Hormone Therapy Fails to Fully Restore Sex Lives After Preventive Ovary Removal

For women carrying BRCA1 or BRCA2 mutations, removing the ovaries and fallopian tubes before menopause is one of the most powerful tools available to slash the risk of ovarian and breast cancer. Yet a new mixed-methods study published in Archives of Sexual Behavior reveals a sobering trade-off that many patients say they were never adequately warned about: the surgery, known as risk-reducing bilateral salpingo-oophorectomy, or RRBSO, leaves many women with substantially worse sexual function and greater sexual distress—and the standard remedy, estradiol therapy, does not fix everything.

The research, led by Anuki Amarakoon, Jana Galley, and senior author Gillian Einstein at the University of Toronto, combined validated questionnaires with in-depth interviews. In the quantitative arm, 103 women completed the Female Sexual Function Index (FSFI), a 19-item inventory covering desire, arousal, lubrication, orgasm, satisfaction, and pain, along with the revised Female Sexual Distress Scale (FSDS-R), which measures how worried or upset women feel about their sex lives. The researchers compared four groups: women with BRCA1/2 mutations who had RRBSO and were not taking estradiol therapy, women with RRBSO who were taking it, age-matched women with intact ovaries and regular menstrual cycles, and older women in spontaneous menopause who were roughly ten years older on average.

The results were striking. Women who had RRBSO without estradiol therapy scored significantly lower on total sexual function than age-matched controls, with a large effect size, and they reported significantly more sexual distress than both the controls and the older spontaneously menopausal women. On the distress scale, the RRBSO group’s average exceeded the clinical cutoff of 11, indicating risk of clinically significant sexual distress. Notably, age itself was not a significant predictor of any sexual outcome, suggesting that the endocrine upheaval of surgical menopause—not the passage of years—drives the differences.

Perhaps the most consequential finding concerns estradiol therapy. Women taking the hormone after surgery did not differ significantly from those not taking it on total sexual function, and their distress scores did not fall to the low levels seen in age-matched controls. Estradiol therapy appeared to help some women—those on it did not differ significantly from controls on total function or distress—but the variability was wide, and the therapy clearly did not ameliorate all aspects of sexual response for everyone. As the authors put it, estradiol therapy is not a silver bullet, echoing their earlier work showing that the same treatment rescues some cognitive functions after RRBSO but not others.

Depressive symptoms emerged as a powerful and previously underappreciated factor. Using the Center for Epidemiologic Studies Depression Scale (CES-D), the team found that as depressive symptoms rose, total sexual function, arousal, lubrication, and satisfaction fell, while sexual pain and sexual distress climbed. Women with RRBSO who were not on estradiol therapy averaged slightly above the clinical depression cutoff of 16. The authors note that prior research has documented a roughly twofold risk of new-onset depressive symptoms within a year of the surgery, and they suggest that treating mood may help relieve sexual difficulties—though the study cannot determine which condition drives the other.

The qualitative half of the study added a dimension questionnaires cannot capture. Fourteen women with BRCA1/2 mutations who had undergone RRBSO were interviewed about their memory after surgery, with no questions about sex. Thirteen of them spontaneously brought up their sexual lives anyway—a telling measure of how central the changes had become. Thematic analysis yielded six themes: loss of desire, vaginal dryness, sexual pain, strain on the marriage bed, questions of identity and the self, and the insistence that women care deeply about sex.

The women’s words were often stark. One participant, taking estradiol therapy, likened her vanished libido to an appetite: “Physically, I wasn’t craving that aspect because it’s like if you were hungry or not hungry. I just felt like I had no appetite for it whatsoever.” Another said simply, “I don’t have any libido. There’s nothing.” Several described the loss as nearly immediate after surgery. Even a woman whose desire returned with added testosterone therapy described it as an “artificial trigger,” leaving her uncertain whether what she felt was genuine or merely physiological. Burning vaginal pain was nearly universal in the narratives, and some women reported that dryness and pain persisted despite hormone treatment, while others were spared—underscoring the individual variability in response.

The repercussions extended well beyond the bedroom. Women worried that sexual difficulties were eroding their marriages, with one noting that relationships highly dependent on physical appearance or sexual frequency were particularly vulnerable. Another was surprised not only by lost sexual intimacy but by the disappearance of ordinary touching. Participants also linked the changes to their sense of self, describing feeling older and associating sexuality with vitality and youth. One woman, denied the quick pharmaceutical fixes available for male erectile dysfunction, captured the frustration in the study’s title: “There’s no magic pill to help me, right?”

Underlying many accounts was a failure of informed consent. Although the sexual consequences of RRBSO have been documented in the literature since at least 1992, most participants said they were inadequately informed about what the surgery would do to their sex lives. Some were warned about hot flashes and weight changes but never about lost desire. Others knew the risk existed but did not truly understand it. The authors argue that being told something is not the same as understanding it, and that fully informed consent requires candid discussion of the possible sexual ramifications—including their persistence and magnitude—before women commit to the operation.

The study has limitations worth noting. The cohort was predominantly Canadian, white, and highly educated; the FSFI carries a known dysfunction bias; and the researchers did not quantify hormone doses or estradiol levels, limiting causal conclusions. Only a handful of participants were taking testosterone, so its potential benefits—supported by randomized trials showing that transdermal testosterone at physiological doses improves desire and satisfying sexual activity in surgically menopausal women—could not be assessed here. Still, the convergence of numbers and narratives makes the central message hard to ignore: women value their sexual lives, estradiol therapy alone will not restore them for everyone, and clinicians owe patients a far more honest conversation before they consent to losing their ovaries.

Subject of Research: Sexual function and distress after risk-reducing bilateral salpingo-oophorectomy in women with BRCA1/2 mutations

Article Title: “There’s No Magic Pill to Help Me, Right?”: Sex After Early Midlife Bilateral Salpingo-Oophorectomy

Article References: “There’s No Magic Pill to Help Me, Right?”: Sex After Early Midlife Bilateral Salpingo-Oophorectomy. (n.d.). https://doi.org/10.1007/s10508-026-03548-5

Image Credits: AI Generated

DOI: 10.1007/s10508-026-03548-5

Keywords: BRCA1/2, bilateral salpingo-oophorectomy, surgical menopause, estradiol therapy, sexual dysfunction, sexual distress, female sexual function, depressive symptoms, informed consent, testosterone therapy, cancer risk reduction, menopause