poor sensitivity and specificity for ovarian cancer.: 175–207 in both breast and ovarian screening, areas of tissue that look suspicious are investigated with either more imaging, possibly using a different type of imaging or after a delay, or with biopsies of the suspicious areas. medication birth control pills are associated with substantially lower risk of ovarian cancer in women with brca mutations. a 2013 meta-analysis found that oral contraceptive use was associated with a 42% reduction of the relative risk of ovarian cancer, the association was similar for brca1 and brca2 mutations. use of oral contraceptives was not significantly associated with breast cancer risk although a small increase of risk that did not reach statistical significance was observed. a 2011 meta-analysis found that oc use was associated with a 43% relative reduction in risk of ovarian cancer in women with brca mutations, while data on the risk of breast cancer in brca mutation carriers with oral contraceptive use were heterogeneous and results were inconsistent. selective estrogen receptor modulators, specifically tamoxifen, have been found to reduce breast cancer risk in women with brca mutations who do not have their breast removed.: 113–142 it is effective as for primary prevention (preventing the first case of breast cancer) in women with brca2 mutations, but not brca1 mutations, and for secondary prevention (preventing a second, independent breast cancer) in both groups of women. taking tamoxifen for five years has been found to halve the breast cancer risk in women who have a high risk of breast cancer for any reason, but potentially serious adverse effects like cataracts, blood clots, and endometrial cancer, along with quality of life issues like hot flashes, result in some women discontinuing its use and some physicians limiting its use to women with atypical growths in the breasts. tamoxifen is contraindicated for women who are most likely to be harmed by the common complications. raloxifene (evista), which has a reduced risk of side effects, is used as an alternative, but it has not been studied in brca mutation carriers specifically. tamoxifen use can be combined with oophorectomy for even greater reduction of breast cancer risk, particularly in women with brca2 mutations.: 113–142 aromatase inhibitors are medications that prevent estrogen production in the adrenal glands and adipose tissue. they have fewer side effects than selective estrogen receptor modulators like tamoxifen, but do not work in premenopausal women, because they do not prevent the ovaries from producing estrogen.: 113–142 surgery several type of preventive surgeries are known to substantially reduce cancer risk for women with high-risk brca mutations. the surgeries may be used alone, in combination with each other, or in combination with non-surgical interventions to reduce the risk of breast and ovarian cancer. note that surgeries such as mastectomy and oophorectomy do not eliminate the chance of breast cancer; cases have reportedly emerged despite these procedures. tubal ligation is the least invasive of these surgeries and appears to reduce ovarian cancer risk for brca1 carriers by over 60%. salpingectomy is another option which is more invasive than tubal ligation and may result in additional risk reduction. both of these can be performed anytime after childbearing is complete. unlike other prophylactic surgeries, these two surgeries do not reduce the risk of breast cancer. prophylactic (preventive) mastectomy is associated with small risks and a large drop in breast cancer risk. prophylactic salpingo-oophorectomy (removal of the ovaries and fallopian tubes) results in a very large reduction in ovarian cancer risk, and a large reduction in breast cancer risk if performed before natural menopause. however, it also comes with the risk of substantial adverse effects if performed at a young age. hysterectomy has no direct effect on brca-related cancers, but it enables the women to use some medications that reduce breast cancer risk (such as tamoxifen) with the risk of uterine cancer and to use fewer hormones to manage the adverse effects of a prophylactic oophorectomy. whether and when to perform which preventive surgeries is a complex personal decision. current medical knowledge offers some guidance about the risks and benefits. even carriers of the same mutation or from the same family may have substantially different risks for the kind and severity of cancer they are likely to get, as well as the age at which they may get them. different people also have different values. they may choose to focus on total cancer prevention, psychological benefits, current quality of life, or overall survival. the possible impact of future medical developments in treatment or prognosis may also be of some importance for very young women and family planning. the decision is individualized and is usually based on many factors, such as earliest occurrence of brca-related cancer in close relatives. an increasing number women who test positive for faulty brca1 or brca2 genes choose to have risk-reducing surgery. at the same time the average waiting time for undergoing the procedure is two-years which is much longer than recommended. the protective effect of prophylactic surgery is greater when done at young age; however, oophorectomy also has adverse effects that are greatest when done long before natural menopause. for this reason, oophorectomy is mostly recommended after age 35 or 40, assuming childbearing is complete. the risk of ovarian cancer is low before this age, and the negative effects of oophorectomy are less serious as the woman nears natural menopause. for carriers of high-risk brca1 mutations, prophylactic oophorectomy around age 40 reduces the risk of ovarian and breast cancer and provides a substantial long-term survival advantage. having this surgery at a very young age provides little or no additional survival advantage, but it does increase the adverse effects from the surgery. compared to no intervention, having this surgery around age 40 increases the woman's chance of reaching age 70 by fifteen percentage points, from 59% to 74%. adding prophylactic mastectomy increases the expected survival by several more percentage points. for carriers of high-risk brca2 mutations, oophorectomy around age 40 has a smaller effect. the surgery increases the woman's chance of reaching age 70 by only five percentage points, from 75% to 80%. when only preventive mastectomy is done at age 40 instead, the improvement is similar, with the expected chance rising from 75% to 79%. doing both surgeries together around age 40 is expected to improve the woman's chance of reaching age 70 from 75% to 82% for comparison, women in the general population have an 84% chance of living to age 70. research has looked into the effects of risk-reducing surgery on the psychological and social wellbeing of women with a brca mutation. due to limited evidence, a 2019 meta analysis was unable to draw conclusions on whether interventions can help with the psychological effects of surgery in female brca carriers. more research is needed to conclude how best to support women who choose surgery. mastectomy further information: mastectomy § types in a woman who has not developed breast cancer, removing the breasts may reduce her risk of ever being diagnosed with breast cancer by 90%, to a level that is approximately half the average woman's risk.: 209–244 bilateral mastectomy is the removal of both breasts by a breast surgeon.: 209–244 the modified radical mastectomy is only used in women diagnosed with invasive breast cancer. techniques for prophylactic mastectomies include:: 209–244 simple mastectomy, which is recommended for women not having breast reconstruction, leaves the least amount of breast tissue in the body and therefore achieves the greatest risk reduction. in addition to prophylactic use, it is also used by women who have been diagnosed with earlier stages of cancer. skin-sparing mastectomy removes the tissue of the breast, nipple, and areola, but leave the "excess" skin in place for reconstruction. it has less visible scar tissue than a simple mastectomy. nipple-sparing mastectomy removes the breast tissue, but leaves the nipple and the areola intact for a more natural appearance. subcutaneous mastectomy removes the breast tissue, but leaves the nipple and areola intact. the scars are hidden in the inframammary fold under the breast. areola-sparing mastectomy removes the breast tissue and the nipple, but not the areola. nerve-sparing mastectomy is an effort to maintain the nerves that provide sensation to the skin over the breasts. breasts that have undergone any of these surgeries have much less tactile sensation than natural breasts. nerve-sparing techniques are an effort to retain some feeling in the breasts, with limited and often only partial success.: 209–244 which technique is used is determined by the existence of any cancer and overall health, as well as by the woman's desire, if any, for breast reconstruction surgery for aesthetic purposes.: 209–244 women who choose a flat-chested appearance or use external breast prostheses typically choose simple mastectomy, with its greater risk reduction.: 209–244 breast reconstruction is usually done by a plastic surgeon, and may be started as part of the same multi-hour surgery that removes the breasts. multiple techniques for reconstruction have been used, with different locations and amounts of scarring. some techniques use tissue from another part of the body, such as fat tissue from the lower abdomen or occasionally muscles from other parts of the torso. others use breast implants, possibly preceded by tissue expanders, to provide volume. some reconstruction techniques require multiple surgeries. afterwards, some women have tattoos added to simulate breast areolas or have the skin reshaped to form a nipple.: 209–244 salpingo-oophorectomy oophorectomy (surgical removal of the ovaries) and salpingectomy (surgical removal of the fallopian tubes) are strongly recommended to women with brca mutations.: 275–302 salpingo-oophorectomy is the single most effective method of preventing ovarian and fallopian tube cancer in women with a brca mutation. however, a small risk of primary peritoneal cancer remains, at least among women with brca1 mutations, since the peritoneal lining is the same type of cells as parts of the ovary. this risk is estimated to produce about five cases of peritoneal cancer per 100 women with harmful brca1 mutations in the 20 years after the surgery.: 275–302 brca2 related ovarian cancer tends to present in perimenopausal or menopausal women, so salpingo-oophorectomy is recommended between ages 45 and 50.: 275–302 the surgery is often done in conjunction with a hysterectomy (surgical removal of the uterus) and sometimes a cervicectomy (surgical removal of the cervix), especially in women who want to take tamoxifen, which is known to cause uterine cancer, or who have uterine fibroids.: 275–302 multiple styles of surgery are available, including laparoscopic (keyhole) surgery. because about 5% of women with a brca mutation have undetected ovarian cancer at the time of their planned surgery, the surgery should be treated as if it were a removal of a known cancer.: 275–302 salpingo-oophorectomy makes the woman sterile (unable to bear children). infertility services can be used to preserve her eggs, if wanted. however, as the benefits to the surgery are greatest close to menopause, most women simply postpone the surgery until they have already borne as many children as they choose to.: 275–302 the surgery also artificially induces menopause, which causes hot flashes, sleep disturbances, mood swings, vaginal dryness, sexual difficulties, difficulty with word recall, and other medical signs and symptoms. the side effects range from mild to severe; most can be treated at least partially. many women with a brca take hormone replacement therapy to reduce these effects: estrogen-progesterone combinations for women who have a uterus, and unopposed estrogen for women whose uterus was removed. estrogen can cause breast cancer, but as the amount of estrogen taken is less than the amount produced by the now-removed ovaries, the net risk is usually judged to be acceptable.: 303–317 some sources assume that oophorectomy before age 50 doubles the risk of cardiovascular disease and increases risk of hip fractures caused by osteoporosis in the relevant population. non-medical choices given the high risks and the low benefit of lifestyle choices in brca mutation carriers, no lifestyle choices provide sufficient protection.: 113–142 having her first child at a younger age, having more children than average, and breastfeeding for more than one year decreases the risk of breast cancer for an average-risk woman.: 113–142 studies about this effect among brca mutation carriers have produced conflicting results, but generally speaking, having children is believed to provide little or no protection against breast cancer for women with brca1 mutations, and to paradoxically increase the risk