Ovarian Cancer: Symptoms, Stages & Treatment Guide

What Are the Symptoms of Ovarian Cancer?

The most common symptoms of ovarian cancer include persistent bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary urgency or frequency. These symptoms are often subtle and can be easily attributed to other conditions, which is why ovarian cancer is frequently called the "silent killer." If you experience these symptoms almost daily for more than 2-3 weeks, consult a healthcare provider.

Ovarian cancer symptoms are notoriously difficult to recognize because they mimic common digestive and urinary problems. The ovaries are located deep within the pelvis, which means tumors can grow quite large before causing noticeable symptoms. Additionally, the peritoneal cavity can accommodate significant tumor growth and fluid accumulation before a woman experiences discomfort.

Research has identified a cluster of symptoms that, when persistent and unusual for the individual, may indicate ovarian cancer. The key is not the presence of these symptoms occasionally, but their persistence and combination. Studies have shown that women with ovarian cancer typically experience these symptoms more frequently and with greater severity than women without the disease.

The Ovarian Cancer Research Alliance and major medical organizations have developed symptom awareness guidelines to help women recognize potential warning signs. Understanding these symptoms and monitoring their persistence is crucial because early-stage ovarian cancer has a significantly better prognosis than advanced disease.

Primary Symptoms to Watch For

The four most commonly reported symptoms in women with ovarian cancer form what is sometimes called the "symptom index." These symptoms become concerning when they occur almost daily for more than two to three weeks and represent a change from normal:

• Bloating: Persistent abdominal bloating or increased abdominal size that doesn't resolve with dietary changes or over-the-counter remedies
• Pelvic or abdominal pain: Ongoing discomfort or pain in the pelvic region, lower abdomen, or back that is different from menstrual cramps
• Difficulty eating or feeling full quickly: Loss of appetite, feeling full after eating small amounts, or early satiety
• Urinary symptoms: Needing to urinate more urgently or more frequently than usual

Additional Symptoms

While the primary symptoms are most common, women with ovarian cancer may also experience a range of additional symptoms that can vary depending on the size and location of the tumor, as well as whether the cancer has spread:

• Unexplained weight loss or gain
• Fatigue that doesn't improve with rest
• Back pain, especially lower back pain
• Constipation or changes in bowel habits
• Menstrual irregularities (in premenopausal women)
• Pain during intercourse
• Indigestion, heartburn, or nausea
• Shortness of breath (if fluid accumulates around the lungs)

When Should You See a Doctor for Ovarian Cancer Symptoms?

You should see a doctor if you experience bloating, pelvic pain, difficulty eating, or urinary symptoms almost daily for more than 2-3 weeks, especially if these symptoms are unusual for you. If you have a family history of ovarian or breast cancer, or if you carry a BRCA mutation, discuss your screening options with a gynecologic oncologist or genetic counselor.

The decision to seek medical care for potential ovarian cancer symptoms requires balancing vigilance with the understanding that these symptoms are common and usually have benign causes. However, given that early detection significantly improves outcomes, it is better to err on the side of caution when symptoms are persistent and unusual.

Healthcare providers who specialize in gynecologic conditions are best equipped to evaluate symptoms that might indicate ovarian cancer. This includes gynecologists, who can perform pelvic examinations and order appropriate tests, and gynecologic oncologists, who specialize in cancers of the female reproductive system.

When you visit your healthcare provider, be prepared to describe your symptoms in detail, including when they started, how often they occur, and whether anything makes them better or worse. Keeping a symptom diary for a few weeks before your appointment can be helpful in providing this information.

High-Risk Situations Requiring Proactive Care

Certain women should be particularly vigilant and may benefit from earlier or more frequent evaluation:

• Family history: One or more first-degree relatives (mother, sister, daughter) with ovarian or breast cancer
• Known genetic mutations: BRCA1, BRCA2, Lynch syndrome, or other hereditary cancer syndromes
• Personal history: Previous breast, colorectal, or endometrial cancer
• Ashkenazi Jewish ancestry: Higher carrier rate for BRCA mutations

How Is Ovarian Cancer Diagnosed?

Ovarian cancer is diagnosed through a combination of pelvic examination, transvaginal ultrasound, CA-125 blood test, and imaging studies such as CT scans. However, the only definitive way to confirm ovarian cancer is through surgical biopsy, where tissue is removed and examined under a microscope by a pathologist. Genetic testing for BRCA mutations is recommended for all patients with ovarian cancer.

The diagnostic process for ovarian cancer typically begins when a woman presents with symptoms or when an abnormality is found during a routine pelvic examination. Because there is no reliable screening test for ovarian cancer in the general population, most cases are diagnosed after symptoms appear or when an ovarian mass is detected incidentally.

The diagnostic workup involves multiple steps and tests, each providing different information about the likelihood of cancer and its extent. Understanding this process can help patients prepare for what to expect and participate actively in their care.

It is important to note that many ovarian masses are benign (non-cancerous), and the goal of the diagnostic workup is not only to identify cancer but also to determine the best approach for treatment while avoiding unnecessary surgery for benign conditions.

Physical Examination

The initial evaluation typically includes a thorough physical examination with particular attention to the abdomen and pelvis. During a pelvic examination, the healthcare provider can sometimes feel an enlarged ovary or a mass. They will also check for fluid accumulation in the abdomen (ascites), which can occur with advanced ovarian cancer.

A rectal examination may also be performed to check for masses that might be pressing on the rectum or to assess the extent of disease in the pelvis.

Blood Tests

Several blood tests are used in the evaluation of suspected ovarian cancer:

• CA-125: This is the most commonly used tumor marker for ovarian cancer. CA-125 is elevated in approximately 80% of women with advanced epithelial ovarian cancer. However, it can also be elevated in benign conditions such as endometriosis, fibroids, and pelvic inflammatory disease, as well as during menstruation and pregnancy.
• HE4: Human epididymis protein 4 is another tumor marker that may be used in combination with CA-125 to improve diagnostic accuracy.
• Other markers: Depending on the suspected type of ovarian tumor, other markers such as AFP, LDH, and hCG may be checked.

Imaging Studies

Various imaging modalities are used to visualize ovarian masses and assess the extent of disease:

• Transvaginal ultrasound: This is usually the first imaging test performed. It can provide detailed images of the ovaries and help distinguish between solid masses (more concerning for cancer) and fluid-filled cysts (often benign).
• CT scan: Computed tomography provides detailed cross-sectional images and is essential for staging, showing whether cancer has spread to lymph nodes, the liver, or other organs.
• MRI: Magnetic resonance imaging may be used to better characterize complex ovarian masses or to evaluate the pelvis in detail.
• PET-CT: This combination of positron emission tomography and CT may be used in certain cases to detect cancer spread or to monitor response to treatment.

Surgical Diagnosis and Staging

Unlike many other cancers, ovarian cancer usually cannot be definitively diagnosed without surgery. A tissue sample (biopsy) examined by a pathologist is required to confirm the diagnosis. In most cases, this is accomplished during surgery that also serves to remove the cancer and determine the extent of disease (staging).

Surgery may be performed as:

• Laparoscopy: A minimally invasive procedure using small incisions and a camera, sometimes used for diagnosis or in early-stage disease
• Laparotomy: An open surgical procedure through a larger abdominal incision, typically used for comprehensive staging and debulking surgery

Genetic Testing

All women diagnosed with ovarian cancer should be offered genetic testing for hereditary cancer syndromes, particularly BRCA1 and BRCA2 mutations. This testing has important implications for treatment decisions, as certain therapies like PARP inhibitors are particularly effective for BRCA-mutated cancers. Additionally, identifying a hereditary mutation can inform risk reduction strategies for family members.

What Are the Stages of Ovarian Cancer?

Ovarian cancer is staged from I to IV based on how far it has spread. Stage I is confined to the ovaries, Stage II involves pelvic spread, Stage III has spread to the abdomen or lymph nodes, and Stage IV has spread to distant organs. Stage at diagnosis is the most important factor in determining prognosis, with Stage I having a 5-year survival rate of approximately 90% compared to about 17% for Stage IV.

Staging is a critical part of the diagnostic process because it determines prognosis and guides treatment decisions. Ovarian cancer is staged using the FIGO (International Federation of Gynecology and Obstetrics) system, which is based on surgical findings. Unlike some other cancers that can be staged clinically, ovarian cancer staging requires surgical exploration.

The staging system takes into account whether the cancer is confined to one or both ovaries, whether it has spread to the pelvis, whether it has spread beyond the pelvis to the abdominal cavity or lymph nodes, and whether it has metastasized to distant organs such as the liver or lungs.

Understanding the stage of ovarian cancer helps patients and their healthcare teams make informed decisions about treatment and set realistic expectations for outcomes.

Approximately 60-70% of ovarian cancer cases are diagnosed at Stage III or IV, which is one reason the overall survival rates for ovarian cancer are lower than for some other cancers. This underscores the importance of symptom awareness and prompt medical evaluation.

How Is Ovarian Cancer Treated?

Ovarian cancer treatment typically involves a combination of surgery and chemotherapy. Surgery aims to remove as much cancer as possible (debulking), while chemotherapy destroys remaining cancer cells. Targeted therapies such as PARP inhibitors and bevacizumab have significantly improved outcomes, especially for women with BRCA mutations. Treatment plans are individualized based on the cancer stage, type, genetic features, and overall health of the patient.

Treatment for ovarian cancer has evolved significantly over the past decades, with new therapies providing improved outcomes and quality of life for patients. The standard approach involves a multidisciplinary team including gynecologic oncologists, medical oncologists, radiologists, pathologists, and supportive care specialists working together to develop an individualized treatment plan.

The goals of treatment vary depending on the stage and extent of disease. For early-stage cancer, the goal is often cure. For more advanced disease, treatment aims to control the cancer, relieve symptoms, and maintain quality of life for as long as possible. Even when cancer cannot be cured, modern treatments allow many women to live well with their disease for years.

The sequence of treatment (whether surgery comes before or after chemotherapy) depends on several factors including the extent of disease at diagnosis, the likelihood of achieving optimal surgical debulking, and the patient's overall health status.

Surgical Treatment

Surgery is the cornerstone of ovarian cancer treatment and serves multiple purposes: it provides tissue for diagnosis, determines the stage of disease, and removes as much cancer as possible. The concept of "optimal debulking" or "cytoreduction" refers to removing all visible tumor or reducing residual disease to less than 1 cm. Studies have consistently shown that women who achieve optimal debulking have significantly better outcomes.

A standard surgery for ovarian cancer typically includes:

• Removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy)
• Removal of the uterus (hysterectomy)
• Removal of the omentum (fatty tissue in the abdomen where ovarian cancer commonly spreads)
• Sampling or removal of pelvic and para-aortic lymph nodes
• Removal of any other visible tumor deposits in the abdomen

For younger women with early-stage disease who wish to preserve fertility, limited surgery removing only the affected ovary may be an option in carefully selected cases.

In cases of advanced disease, surgery may need to be more extensive, potentially including removal of portions of the bowel, bladder, spleen, or other organs where cancer has spread. While this sounds daunting, such surgery, when performed by experienced gynecologic oncologists, can significantly improve outcomes.

Chemotherapy

Chemotherapy is a critical component of treatment for most women with ovarian cancer. The standard regimen combines a platinum-based drug (usually carboplatin) with a taxane (usually paclitaxel). This combination is given intravenously, typically every three weeks for six cycles.

The timing of chemotherapy relative to surgery can vary:

• Adjuvant chemotherapy: Given after surgery to destroy any remaining cancer cells
• Neoadjuvant chemotherapy: Given before surgery to shrink the tumor and make complete surgical removal more likely

Side effects of chemotherapy can include fatigue, nausea, hair loss, decreased blood counts, neuropathy (tingling in hands and feet), and increased risk of infection. However, many side effects can be managed with supportive medications, and most resolve after treatment is completed.

Targeted Therapy and PARP Inhibitors

One of the most significant advances in ovarian cancer treatment has been the development of targeted therapies, particularly PARP inhibitors. These drugs work by blocking an enzyme that cancer cells need to repair their DNA, leading to cancer cell death.

PARP inhibitors are particularly effective in women with BRCA1 or BRCA2 mutations, as well as those with other defects in DNA repair pathways (known as homologous recombination deficiency or HRD). Available PARP inhibitors include:

• Olaparib (Lynparza)
• Niraparib (Zejula)
• Rucaparib (Rubraca)

These drugs are typically given as maintenance therapy after completion of chemotherapy and have been shown to significantly extend the time before cancer returns (progression-free survival). In some studies, PARP inhibitors have more than doubled progression-free survival in women with BRCA mutations.

Bevacizumab (Avastin) is another targeted therapy that may be used in combination with chemotherapy or as maintenance therapy. It works by blocking the formation of new blood vessels that tumors need to grow.

Treatment for Recurrent Ovarian Cancer

Unfortunately, ovarian cancer often returns after initial treatment, particularly when diagnosed at an advanced stage. When cancer recurs, treatment options depend on how long it has been since the initial treatment (platinum sensitivity), the location and extent of recurrence, and the patient's overall health.

Options for recurrent disease may include:

• Additional chemotherapy (same or different drugs)
• Secondary debulking surgery (in selected cases)
• PARP inhibitors
• Bevacizumab
• Hormonal therapy (for certain types of ovarian cancer)
• Clinical trials of new treatments

Even when ovarian cancer cannot be cured, it can often be controlled for extended periods with sequential treatments, allowing women to maintain good quality of life.

What Causes Ovarian Cancer and Who Is at Risk?

The exact cause of ovarian cancer is not fully understood, but several risk factors have been identified. The most significant is hereditary genetic mutations, particularly BRCA1 and BRCA2, which can increase lifetime risk to 15-45%. Other risk factors include age (most common after 50), family history of ovarian or breast cancer, endometriosis, obesity, and never having been pregnant. Factors that reduce ovulations, such as oral contraceptive use and pregnancy, appear to be protective.

Understanding risk factors for ovarian cancer is important for several reasons: it helps identify women who may benefit from enhanced surveillance or preventive strategies, it guides decisions about genetic testing, and it informs public health efforts to reduce the burden of this disease.

It is important to note that having one or more risk factors does not mean a woman will develop ovarian cancer. Many women with ovarian cancer have no identifiable risk factors, while many women with risk factors never develop the disease. Risk factors simply indicate an increased probability compared to the general population.

Current research suggests that many epithelial ovarian cancers actually originate in the fallopian tubes rather than the ovaries themselves. This understanding has led to changes in prevention strategies, with more emphasis on removing the fallopian tubes even when the ovaries are preserved.

Hereditary Risk Factors

Approximately 15-20% of ovarian cancers are associated with hereditary genetic mutations. The most important of these are:

• BRCA1 mutations: Increase lifetime ovarian cancer risk to approximately 35-45%
• BRCA2 mutations: Increase lifetime ovarian cancer risk to approximately 15-25%
• Lynch syndrome: Mutations in DNA mismatch repair genes (MLH1, MSH2, MSH6, PMS2) increase risk of ovarian, colorectal, and endometrial cancers
• Other genes: BRIP1, RAD51C, RAD51D, and others may moderately increase risk

Women with a family history of ovarian or breast cancer, particularly if diagnosed at young ages or if multiple family members are affected, should consider genetic counseling to assess their risk and discuss genetic testing.

Other Risk Factors

• Age: Risk increases with age; most cases are diagnosed in women over 50, with the average age at diagnosis being 63
• Family history: Having a first-degree relative with ovarian cancer doubles the risk, even without an identified genetic mutation
• Personal history of breast cancer: Increases ovarian cancer risk, partly due to shared genetic factors
• Endometriosis: Associated with increased risk of certain types of ovarian cancer
• Obesity: Higher body mass index is associated with increased risk
• Hormone replacement therapy: Long-term use (more than 5 years) may slightly increase risk
• Reproductive factors: Never having been pregnant, early menstruation, late menopause, and fertility treatment may increase risk

Protective Factors

Several factors have been associated with reduced risk of ovarian cancer:

• Oral contraceptive use: Can reduce risk by up to 50% with 5 or more years of use; protection persists for years after stopping
• Pregnancy and breastfeeding: Each pregnancy reduces risk; breastfeeding provides additional protection
• Tubal ligation: Having the fallopian tubes surgically blocked reduces risk
• Hysterectomy: Removal of the uterus (with or without ovaries) reduces risk
• Prophylactic salpingo-oophorectomy: Removal of ovaries and fallopian tubes in high-risk women can reduce risk by 80-90%

Can Ovarian Cancer Be Prevented?

While ovarian cancer cannot be completely prevented, several strategies can significantly reduce risk. For high-risk women with BRCA mutations, prophylactic removal of the ovaries and fallopian tubes after childbearing is the most effective prevention method, reducing risk by 80-90%. For average-risk women, oral contraceptive use, pregnancy, breastfeeding, and tubal ligation all provide some protection. There is no effective screening test for the general population.

Prevention strategies for ovarian cancer depend on an individual woman's risk level. For women at average risk, the focus is on lifestyle factors and understanding protective reproductive factors. For women at high risk due to genetic mutations or strong family history, more aggressive preventive measures may be appropriate.

It is important to emphasize that there is currently no recommended screening test for ovarian cancer in the general population. Large studies have shown that screening with CA-125 blood tests and ultrasound in average-risk women does not reduce deaths from ovarian cancer and can lead to harm from unnecessary surgeries for benign conditions.

For High-Risk Women

Women with BRCA1, BRCA2, or Lynch syndrome mutations should work with a genetic counselor and gynecologic oncologist to develop a personalized risk management plan. Options include:

• Risk-reducing salpingo-oophorectomy (RRSO): Prophylactic removal of the ovaries and fallopian tubes is the most effective prevention method, reducing ovarian cancer risk by 80-90% and breast cancer risk by approximately 50%. This is typically recommended between ages 35-40 for BRCA1 carriers and ages 40-45 for BRCA2 carriers, after completion of childbearing.
• Enhanced surveillance: For women who have not yet had RRSO or who decline surgery, some experts recommend CA-125 testing and transvaginal ultrasound every 6 months, though this has not been proven to reduce mortality.
• Oral contraceptives: Birth control pills reduce ovarian cancer risk even in BRCA mutation carriers and may be considered for protection until RRSO.

For Average-Risk Women

Women at average risk can consider the following to reduce their ovarian cancer risk:

• Oral contraceptives: Consider the protective benefits when discussing birth control options with a healthcare provider
• Opportunistic salpingectomy: Removal of the fallopian tubes during other pelvic surgeries (such as hysterectomy or tubal ligation) may reduce ovarian cancer risk
• Breastfeeding: Provides additional protection beyond pregnancy alone
• Maintaining a healthy weight: Obesity is associated with increased risk

How Does Ovarian Cancer Affect Daily Life?

Living with ovarian cancer involves managing the physical effects of the disease and treatment, as well as emotional and practical challenges. Common concerns include fatigue, digestive issues, early menopause symptoms, and changes in body image and sexuality. Support from healthcare teams, counselors, and support groups can help women navigate these challenges and maintain quality of life.

A diagnosis of ovarian cancer affects all aspects of a woman's life, from physical health to emotional well-being, relationships, work, and daily activities. Understanding what to expect and knowing that support is available can help women and their families cope with these changes.

The impact varies depending on the stage of disease, the type of treatment, and individual factors. Some women are able to continue working and maintain their usual activities during treatment, while others may need to make significant adjustments. It is important to communicate openly with healthcare providers about how the disease and treatment are affecting daily life so that appropriate support can be provided.

Physical Effects

Women with ovarian cancer may experience various physical effects related to the disease itself, surgery, and other treatments:

• Fatigue: Cancer-related fatigue is very common and can persist even after treatment ends. Rest, gentle exercise, and pacing activities can help manage fatigue.
• Digestive issues: Surgery and chemotherapy can affect digestion, causing nausea, changes in appetite, constipation, or diarrhea. Dietary modifications and medications can help.
• Early menopause: Removal of the ovaries causes immediate menopause, with symptoms including hot flashes, vaginal dryness, mood changes, and bone density loss. Hormone therapy may be an option for some women.
• Neuropathy: Some chemotherapy drugs can cause numbness, tingling, or pain in the hands and feet. This may improve after treatment ends but can be permanent in some cases.
• Changes in body image: Surgery scars, hair loss from chemotherapy, and weight changes can affect how women feel about their bodies.

Emotional and Psychological Impact

Receiving a cancer diagnosis and going through treatment can trigger a range of emotions, including fear, anxiety, sadness, anger, and grief. These feelings are normal and valid. Many women also experience:

• Worry about the cancer returning (fear of recurrence)
• Anxiety about treatment and its side effects
• Depression or feelings of hopelessness
• Stress related to changes in work, finances, or family roles
• Grief over losses related to fertility, sexuality, or life expectations

Psychological support from counselors, psychologists, or psychiatrists experienced in working with cancer patients can be invaluable. Support groups, whether in-person or online, allow women to connect with others who understand what they are going through.

Sexuality and Intimacy

Ovarian cancer and its treatment can affect sexuality and intimate relationships in multiple ways. Physical changes such as surgical menopause, fatigue, and body image concerns, combined with emotional factors like anxiety and depression, can impact sexual desire and function.

Specific issues may include vaginal dryness and discomfort during intercourse, decreased libido, and changes in how a woman perceives her body. Open communication with partners, along with support from healthcare providers (including gynecologists and sex therapists), can help couples maintain intimacy and adapt to changes.