that there is training and information available for healthcare professionals on equality and inclusiveness issues that could improve access to services, for example, for people who:

  • are from under-represented or underserved communities who may need more support to access services (for example, people who are physically disabled, people with neurodevelopmental conditions or a learning disability, people from Black, Asian and ethnic minority backgrounds, and people who are LGBTQ+)

  • may not come forward for testing because they do not realise that they may be at risk of having a pathogenic variant associated with ovarian cancer (for example, men, trans women and non-binary people born with male reproductive organs).

Primary care services

Genetics services

1.1.5

Genetics services should be responsible for:

  • providing information and support (see the section on information and support)

  • assessing the risk of having a pathogenic variant for people who do not have ovarian cancer

  • genetic counselling and genetic testing for people who do not have ovarian cancer

  • genetic counselling and genetic testing for people diagnosed with non-epithelial ovarian cancer (see recommendation 1.4.6 in the section on people with ovarian cancer)

  • arranging cascade testing of relatives, if appropriate

  • assessing the risk of developing ovarian cancer

  • discussing potential management options

  • referral (if needed) to the familial ovarian cancer multidisciplinary team and other specialist services.

Gynaecology oncology multidisciplinary team

Familial ovarian cancer multidisciplinary team

1.1.7

The familial ovarian cancer multidisciplinary team should be responsible for:

  • clinical care pathways and management protocols

  • the lifelong care of people at risk of familial ovarian cancer (those with a pathogenic variant or those above a risk threshold; see the section on criteria for genetic counselling and genetic testing)

  • providing information and support (see the section on information and support)

  • assessing the risk of developing ovarian cancer

  • discussing potential management options (for example, risk-reducing surgery)

  • carrying out surveillance and reviews

  • liaising with other services and healthcare professionals, including primary care and specialist services (see recommendation 1.1.9)

  • contributing to local and network audits

  • facilitating access to clinical trials.

1.1.8

The familial ovarian cancer multidisciplinary team should have a designated lead clinician, and include healthcare professionals with expertise in areas including:

  • clinical genetics

  • gynaecology

  • gynaecological oncology.

1.1.9

The familial ovarian cancer multidisciplinary team should have established relationships with, and agreed referral pathways to, other specialist services such as:

  • psychological services

  • menopause services

  • fertility services

  • breast cancer risk management services

  • ovarian cancer services

  • colorectal cancer services.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on organisation of services.

Full details of the evidence and the committee's discussion are in evidence review C: configuration of services.

1.2 Information and support

These recommendations are for anyone who has a familial or genetic risk of having a pathogenic variant associated with ovarian cancer. This includes women, men, trans people and non-binary people, and their family or carers (as appropriate).

Information and support about familial ovarian cancer in all settings

1.2.1

Healthcare professionals in all settings (primary care, genetics services and specialist multidisciplinary services) should provide ongoing information and support in line with:

Table 1 Information and support about familial ovarian cancer in all settings
  • Information about the risk of ovarian cancer from a person's family history.

  • Information about the risk of ovarian cancer for people from Ashkenazi Jewish, Sephardi Jewish and Greenlander backgrounds.

  • Information for men, trans women and non-binary people born with male reproductive organs who may have a genetic risk of having a pathogenic variant associated with ovarian cancer and other cancers.

  • The message that if the person's family history alters (for example, if someone in their family develops ovarian cancer), their risk may alter.

  • Advice to return to discuss any implications if there is a change in family history or symptoms develop.

  • Ovarian cancer symptom awareness information – bloating, feeling full on eating, pelvic or abdominal pain, increased urinary urgency and/or frequency); also see the section on awareness of symptoms and signs in the NICE guideline on ovarian cancer.

  • Advice about ovarian cancer risk, including information about:

    • level of ovarian cancer risk in relation to the general population

    • hormone replacement therapy (HRT) and oral contraceptives

    • lifestyle factors

    • family size and timing.

  • Information about referral for genetic counselling and genetic testing.

  • Information about the pathway for risk assessment and management.

  • Information and support about referral to a different service, what the service does and why the person is being referred.

  • Information and support about psychological factors such as anxiety, and psychological support services.

  • Information about sources of support and information, for example, local and national support groups and networks, patient organisations and specialist services.

  • Reassurance about bringing a family member, friend or carer to appointments.

1.2.2

Healthcare professionals should ensure that information and support:

  • supports shared decision making

  • is balanced and accurate

  • is available on an ongoing basis

  • is available when needed

  • is relevant to the person's circumstances

  • is tailored to the person's needs, for example, it is in an accessible format or available in a different language.

1.2.3

Provide opportunities for people to review decisions, and share any additional information on how they can access services for further discussions, for example, at:

  • re-referral to specialist services

  • patient-initiated follow‑up appointments directly with specialist services

  • self-referral to genetics services.

1.2.5

Raise awareness that men, trans women and non-binary people born with male reproductive organs can have a genetic risk of having a pathogenic variant associated with ovarian cancer and other cancers.

1.2.6

Ensure that services are easy to access (for example, by offering online appointments) and welcoming for everyone, particularly for people who may have additional support needs (also see recommendation 1.1.3).

Information and support about risk assessment and genetic testing in genetics services

Table 2 Information and support about risk assessment and genetic testing in genetics services

At referral for risk assessment and genetic testing

  • Information about how the risk of having a pathogenic variant is assessed, and how to obtain a comprehensive family history (including up to third-degree relatives) if needed.

  • Clarification about which family members could be at risk, and advice about appropriate ages for testing.

  • Information about genetic testing, including details of what genetic testing involves, what the tests mean and how informative they are likely to be, and the likely timescale of getting the results.

  • Information and support on the importance of, and how to discuss, the results of assessment and testing with relatives, including different methods of contacting relatives about cascade testing.

  • Information about potential next steps depending on the risk assessment (including referral back to primary care, management within secondary care and/or a genetics service, risk-reducing surgery and surveillance).

  • Information and support to aid decision making about topics such as genetic testing, risk-reducing surgery, fertility and whether the person wants to have children, and menopause and managing symptoms.

  • Details of any trials or studies that may be appropriate.

If genetic testing has not been offered

  • Information about why genetic testing has not been offered (as applicable).

  • Advice to return to primary care to discuss any implications if there is a change in family history or symptoms develop.

1.2.9

Take into account the following factors when deciding whether to offer face-to-face or remote (for example, video call, telephone) genetic counselling:

  • the person's preference

  • the decision that needs to be made (for example, genetic testing or risk-reducing surgery)

  • accessibility needs (for example, geographic location, digital access, language or communication impairment, participation of family members in other locations)

  • the need for an interpreter.

1.2.10

Consider giving information in a group session before an individual genetic counselling session.

Information and support in specialist services if a person has a pathogenic variant or a strong family history of ovarian cancer

Table 3 Information and support in specialist services if a person has a pathogenic variant or a strong family history of ovarian cancer

Risk of developing ovarian cancer

  • Information about the person's risk of developing familial ovarian cancer, how the risk is assessed, what their personal risk estimate means, and other factors that could increase or decrease the risk.

  • Information and support to aid shared decision making.

Reproductive choices

  • Information about the likelihood of passing down the pathogenic variant to their children.

  • Information about the impact of risk-reducing surgery on fertility.

  • Information about the availability of fertility preservation by storing eggs or embryos.

  • Information about the availability of pre-implantation genetic testing of embryos to avoid passing down the genetic risk to their children.

Risk-reducing surgery

  • Information about risk-reducing surgery and what it involves.

  • Advice that risk-reducing bilateral salpingo-oophorectomy is the most reliable way to substantially reduce the likelihood of developing ovarian cancer and therefore improve life expectancy, but that there will still be a small residual risk.

  • Information that, if risk-reducing bilateral salpingo-oophorectomy is appropriate, it is because of a pathogenic variant associated with ovarian cancer, or a family history that has been shown to increase risk.

  • Information about the timing of risk-reducing surgery and different surgical procedures (also see the recommendations on risk-reducing mastectomy in the NICE guideline on familial breast cancer).

  • The possible biopsychosocial and sexual consequences of risk-reducing surgery.

  • Information about the possible impact of risk-reducing surgery on other areas of the person's life, for example, that risk-reducing surgery will lead to early menopause (if premenopausal) and the symptoms they may experience, hormone replacement therapy (HRT), impact on sex life and body image, and fertility (see also the section on people with cancer who wish to preserve fertility in the NICE guideline on fertility problems).

  • Information about ovarian cancer surveillance if they choose to delay or not have risk-reducing surgery – see recommendation 1.8.6 for details of the information that should be given.

  • Information about the risk of other cancers (for example, primary peritoneal, breast, pancreas, prostate or bowel cancer).

1.3 Assessing the risk of having a pathogenic variant

These recommendations are for anyone who has a risk of having a pathogenic variant associated with ovarian cancer. This includes women, men, trans people and non-binary people.

1.3.1

Healthcare professionals in primary care and secondary care should refer people for genetic counselling and genetic testing if any of the following apply:

1.3.2

If a person had a direct-to-consumer genetic test and is reported to have a pathogenic variant for which NHS testing is offered (for example, BRCA), healthcare professionals should liaise with the regional NHS genetics service to discuss whether referral is appropriate.

1.3.3

Genetics services should assess the probability of having a pathogenic variant using a calculation method with demonstrated accuracy, such as the Manchester scoring system, CanRisk (BOADICEA), BRCAPRO, or criteria based on specific clinical circumstances or a verified family history that are designed for the threshold used for testing.

1.4 Criteria for genetic counselling and genetic testing (in genetics services or in gynaecology oncology multidisciplinary services)

Family history of ovarian cancer

These recommendations are for anyone who has a risk of having a pathogenic variant associated with ovarian cancer. This includes women, men, trans people and non-binary people.

1.4.1

Genetics services should offer genetic counselling and genetic testing to anyone who:

  • has not had ovarian cancer and

  • has a raised probability of having a pathogenic variant (see table 4 on genetic testing criteria) based on a verified family history and

  • has a relative who has had a confirmed diagnosis of breast cancer or ovarian cancer but genetic testing of the relative (or the tissue) is not possible or clinically appropriate (for example, consent is declined).

Table 4 Criteria for carrying out genetic testing in genetics services
Age of the person Women, trans men and non-binary people registered female at birth. Men, trans women and non-binary people registered male at birth.

30 to 39 years

2% or higher

6% or higher

40 to 49 years

2% or higher

9% or higher

50 to 59 years

3% or higher

10% or higher

60 to 69 years

6% or higher

10% or higher

70 years or over

10% or higher

10% or higher

1.4.2

If a person has not had ovarian cancer, genetics services should offer genetic counselling and genetic testing if they are a first-degree relative of a person with a known pathogenic variant (cascade testing).

1.4.3

If a person has not had ovarian cancer, genetics services should offer genetic counselling and genetic testing if:

  • they are a second-degree or more distant blood relative of a person with a known pathogenic variant and

  • testing of an intervening blood relative is impossible or not clinically appropriate (for example, consent is declined).

1.4.4

If a person has a personal or family history of breast cancer, also see the NICE guideline on familial breast cancer, in particular the sections on the clinical significance of a family history of breast cancer, and referral to a specialist genetic clinic.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on family history of ovarian cancer.

Full details of the evidence and the committee's discussion are in:

At-risk populations

This recommendation is for anyone who has a risk of having a pathogenic variant associated with ovarian cancer. This includes women, men, trans people and non-binary people.

1.4.5

Recognise and raise awareness that people from the following populations (with at least 1 grandparent from the respective population), have a higher risk of having a founder pathogenic variant associated with familial ovarian cancer, so should be offered referral for genetic counselling and genetic testing for this variant, even if the person has no family or personal history of cancer:

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on at-risk populations.

Full details of the evidence and the committee's discussion are in evidence review H: populations with high prevalence.

People with ovarian cancer

This recommendation is for women, trans men and non-binary people born with any female reproductive organs (ovaries, fallopian tubes, uterus).

1.4.6

Offer pre-test counselling and germline testing to anyone diagnosed with:

  • invasive epithelial ovarian cancer

  • ovarian Sertoli–Leydig cell tumour

  • small cell carcinoma of the ovary hypercalcaemic type

  • ovarian sex cord tumour with annular tubules

  • embryonal rhabdomyosarcoma of the ovary

  • ovarian gynandroblastoma.

For a short explanation of why the committee made this recommendation and how it might affect practice and services, see the rationale and impact section on people with ovarian cancer.

Full details of the evidence and the committee's discussion are in evidence review I: carrier probability – people with ovarian cancer.

1.5 Gene panel testing

1.5.2

Decide which gene panel from the UK national genomic test directory to use in relation to each person's family or personal history (for example, ovarian cancer alone, breast and ovarian cancer, or Lynch syndrome).

For a short explanation of why the committee made these recommendations and how they might affect practice and services, see the rationale and impact section on gene panel testing.

Full details of the evidence and the committee's discussion are in evidence review J: which genes to include in gene panel testing.

1.6 Assessing the risk of developing ovarian cancer

These recommendations are for women, trans men and non-binary people born with any female reproductive organs (ovaries, fallopian tubes, uterus).

1.6.1

If a person is under the care of genetics services or a familial ovarian cancer multidisciplinary team and has not had genetic testing, the service or team should offer to assess their risk of developing ovarian cancer.

1.6.2

If a person has a pathogenic variant associated with an increased risk of ovarian cancer, the familial ovarian cancer multidisciplinary team should offer to assess their risk of developing ovarian cancer.

1.6.3

When assessing a person's risk of developing ovarian cancer:

  • use a tool with demonstrated accuracy that includes their age, family history of ovarian and other cancers, and their pathogenic variant (such as CanRisk)

  • inform the person that there are other factors that could also increase or decrease their risk when using a tool or method that includes only limited information (for example, their age and pathogenic variant)

  • take into account factors that may not be accurately assessed by tools, for example, parity, use of the combined oral contraceptive pill, endometriosis, and whether relatives have only ovarian cancer.

For a short explanation of why the committee made these recommendations and how they might affect practice and services, see the rationale and impact section on assessing the risk of developing ovarian cancer.

Full details of the evidence and the committee's discussion are in evidence review E: optimal methods of assessing the absolute risk of having a pathogenic variant.

1.7 Primary preventive medicines

These recommendations are for women, trans men and non-binary people born with any female reproductive organs (ovaries, fallopian tubes, uterus), and who are at risk of epithelial ovarian cancer.

Aspirin

1.7.1

Do not offer aspirin for the sole purpose of reducing ovarian cancer risk.

Combined oral contraceptives

1.7.3

Only consider the combined oral contraceptive pill to reduce the risk of ovarian cancer:

  • if the reduction in the risk of developing ovarian cancer outweighs the increased risk of developing breast cancer and

  • after taking into account the timing of any risk-reducing surgery (mastectomy or salpingo-oophorectomy; see the section on risk-reducing surgery).

    In March 2024, this was an off‑label use of combined oral contraceptives. See NICE's information on prescribing medicines.

1.7.4

Discuss the reduced risk of developing ovarian cancer and the increased risk of developing breast cancer when offering a combined oral contraceptive.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on primary preventive medicines.

Full details of the evidence and the committee's discussion are in evidence review M: preventive medicines.

1.8 Risk-reducing surgery

These recommendations are for women, trans men and non-binary people born with any female reproductive organs (ovaries, fallopian tubes, uterus), and who are at risk of epithelial ovarian cancer.

Factors to take into account when considering risk-reducing surgery

1.8.1

Only offer risk-reducing surgery to people who have:

  • completed their family or are not planning to conceive naturally (that is, they would only conceive using assisted reproduction) and

  • a total lifetime risk of ovarian cancer of 5% or over because they have:

1.8.3

When discussing risk-reducing surgery, take into account psychological factors (such as anxiety) that could influence decision making. Discuss psychological support services available and, if needed, refer the person for psychological support before surgery.

1.8.4

When discussing risk-reducing bilateral salpingo-oophorectomy surgery with people who are premenopausal:

1.8.5

Refer people who have bi-allelic pathogenic variants in mismatch repair genes (for example, homozygous PMS2), to a specialist tertiary team for discussions about risk-reducing surgery.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on factors to take into account when considering risk-reducing surgery.

Full details of the evidence and the committee's discussion are in evidence review N: risk-reducing surgery.

Types of risk-reducing surgery and timing in relation to the person's specific pathogenic variant

The recommendations are for risk-reducing surgery related to ovarian cancer. For people who have a pathogenic variant that also increases their risk of breast cancer and are considering risk-reducing mastectomy, also see the NICE guideline on familial breast cancer.

1.8.6

Offer risk-reducing surgery that is appropriate for the person's age, specific pathogenic variant and family history (including age of onset of any confirmed ovarian cancers in the family), after discussing the person's individual circumstances with the familial ovarian cancer multidisciplinary team. See table 5 on timing and types of risk-reducing surgery for people with a pathogenic variant that increases the risk of ovarian cancer.

Table 5 Timing and types of risk-reducing surgery for people with a pathogenic variant that increases the risk of ovarian cancer
Pathogenic variant Procedure Age (also see recommendation 1.8.11)

BRCA1

Bilateral salpingo-oophorectomy

No earlier than 35 years

BRCA2

Bilateral salpingo-oophorectomy

No earlier than 40 years

RAD51C, RAD51D, BRIP1 or PALB2 pathogenic variant with a total lifetime risk of ovarian cancer of 5% or over

Bilateral salpingo-oophorectomy

No earlier than 45 years

MLH1, MSH2 or MSH6

Hysterectomy with bilateral salpingo-oophorectomy (to reduce the risk of endometrial cancer as well as ovarian cancer)

No earlier than 35 years

1.8.7

Consider risk-reducing total hysterectomy alone to prevent endometrial cancer for people (no earlier than 45 years) who have:

  • a heterozygous PMS2 pathogenic variant and

  • no family history of ovarian cancer.

1.8.8

If a person with a heterozygous PMS2 pathogenic variant has been offered total hysterectomy to prevent endometrial cancer, consider additional bilateral salpingo-oophorectomy depending on verified family history of ovarian cancer, age and menopausal status.

1.8.9

Consider risk-reducing surgery in people younger than the ages in table 5 on timing and types of risk-reducing surgery after carrying out an individualised risk assessment (including an assessment of menopausal symptoms) and providing information and support to aid shared decision making (also see the section on information and support).

1.8.10

Only offer risk-reducing bilateral salpingectomy with delayed oophorectomy as part of a clinical trial.

1.8.11

Do not carry out risk-reducing total hysterectomy in people with pathogenic variants other than MLH1, MSH2, MSH6 and PMS2, unless a personalised risk assessment shows a high risk of endometrial cancer that would necessitate hysterectomy or there is another gynaecological indication for hysterectomy.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on types of risk-reducing surgery and timing in relation to the person's specific pathogenic variant.

Full details of the evidence and the committee's discussion are in evidence review N: risk-reducing surgery.

Tests before risk-reducing surgery

1.8.12

Before carrying out risk-reducing bilateral salpingo-oophorectomy, perform a transvaginal ultrasound and a serum CA125 test to minimise the risk of missing asymptomatic ovarian cancer.

1.8.13

Before carrying out a risk-reducing hysterectomy, perform an endometrial biopsy to minimise the risk of missing asymptomatic endometrial cancer.

Referral to the gynaecology oncology multidisciplinary team

During risk-reducing surgery

1.8.15

Carry out risk-reducing minimal access surgery, unless a laparotomy is more clinically appropriate.

1.8.16

Take peritoneal washings during risk-reducing surgery for cytological examination to test for the presence of malignant cells.

1.8.17

If any suspicious lesions are found outside the organs being removed, take a biopsy if it is feasible and safe to do.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on tests before risk-reducing surgery, referral to the gynaecology oncology multidisciplinary team, and what to consider during surgery.

Full details of the evidence and the committee's discussion are in evidence review N: risk-reducing surgery.

Ovarian cancer surveillance by the familial ovarian cancer multidisciplinary team for people who choose to delay or not have risk-reducing surgery

These recommendations are for women, trans men, non-binary people born with any female reproductive organs (ovaries, fallopian tubes, uterus).

1.8.18

If a person is at risk of developing ovarian cancer and chooses to delay or not have risk-reducing surgery, discuss their reasons and explain that:

  • they have an increased risk of developing ovarian cancer and that the only way to reduce their risk is to have risk-reducing surgery

  • delaying risk-reducing surgery should only be seen as a short-term option

  • regular surveillance does not reduce their risk of developing ovarian cancer

  • although regular surveillance means that ovarian cancer may be detected earlier, they should not view surveillance as an alternative to risk-reducing surgery (because there is little evidence on whether this leads to improved outcomes and saves lives)

  • surveillance will involve them having a blood test every 4 months to check their level of the protein CA125 (cancer antigen 125), with an algorithm to analyse results, and a review at least once a year to discuss the recommendation of having risk-reducing surgery

  • there is a possibility of getting a false-positive or false-negative test result.

1.8.19

The familial ovarian cancer multidisciplinary team (see the section on familial ovarian cancer multidisciplinary teams) should only consider surveillance for people in the following groups who are at risk of developing ovarian cancer but who choose to delay or not have risk-reducing surgery (see also table 5 on timing and types of risk-reducing surgery):

  • over 35 and have a BRCA1 pathogenic variant or

  • over 40 and have a BRCA2 pathogenic variant or

  • over 45 and have RAD51C, RAD51D, BRIP1 and PALB2 pathogenic variants.

1.8.20

If carrying out surveillance (see recommendation 1.8.19), the familial ovarian cancer multidisciplinary team should:

  • carry out serial 4‑monthly CA125 longitudinal testing using an algorithm with demonstrated accuracy (for example, the Risk of Ovarian Cancer Algorithm [ROCA] Test)

  • coordinate, audit and interpret CA125 testing using a call and recall system

  • have a review appointment with the person at least once a year to discuss the recommendation of having risk-reducing surgery (see the section on risk-reducing surgery).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on ovarian cancer surveillance in secondary care for people who choose to delay or not have risk-reducing surgery.

Full details of the evidence and the committee's discussion are in:

1.9 Pathology protocol for handling specimens from risk-reducing surgery

1.9.1

Submit all ovaries and fallopian tubes for histological examination using a SEE‑FIM (Sectioning and Extensively Examining the FIMbriated End) protocol.

1.9.2

Carry out immunohistochemistry (p53 and Ki67/MIB1) only if a premalignant or malignant lesion is suspected on morphological examination.

1.9.3

Submit the adnexa in separate, appropriately labelled specimen containers so that the laterality is available to the pathologist. Include this information in the pathology report.

1.9.4

Always perform peritoneal cytology when carrying out risk-reducing surgery.

1.9.5

Submit the entire endometrium, including the lower uterine segment, for histological examination in risk-reducing hysterectomy specimens in people with Lynch syndrome.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pathology protocol for handling specimens from risk-reducing surgery.

Full details of the evidence and the committee's discussion are in evidence review O: pathology protocol.

1.10 Hormone replacement therapy after risk-reducing surgery

These recommendations are for women, trans men and non-binary people who have had risk-reducing surgery on female reproductive organs.

1.10.1

Offer hormone replacement therapy (HRT) until the average age of menopause (usually around 51 years) for people who:

1.10.2

Liaise with the person's breast cancer care team before offering HRT to people who:

  • have had breast cancer and

  • have had risk-reducing bilateral salpingo-oophorectomy.

1.10.3

When offering HRT to people who meet the criteria in recommendation 1.10.1:

  • use combined HRT for people who have a uterus

  • use oestrogen-only HRT for people who do not have a uterus

  • start HRT as soon as clinically appropriate after surgery

  • consider the insertion of a levonorgestrel intrauterine system at time of surgery

  • discuss the individual risks and benefits of HRT use beyond the average age of menopause.

1.10.4

Offer vaginal oestrogen to people with genitourinary symptoms associated with menopause, who have not had breast cancer.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on HRT after risk-reducing surgery.

Full details of the evidence and the committee's discussion are in evidence review P: HRT after risk-reducing surgery.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

Bi-allelic

Of or relating to both alleles of a single gene (paternal and maternal).

Bilateral salpingo-oophorectomy

A surgical procedure to remove both (bilateral) fallopian tubes (salpingectomy) and the ovaries (oophorectomy).

Cascade testing

A systematic process to identify individuals within a family at risk of developing a hereditary condition. Cascade testing begins with finding a pathogenic variant through testing (such as multigene panel testing) in 1 family member, usually affected by the condition. Then, testing just for the specific family variant is extended to blood relatives. This process is repeated as more affected individuals or pathogenic variant carriers are identified.

First-degree relative

Mother, father, daughter, son, sister or brother.

Founder pathogenic variant

A genetic alteration observed with high frequency in a group that is or was geographically or culturally isolated, in which 1 or more of the ancestors was a carrier of the altered gene.

Genetic testing

The study of a person's DNA in order to identify potentially disease-causing differences (pathogenic variants) or susceptibility to particular diseases or abnormalities.

Germline testing

A type of genetic test that looks for inherited mutations that are present in the DNA of every cell of the body and have been present since birth.

Intervening blood relative

A relative on the same side of the family who is more closely related to the family member with ovarian cancer than the person themselves.

Mainstream pre-test counselling and genetic testing

Pre-test counselling, consent and genetic testing being undertaken at the point of care by a member of the gynaecology oncology multidisciplinary team rather than genetics services.

Mismatch repair genes

Mismatch repair (MMR) genes code for proteins that are involved in correcting mistakes made when DNA is copied in a cell. MMR-deficient cells usually have many DNA alterations, which may lead to cancer.

Pathogenic variant

A genetic alteration that increases a person's susceptibility or predisposition to a certain disease or disorder. If someone has a pathogenic variant, they are sometimes known as a 'carrier'. This is because they 'carry', and can pass on to their children, a pathogenic variant associated with a disease (or trait) that is inherited in an autosomal dominant, autosomal recessive manner, even though they do not show symptoms of that disease (or features of that trait). The likelihood of having the pathogenic variant is also known as their 'carrier probability'.

In this guideline, the term 'pathogenic variant' refers to the presence of a pathogenic variant or 'likely pathogenic variant' (which is a variant with strong evidence that suggests it is associated with an increased risk of ovarian cancer).

Second-degree relative

Grandparent, grandchild, aunt, uncle, niece, nephew, half-sister or half-brother.

Strong family history of ovarian cancer

A person has a strong family history of ovarian cancer if they have 1 or more first-degree relatives (for example, a grandmother, mother, sister or daughter) on the same side of their family (the mother's or father's side of the family) with ovarian cancer.

Third-degree relative

Great grandparent, great grandchild, great aunt, great uncle, first cousin, grandnephew or grandniece.