BE+ WITH BEING BRCA+

THE BRCA PHENOMENON

You could hear a lot about the Angelina Effect one time. Angelina Jolie announced on May 14, 2013 that she underwent bilateral breast removal surgery because of the 87% risk of hereditary breast cancer, and soon after she underwent ovarian removal surgery. His mother died young of gynecological cancer, which she inherited. It stirred the public. I admit, back then, I thought it was some crazy Hollywood sub, that Angie was doing something extreme again, and that she was calling her attention by self-mutilation. But after 4 years, in 2017, I found out that I should have read more than a superficial judgment of the news.

HOW IT STARTED AND HOW TO CONTINUE

Perhaps my case also encourages others that if something is shocking, because it is not ordinary, not necessarily unreasonable and unfounded. And just because a solution is too drastic, you don’t have to sweep it right under the carpet.

So my story at first sight started like this: I treated the brave expression of a little exalted actress superficially and ignored it. There is so much information flowing daily and Hollywood is so far away. It was just unbelievable that this could happen to me in Hungary too.

My mother was diagnosed with unilateral breast cancer at the age of 43, when I was 15 years old. We were scared, but Mom followed the protocol through: chemotherapy, surgery, recovery, radiation. Then we had 17 quiet years when she was diagnosed with cancer again at age 60, this time with ovarian cancer. The ordeal came, after 7 years of struggle, and in December 2017 she left us here with worsening symptoms of ovarian cancer metastases. One year before her death, her oncologist sent her for a genetic test showing BRCA 2 positivity, which is a gene mutation and more prone to gynecological cancers. Based on a family history, the oncologist advised me and my sister to do the genetic test, as it can be 50% inherited (for both women and men!).

I have a proven predisposition and in October 2017 I received my finding that I am BRCA 2 positive.

I am an amateur athlete, and I also feel like an athlete spiritually, with all its advantages and disadvantages. I have always been confronted with the facts, the obstacles, being able to formulate short and long term goals and getting on the road to achieving the goal. Therefore, the gene test itself was not a question mark, nor was the use of the most effective way of reducing risk, even if itwas not a dream of vacation...

BRCA positivity predisposes to a very high percentage of breast cancer and a lower percentage, but still a significant risk of developing ovarian cancer.

Therefore, in the case of prevention, we must focus on these two areas. For some reason, breast cancer prevention gets more space, but I would treat the two together, especially since ovarian cancer occurs at a lower rate, but is a more aggressive form of cancer, more difficult to filter, and has a higher death rate.

I have already undergone bilateral breast removal surgery (two steps). My first surgery – the specific tissue removal – was in March 2018, and the second – reconstruction – in December 2018. I plan to have ovarian surgery within five years, before I reach the age of 45.

BUT WHAT IS BRCA? What is BRCA Positivity? Who’s in danger?

Some facts:

• BRCA – abbreviation for BReast CAncer, is the name given to two important DNA repair genes!

• Both genes produce proteins that help repair damaged DNA while keeping the genetic material in the cell stable.

• The loss of their repairing function results structural chromosome aberrations that contribute to malignancy/ominous processes

• Damaged BRCA gene can increase cancer risk at both sites, especially for breast or ovarian cancer

• Thus, BRCA positivity is not a disease, but a reduction in resistance to certain cancers due to a gene defect, that is, a chance of cancer predisposition due to a genetic defect.

• BRCA 1 has a cytogenetic site at position 17q21, or 21st positionon the q arm of chromosome 17. The cytogenetic site of BRCA 2 is at position 13q12.3 or 12.3 position of the q arm of chromosome 13.

• In the background of breast cancers there are 5-9% gene mutations.

• 50% inherited from father side, so there is no need for a specific case of female tumors in the family history

• Germ cell BRCA1 and BRCA2 mutations can cause hereditary breast and ovarian cancer syndrome.

• The ratio of BRCA1 and BRCA2 mutations is 1 / 300-500 in the average population

• These mutations may be hereditary (in about 10% of cases), sothey are present at birth but they can be also sporadic, which means they develop only later, spontaneously, mostly due to environmental influences or just spontaneously.

• The average age of onset of breast cancer is 43 years for BRCA1 and 47 years for BRCA2 mutants.

• The presence of the mutation also predisposes to other cancers, e.g. ovarian cancer, pancreatic cancer, prostate cancer, colon cancer.

• According to statistics, 100,000 women in Hungary are affected by hereditary breast cancer.

• Ancestor-related changes in the founding DNA sequence are typical of a given geographic or cultural population. BRCA founding mutations are known in Ashkenazi Jews in the Hungarian, Canadian, Swedish, Dutch, Italian and Icelandic populations.

• The 5382insC mutation of the BRCA1 gene, the most common in Hungary, dates to about 38 generations.

GENE STUDIES

BRCA positivity can be screened by genetic blood testing.

Unfortunately, more and more families now have some form of gynecological cancer. More and more women are wondering whether they also have the BRCA1 or BRCA2 gene mutation. This can be ascertained by a gene test on blood. There are several types of gene assays, the simplest analyzes the most common mutations, while there are assays where the entire gene sequence is verified. Of course, the difference is also reflected in price.

BREAST PREVENTION

I passed around it: talking to doctors, oncologists, acquaintances, acquaintances who have already had surgery, Hungarian and English articles, recommendations, opportunities on the Internet. What has crystallized in me is that, according to the state of the medical science today, bilateral prophylactic mastectomy is the most effective risk reduction procedure Alternating recommended strict screening (MR every half year, mammography and ultrasound).

BILATERAL PROFILACTIC MASTECTOMY

Oh God, but what is this terrible Latin medical name?

For bilateral (bilateral – Latin word = bi – Latin “two” + lateral – Latin “side related” words) preventive (prophylactic – Latin word = pro – Latin “pre” + phulaxis Greek “guarding”) breast tissue removal (mastectomy – Latin word = masto – Greek for “breast” + ectomy – Latin for “exception, cut out”).

Basically, surgical intervention is the removal of the entire gland just as in the case due to cancerous tumors. At first, everyone is thinking of drastic breast amputation. By the way, this is what I thought at first, no wonder, since a couple of years ago it meant nothing else. But breast cancer-related reconstruction surgeries have progressed dramatically, with the emphasis on minimizing the mutilation of femininity alongside physical loss. It is important to clarify this is

NOT BREAST AMPUTATION, THEY DON’T CUT OFF THE BREASTS!

These are the scary banners that were likely to discourage and frighten the common man more than they helped raise awareness of this prevention option.

NIPPLE AND SKIN PRESERVATION

Skin and nipple preservation is now commonly used for prevention, so it is not the same as full breast amputation, which most people find most drastic. The gland is excised through an incision under the breast. From the outside, nothing is visible except the semicircular cut. Immediately or a few months after the removal of the tissue, a reconstruction procedure is performed when the final implant is inserted into the breast. Keeping the nipple has a minimal chance of developing cancer, but aesthetically, it expects a lot.

RECONSTRUCTION = one-step or two-steps?

Although reconstruction can be done immediately when glandular tissue is removed, experience has shown that this case there is a greater chance of complications that can lead to skin death.

It is worth waiting after the surgery for the internal wound to calm down, heal and the transformed structure of the breast to take a final shape. After that, a much more successful aesthetic result can be achieved with a second stage plastic reconstruction. I think a few months are worth the wound healing and the result will be amore successful aesthetic experience. A minimum of six months is recommended at home between the two surgeries.

BREAST AMPUTATION (for comparison)

I was not tired of reading pictures and stories of traditional mastectomy. I think that is also a matter of spiritual preparation and being grateful that they can now achieve the same result with much more gentle intervention. Some for illustration.

Conventional mastectomy is used today with tumors, not always there also, unless the type and prevalence of cancer justify the removal / amputation of the entire breast.

EXPANDER

The expander is similar to the final implant but can be gradually charged. It is then filled with sodium chloride by injection through a valve close to the armpit, just below the skin. The valve is filled externally every 1-2-3 weeks according to the judgment of the physician and the state of regeneration. Within a few months, the breasts will reach their final size with gradual fillings. In this way, the injured tissue as well as the skin is protected from sudden stretching and the breast can be customized to the desired size. After surgery, the breasts are still relatively insensitive, so the filling sting does not hurt at all.

What to expect after surgery:

Drainpipe is tapped out from the breasts for about 2 weeks to clear the wound. The bottles attached to the drainpipes are replaced every few days depending on how quickly they fill with whey.
Suture removal approximately after 3 weeks
Recovery is about 6 weeks – driving, exercising or liftingmore than 2 kg are forbidden!!! Failure to do so can lead to complications and inflammation, which can affect subsequent reconstruction surgery and significantly prolong the period of recovery and immobility.
The expander is gradually filled with saline solution every few weeks, as healing progresses, until the the breast reaches the final volume. This process can take 2 – 2,5 months, gradually stretching the surrounding tissues and skin.
The breasts (including the nipples) are relatively insensitive at the beginning, which is beneficial for filling, but is a cause for concern in the future. Usually the insensitivity goes away slowly, in about a year, but as a final result, breasts are more insensitive than before. This is because nerve endings, other than tissue, can also be destroyed. You have to be aware of that, but the doctors also tell you.
The expander feels much more unnatural than your own breast, and is much harder than a silicone implant.
On the side, there is a valve inside the skin, the silhouette of which shows through the skin and is clearly palpable. I called it “robot breast” or “cyberbreast“.

MULTIDISCIPLINARY TEAM

Medical approval of prophylactic mastectomy is a longer, detailed multidisciplinary task. It covers several medical fields: genetic, oncologist, mammalian specialist, oncopsychologist, plastic surgeon, mammal committee. This complex multidisciplinary / multidisciplinary team examines the individual’s findings, screening results, family history, patient expectations and needs in detail. So it should not work like we walk into a private practice and come up with a cancer prevention surgery.

Before surgery, it is therefore necessary to:

Genetic consultation
Oncologist consultation
Mammalian Specialist / Reconstruction Consultation
Mammography
Ultrasound
Breast MR
Labor
Oncopsychologist – 2 x
Visit at Multidisciplinary

Of course, this kind of detailed tour shows that decision, its effects, and surgery are not routine tasks either.

I had a question. Are there really no other options? I have found some alternatives:

CHEMOPREVENTION / RADIATION TREATMENT

That is, chemotherapy treatment for the prevention of cancer, the substances used in this case are: tamixofen / raloxifene.

I have found no encouraging results or recommendations for such chemotherapy treatments in the domestic or foreign articles or literature. Neither did the doctors I consulted recommend, nor is it part of the domestic preventive protocol. In addition, I accompanied my mother through many, many chemotherapy treatments… a long, vicious, and ill-advised journey. So it was out of the box quite quickly due to the doubts.

SCREENING

There are many places I read in articles that breast screening is a possible risk reduction! It is very important to go for screeningslife-long. However, screening does not reduce the onset of the disease, but increases the possibility of an early diagnosis of an established disease. But it is still important because the stage of the disease in the case of cancer has a major influence on the methods and possibilities of treatment at diagnosis. For some types of cancer, screening is particularly suitable for early detection (eg. breast cancer). Therefore, it is important that women undergo screening beyond mandatory screening.

In Hungary, less than half, 44.6 percent of women between the ages of 50 and 70 participate in mammography, while the European average is 62 percent. As this also means that many people cannot be treated on time, this difference is also reflected in the outcome of breast cancer: while breast cancer mortality was 39.1 percent in 2013 in Hungary, the EU average is “only” 33.2 percent.

In Hungary, breast cancer screening protocol supported by social insurance:

Mammography every 2 years over 50 years
Ultrasound breast examination over 30 years

This is for mutation carriers:

Monthly self-examination
Clinical breast test in every 3-6 months
Annual mammography
Breast MR and ovarian cancer screening.

However, in my reading, due to the propensity shown, screening is inadequate for me. The gene mutation multiplies ten times the likelihood of cancer compared to an average female body (on average, women have a 8% chance of breast cancer, 60-80% for BRCA 2 positivity, up to 90% for BRCA 1 gene mutation).

Screening does not reduce the risk of developing cancer, it is only more likely to detect the cancer at an early stage.

This is a very important condition, but for me it was not satisfactory with the high risk. I want to win many years and reduce the 80% probability to a minimum. This can be reduced to 5-10% with prophylactic mastectomy.

Why just 5-10%?

On the one hand, because there may still be tissue remains (including the nipple) that may be affected by the cancer. On the other hand, BRCA 1-2 can not only cause gynecological cancer but also less likely to cause pancreatic cancer and colon cancer that cannot be prevented by tissue removal.

THE SPIRITUAL PROCESS – Femininity is in decline?

Before surgery, I went to an oncopsychologist for a mandatory protocol. It was useful. I said things that I’d rather diverted before. Since the first surgery was done relatively soon (4 months) after my mother’s death (preparation and consultations even three months earlier), I came to grisps on the surgery together with my mother’s death, as the origin of her illness and death is clearly related to my predisposition. In fact, maybe it was the surgery that helped me get a little deeper into mourning in a healthy way. As a mother, as a working woman, I go on with the daily routines. In today’s society, we tend to mantras ourselves to forget bad thoughts, to be positive – otherwise I tend to do this. But mourning, losing and letting go is a process that has to be lived as part of life and spent time with it. During recovery, one disconnects from the daily squirrel wheel and stays with one’s own thoughts for a while. That helped me.

I convinced myself about the operation with that:

A growing number of women, massively and almost on conveyor belts, goes under the knife for purely vanity reasons (I did it before, so this is not a pejorative statement): hanging breast, small breast, big breast, asymmetrical breast. In most cases, they neglect all health reasons, taking the risk that surgery may be a small percentage, but it can also have complications (even for breastfeeding!). Today, no one is asking if plastic surgery was a difficult decision, are you afraid of complications, and whether family planning played a role in your decision? It has become almost routine both medically and judgmentally, though the process itself is for own sake. We do it for our own beauty and indirectly for our psychological well-being. Before mastectomy, I had undergone breast surgery twice (before and after breastfeeding), so I have experience with that. And I support it because I only had positive experiences with it.

Although breast removal is a bit more complicated surgery, the reason is much clearer to me, and most importantly, it is not only self-serving: it is about extending our lives. We do it not just for ourselves, for our family, for our children, for our environment.

It is said that losing part of our body is also a form of mourning. Maybe I didn’t experience this so tragically because I have breastsafter all. The results of the reconstruction are very good now, and the surgery has not caused any particular aesthetic deterioration in the long run.

AESTHETICS:

Breast is one of the most important symbols of the female aesthetic. And although it can now be wonderfully reconstructed, the loss of one’s own tissue, even from an aesthetic point of view, is enormous.

What you need to know:

In the first months, the spectacle is a bit scary, but much better than we expected
Strange feeling and appearance, but it can’t be noticed in clothes
The nipples and the areola are kept
The cut (starts below the breast and ends sideways towards the armpit at the center of the breast) is approx. twice as large (10 cm) as an implant. However, it is smaller than a breast suture.
In two-stage reconstruction, positioning can be improved after the tissues have “settled”
The overlay above the implant is almost completely gone – even more so with those who has little fat.
The breasts will be very contoured, and foreign matter willalmost appear and can be feel under the skin. This makes it look more unnatural than an average plastic surgery, a bit more wavyand because of the removal of tissue, I would describe it that it is similar to cellulite.
The expander and implant are also placed under the muscle.

The advantage:

They fill the expander as much as we want – so you don’t have to decide the size exactly
Breast doesn’t hang but is tight

The loss of femininity is not limited to aesthetics.

POSSIBLE LOSS OF BREAST FEEDING

After preventive mastectomy, breastfeeding is impossible.

The glandular tract is removed along with the mammary glands. For women facing family planning, this is a huge step down. And although it is now possible to raise a baby without breastfeeding, the ideal process is for the baby to breastfed in the first months. I breastfed all three of my children until the age of 10 months and they only got breast milk in the first 6 months. I know how difficult it is to give up this, because breastfeeding is a very intimate bond between a mother and a child after birth.

However, the following arguments and consequences have to be pondered:

Breast cancer occures at a young age nowadays
Statistics are always just statistics. Life can overwrite them at any time, and who can tell whether a person is in the statistical center or one of the extremes? The statistical average is too much uncertainty for me.
But with preventive surgery, we are 90% more likely to be there when our children grow up.
Screening does not prevent the cancer, screening is a chance to detect the cancer in time. And while breast cancer is a success story, a relatively well-cured type of cancer, it still has some very aggressive types.
Mastectomy, however, greatly reduces the risk of developing cancer, for me this is the real prevention.

MATERIAL ATTENTION – Does health insurance support gene screening and prevention?

GEN TESTS

Health insurance in Hungary only supports gene testing if the family has already shown BRCA 1-2 positivity or if two gynecological cancers have occurred in one ascendant. Therefore, e.g. if a mother had one-sided breast cancer, the girl has no support for insurance assisted genetic testing.

My example: my mother had breast cancer at the age of 43. At that time, she had not yet undergone genetic screening, probably there was no screening for this in Hungary, but perhaps it was not even a widespread procedure worldwide. In fact, the BRCA gene mutation was discovered sometime in the early 1990s. However, she was diagnosed with ovarian cancer at the age of 60 and underwent genetic testing 1 year before her death. It turned out that BRCA 2 is positive, so both me and my sister are supported by insurance.

In most cases, you still have to pay for this test. I went after some reviews on the net:

The cheapest is 100-150.000 HUF (320 – 480 EUR)
The most expensive is 400.000 HUF (1300 EUR)

And then we only have the fact whether we have an inherited predisposition to gynecological cancer or not.

SURGERY

Does health insurance cover preventive surgery?

No, not in preventive phase. (still looked only at the Hungarian situation)

Only if we have already have or had active, cancerous mutations.

But for God’s sake, I would exactly like to prevent myself from this to happen! We have to pay for the prevention from our own pockets. In addition, I have been paying for private health insurance since my children were born, and even this special health insurance did not pay for the costs of prevention.

By the way, I pondered this with common sense, of how much the state saves and how much the state loses if it does not support prevention. The cost of an active cancer patient is many-many millions of HUF (examinations, chemotherapy, surgery, reconstruction, radiation, immunotherapy, hospitalization, etc.) The preventive surgery and the gene test cost maximum of 2 million HUF (6300 EUR) at market price. And that’s the breast removal. This is followed by ovarian removal, which starts at 500,000 HUF (1600 EUR). The likelyhood of cancer if having BRCA is above 80%.

No complicated calculation is needed to state that in some way that prevention is not only better for society, but also financially for a state. Unfortunately, the latter is often more convincing.

Conclusion (Hungary): health insurance may support gene screening (in cases mentioned above), but not the preventive surgery.

The exception is, of course, if someone is diagnosed with ovarian cancer, it can be detected with BRCA, and then mastectomy is supported by the insurance. Thus, gynecological cancer elsewhere may justify support for other gynecological preventive operations. But asymptomatic women have no government support.

REFERENCES:

Announcement of Angelina Jolie in the New York Times – 2013

https://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html

Foreign credentials:

https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet

http://www.mdpi.com/2072-6694/10/2/57

OVARIAN CANCER

In women with an inherited mutation in the BRCA1 or BRCA2 (BRCA1 / 2) gene, the risk of ovarian cancer is 36-63% for the BRCA1 mutation and 10-27% for the BRCA2 mutation. The risk reduction is preventive ovarian removal (salpingo-oophorectomy, SO) after the fertility period.

SO reduces the risk of both ovarian and breast cancer, but some studies may suggest different degrees of reduction in BRCA1 and BRCA2 mutations, and there is evidence that the risk reduction is different in women who have breast cancer, as in those who do not.

Scientists have therefore investigated the effect of mastectomy and the effect of SO on the risk of breast and ovarian cancer. To summarize, the most important data: 1.1% of women who underwent risk-reducing SO had subsequent ovarian cancer, 11.4% had breast cancer, and their overall mortality was 3.1%. In contrast, without SO, 5.8 percent of women had ovarian cancer, 19.2 percent had breast cancer, and overall mortality was 9.8 percent. Risk-minimizing mastectomy is an extremely effective procedure: once done, no breast cancer occurred, while without it, the incidence rate was 7 percent.

Based on the results, both surgeries (Mastectomy and SO) can be strongly recommended for women who are at risk.

We talk a lot about breast cancer and very little about ovarian cancer. However, these two gene mutations certainly increase the risk of developing ovarian cancer.

Ovarian cancer is the 5th most common cancer and the death rate is about 50% !!!!, which is very, very high!

We also know that it is more common in women who have never become pregnant or have given birth, have certain cancers in their families (breast cancer!) or are in the menopause.

However, ovarian cancer is also very insidious because it is very difficult or can be late to diagnose, and once clear symptoms have been detected, it is often impossible to cure it. In many cases, only the symptoms of metastases suggest the existence of a primary tumor (in the case of my mother).

Thus, in the case of BRCA positivity, breast surgery and breast cancer prevention are only one of the pillars of the process. Another important step is the removal of the ovaries.

Ovarian cancer typically occurs over 50 years. It is completely asymptomatic in the early stages of the disease and there is no standard screening method. However, due to genetic factors, it is worthwhile to have regular medical check-ups for those who have had similar illnesses in their families.

Because ovarian cancer is initially asymptomatic, it can only be identified at this stage by imaging or laboratory blood tests (tumor marker levels). Because of the absence of symptoms and the lack of screening tests, ovarian cancer is rarely detected at an early stage.

In some cases, ovarian cancer is a metastasis of cancer formed in another cell. Most often the primary tumor is found in the gastrointestinal tract, breast or uterus, but can also be transmitted from the other organs to the ovarian cancer cells. However, this phenomenon can also be reversed: ovarian cancer easily forms metastases, e.g. can trigger lung cancer.

WHEN (IN WHICH AGE) IS IT RECOMMENDED TOMAKE THE SO SURGERY?

Current practice is that carriers of either of the two genes are advised to have surgery between the ages of 35 and 40, or when they no longer wish to have more children. After surgery, it is impossible to get pregnant naturally, and menopause begins.

New research suggests surgery at different times, depending on which gene the woman carries. Those who inherit the higher-risk BRCA1 are 1.5 percent more likely to develop ovarian cancer at age 35, rising to 4 percent at age 40 and 14 percent at age 50. In contrast, BRCA2 carriers can safely wait for surgery until their late 40s, as the study found a total of one case in a woman younger than 50 years.

Having consulted a gynecologist oncologist several times and having done a mastectomy, I was advised to have the removal done before I was 45 years old. I will do that.

ABOUT THE SURGERY:

Long-term consequences of early menopause can impair quality of life (eg osteoporosis and cardiovascular disease), but may be an alternative with hormone therapy.

I was advised to undergo laporoscopic surgery.

The point of the surgery is that without the opening of the abdominal cavity, a thin tube is inserted into it, through which the ovaries are visualized by means of an optical system – lighting, fiber optics – and the organs are removed through these gates. It has the advantage of shortening the healing time and complications following surgery (less chance of congestion, infection of the abdomen, increased risk of thrombosis due to prolonged movement impairment, aesthetic disadvantages). The disadvantage is that CO2 is injected into the abdomen during surgery to make the internal organs clearer for the doctor. The air introduced during the process is difficult to evacuate and causes severe bloating.

LONG-TERM EFFECT

It is particularly important that after bilateral ovarian removal, pregnancy cannot occur in the absence of ovums, and that premature removal of both ovaries (before the age of 50) results in premature artificial menopause, ie. hormone deficiency.

For me, since I already have three kids, the other big disadvantage is having a bust – and despite the topic, I do not understand it literally.

In fact, ovariectomy involves premature and sudden onset of menopause.

Menopause is the natural, hormonal change expected between the ages of 49 and 51, which is indicated by normal menstruation, which is not followed by another within 12 months.

The menopause is characterized by the gradual cessation of ovulation, decreased production of female hormones, and consequent symptoms of follicular hormone (estrogen) deficiency. Individual hormonal changes may vary in severity from the time of the last bleeding, even years before and / or after years. About a quarter of women have no symptoms at all, while the other quarter suffer from symptoms that severely affect their normal lifestyle, quality of life, work ability, and sexual life for years. Most of the symptoms are shorter and / or mild.

Estrogen levels are dramatically reduced in blood circulation and symptoms are most pronounced:

sweating heat waves become more common
palpitations
night sweats

Appear – other symptoms varying individually:

sleeping troubles
daytime fatigue
increased anxiety
mood swings
vaginal dryness
pain, colored discharge, minor bleeding during sexual activity
frequent urination
minor joint pain
bone loss (1% every year in the menopause)

In the case of ovarian removal, this gradation (5 to 10 years) cannot take place, resulting in a drastic hormone reduction, so hormone replacement is almost a mandatory post-operative treatment. And, as we know, adjusting hormone replacement and getting close to balance is very individual.

I am much more afraid of this surgery than of breast removal. I am not afraid of surgery, the risk of complications and convalescence, but of its long-term effect, which, in my opinion, is much more “mutilating” of femininity before a normal menopause than a breast reconstruction.

However, I have three children, I’m not only responsible for myself, I love to live, I love my life and even with hormonal and quality of life deterioration, it is more important to me to increase my chances of surviving and reducing the onset of the disease.

I believe in myself, I believe that it will be easier to solve the symptoms of menopause than to have the chance of an early cancer, or worse, to acknowledge it. This takes me forward, it will be the origo and I will not compare it to the basics of the lives of others. It is a matter of all comparisons, there are always better and worse life situations. I focus on myself and try to improve it with the tools that are available and workable for me. For example, I am fortunate enough to have already made the decision regarding ovarian removal, but have the opportunity to be mentally prepared. It’s not unexpected, it’s time for me to accept and enjoy my life as a fully functional woman until surgery. And then I’ll try to stay that way.

REFERENCES:

Some articles (scientific and press articles) on ovarian removal:

https://www.nytimes.com/2015/03/24/opinion/angelina-jolie-pitt-diary-of-a-surgery.html

https://time.com/3756167/angelina-jolie-ovaries-removed-cancer/

https://jamanetwork.com/journals/jamaoncology/fullarticle/2276101

https://www.breastcancer.org/treatment/surgery/prophylactic_ovary/what_to_expect/after