4/29/22: Oophorectomy Surgery Consultation Appointment

I will never take for granted having medical providers I like and trust. My OB/GYN surgeon inspired confidence and was super friendly.

First off, the procedure I'll be getting isn't just an oophorectomy, it's called a bilateral salpingo-oophorectomy (BSO). "Salpingo" means "relating to fallopian tubes". Apparently, fallopian tubes serve no purpose without ovaries, plus many ovarian cancers may actually originate in the fallopian tubes, so it just makes sense to also remove fallopian tubes when removing ovaries.

It will be laparoscopic, with 3 entry points. (I found this part fascinating.) One will be through my bellybutton, and the other two will be 0.5 cm incisions towards the outer edges of my hip. I'll get general anesthesia, and the procedure itself should take about an hour. She already scheduled the surgery for June 16th, and I'll have a follow-up appointment 3-4 weeks after that. I'll have typical post-surgery restrictions (e.g., no heavy lifting) for 2 weeks afterwards, and she said full recovery should be "a few weeks".

Before the surgery, I'll need a pelvic ultrasound so the doctor can confirm that the surgery can be done laparoscopically. I'll also need a covid test, which the doctor said will be done at the hospital a couple days beforehand. The hospital for this surgery will not be my usual hospital location, and also not the new OB/GYN office location, but another satellite hospital location. A bit more of a drive, but still better than driving into the city. 

After the surgery, I'll be in surgically-induced menopause, which can sometimes lead to more severe menopause symptoms because the loss of estrogen is more drastic than when the ovaries gradually shut down naturally. But, since I've already been on Lupron for so long, and my body has already experienced chemically-induced menopause, the doctor says my menopause-related symptoms shouldn't be too bad compared with what I already have now. I may have new or worse symptoms for a few months, but hopefully they will only be temporary. 

My estradiol will continue to be monitored, at least for a while, to make sure it's <5 as expected. 

I'm assuming I'll just continue with anastrozole, but I'm not sure, I'll have to ask my oncologist about it.

After all this, it occurs to me that if I had gotten my ovaries out earlier, I would never have been put on Tamoxifen (which is only for premenopausal women), and I never would have gotten non-alcoholic fatty liver disease. That's a whole extra medical condition that puts me at high risk for covid! Oh, well. Could not have been predicted. 

4/28/22: OB/GYN Office Called Me

My regular OB/GYN no longer performs surgeries, so I had to be referred to another office. I was afraid I'd have to drive to the main hospital in the city, but luckily there is another satellite office, just a little bit farther than my usual one. That office called me today, and I was so pleased with how friendly and helpful the caller was!

She was able to get me a surgery consultation appointment for tomorrow. I think there just happened to be a cancellation.

4/26/22: Medical Oncology NP Phone Appointment - I Need an Oophorectomy

Today's phone appointment was a follow-up to see how I'm doing on the anastrozole. I had printed out my list of side effects, but I ended up not mentioning the coughing and increased mucus. It's allergy season, after all, and it might not really be a side effect. 

Mostly, the bottom line is, I have a lot of side effects, but it's all manageable, and none of it limits my activities. My joint stiffness and hot flashes are worse than on Tamoxifen, but better than on exemestane. The dizziness is weird, but I haven't felt it in a couple weeks now. My NP said it's common for lots of side effects to develop around 2-8 weeks after starting a new medication, and then start to settle down after about 3 months, as the body adjusts. She also brought up vaginal dryness, which I hadn't really noticed except maybe some itching, which she said was actually a common symptom; she said she'd send me a list of products that can help. 

I thought that was it, the start of a potential stretch of stable, uneventful cancer care, but then she said, "Did you see your latest estradiol number?"

Ugh. I've been so focused on my LFTs that I totally forgot to check the estradiol from my last blood draw!

Turns out, my estradiol was 15. To be considered post-menopausal, which I need to be in order to take anastrozole, the estradiol should be <5. 

My NP said my medical oncologist already conferred with other oncology colleagues, and they agreed this is unusual. Their only guess is that the Lupron must not be working, but nobody knows why not. The point of the Lupron is to eliminate estrogen production by suppressing the ovaries, and since Lupron isn't doing it well enough, the consensus was to recommend I remove my ovaries. My NP will do some coordinating behind the scenes, and then she's supposed to call me back with next steps.

Incidentally, I mentioned that I never did hear from my hepatologist after seeing my FibroScan results online. I said I'm not really worried because I have an appointment scheduled this summer, but she said she'd check in with him to see if there's anything I should know before then. I appreciate her helping me out, even though hepatology isn't her department. 

To help me wrap my own head around everything, here's the whole hormone therapy / oophorectomy history:

• Fall 2019: My genetic testing showed I have 2 VUSes: one in BRCA2, which is linked to ovarian cancer, and one in PALB2, which may be linked to ovarian cancer. My oncologist did not recommend removing ovaries to prevent ovarian cancer, but my OB/GYN thought it was a viable option for multiple reasons: 1) to prevent ovarian cancer, 2) as birth control, and 3) to eliminate the need for monthly Lupron shots. At this time, an oophorectomy didn't seem necessary, so I didn't pursue it.
  
  
• 2020: Because my cancer was estrogen receptor positive, I needed hormone therapy to eliminate estrogen in my body. I got monthly Lupron shots (to suppress estrogen production in my ovaries) and was prescribed exemestane (a daily pill for post-menopausal women to block estrogen production in other parts of the body). The Lupron put me in a chemically-induced menopause, which allowed me to take exemestane.
  
  
• 2021: A couple blood tests showed my estradiol to be too high; my oncologist thought maybe the Lupron wasn't working as effectively since my ovaries started working again (after having temporarily stopped working during chemo). Since I couldn't be considered post-menopausal anymore, I switched from exemestane to Tamoxifen (a daily pill for pre-menopausal women to block the effects of estrogen on breast cancer cells), while still continuing with Lupron. 
  
  
• 2022: After a year of Tamoxifen, I developed non-alcoholic fatty liver disease. My oncologist took me off Tamoxifen and switched me to anastrozole (the same type of pill as exemestane, just a different drug). Since anastrozole can only be taken post-menopause, my estradiol would be monitored to make sure the Lupron is keeping it <5. My last blood test showed estradiol was 15, so the Lupron is not totally working, which means I can't be considered post-menopausal. The only pre-menopausal hormone therapy pill is Tamoxifen, which we already ruled out as an option. Now, having pretty much exhausted all other options, the only way to sufficiently eliminate estrogen production is to have an oophorectomy. 

4/15/22: Blood Work Results

I got my blood drawn today, before getting my Lupron shot. I checked the results online, and my LFTs are now roughly what they were back in February. I think this is a good sign. They are still too high, but at least they are lower than they were last month.

4/2/22: More Anastrozole Side Effects

Lately, I've been feeling dizzy. I've always imagined "dizzy spells" to mean: a person feels dizzy while standing, has to sit down, and needs to remain still for a while to let the feeling pass. But what happens with me is, I will be standing still, moving around, or just sitting and eating breakfast - doesn't matter - and suddenly, without warning, I will feel a very brief dizziness, like a "shift" inside my head. It passes quickly. Sometimes that's it, and sometimes it's followed by a few more milder occurrences. Sometimes by many more milder occurrences. "Feeling dizzy" or "dizziness" is listed as a side effect of anastrozole, so I guess that's it.

Also, I'm having trouble sleeping. This is really nothing new; ever since I started cancer treatment, I have to get up multiple times a night because of a hot flash or because I have to pee. But lately, I've had trouble just falling asleep. Even when I'm tired, I will end up tossing and turning for quite a while before dozing off. And I'm definitely feeling more tired during the day than I used to. Both web sites linked above also list "feeling tired" or "unusual tiredness" as a side effect, so maybe it's related. 

Anyway, I've added these two items to my list of concerns for when I next talk to my medical oncology NP. 

4/1/22: I Got Advice From a Dietitian

I'm lucky to have a very dear friend who is a dietitian. I shamelessly asked her for free advice on how to reverse my fatty liver. All the information online can be overwhelming, so it was helpful to get just a few key recommendations. Beyond just exercising more and drinking more water, she suggested:

• Avoiding processed foods, which contain preservatives, artificial colors, or other additives that are hard on the liver
• Balancing / reducing carbohydrates by supplementing them with more vegetables / salad
• Eating more cruciferous vegetables like broccoli, cauliflower, and Brussel sprouts, which can help the liver function better
• Engaging in movement after eating; could be a light walk or just being active, not sedentary

This all sounds doable, even if it's no fun refraining from Cheetos and such. She did reassure me that the occasional alchoholic drink is still okay, which is what my hepatologist said, too, though that was before I had my FibroScan. 

She also reminded me to not expect noticeable change right away; reversing a fatty liver is a slow process.