This content provides you with information to help you better understand the signs, symptoms, risk factors, detection techniques, treatment choices, and post-treatment support linked to ovarian cancer.
Where are my ovaries?
The ovaries are part of a woman’s reproductive system. They are small, about the size of walnuts and are located in the pelvis. If you’re still having monthly periods, it’s your ovaries that produce the eggs for fertilization. Ovaries also produce the hormones progesterone and estrogen.
What are my ovaries made of and how do tumors develop?
A cancer begins when certain changes (called mutations) occur in a cell or cells. Normally, in adults, most cells only reproduce to replace worn-out cells and to repair damage. But some mutations cause cells to continue multiplying rapidly. The excess cells form a lump or growth. This lump is a tumor.
The ovaries are mainly made up of three kinds of cell and each type of cell can develop into a tumor. The most common form of ovarian tumor forms in the epithelial cells which cover the outer surface of the ovaries.
An epithelial tumor can be:
- borderline malignant
A benign tumor is non-cancerous and does not spread throughout the body. Most epithelial tumors turn out to be benign and are usually removed by surgery.
A borderline malignant tumor has the potential to be malignant. This kind of tumor tends to grow more slowly and is generally more common in younger woman. They are usually less life-threatening. Surgery is used to remove them and, as there is a small risk that they can return, you will be regularly checked.
A malignant epithelial tumor is cancerous and can spread throughout the body (metastasis). Most – about 90%- malignant ovarian cancers are epithelial. Treatment includes chemotherapy and surgery.
How common is ovarian cancer?
In the United States, ovarian cancer is the 2nd most common gynaecological cancer, affecting 1/70 women. It can develop at any age but is most commonly diagnosed in women between the age of 55-64, and the risk of developing ovarian cancer increases with age.
The disease is more common in White women, with 11.3 out of every 100,000 women affected. The incidence rate in Hispanic women is 9.8, in Asian/Pacific Islanders 9.0, African Americans 8.5 and American Indian/Alaska natives 7.9.
Ovarian cancer is the deadliest of all gynaecologic cancers and unlike other cancers which have seen reductions in the numbers of people dying of the disease, the mortality rates for ovarian cancer haven’t changed noticeably over the last forty years. While the disease affects fewer African American women than White women, the mortality rate is slightly higher in African American women.
Recent studies suggest that many ovarian cancers may, in fact, begin in the fallopian tube and then spread to the ovaries. Cancer cells from the fallopian tubes, ovaries and the peritoneum look the same under a microscope, so it is likely that the cancer is the same. This finding has an impact on risk factors and implications for prevention and treatment.
Signs and symptoms of ovarian cancer can be vague. They may include:
- bloating in your abdomen (tummy)
- pain in your pelvic area or abdomen
- the need to pee more often or a sudden and urgent need to pee
- losing your appetite or feeling full quickly
These symptoms are not specific to ovarian cancer, however, and can also be caused by many other less serious conditions. There are other symptoms, too, such as fatigue, pain during sex, constipation, back ache or changes to your usual monthly period. These can also be caused by other conditions and are not specific to ovarian cancer. Some women do not have any obvious symptoms and their tumor is discovered at a pelvic health check-up or an ultrasound examination for another problem.
Ovarian cancer is, in the United States, is the most fatal of all female reproductive cancers. Finding ovarian cancer early increases the chances of successful treatment but the majority of ovarian cancers are, sadly, discovered late. Symptoms are vague and both women and doctors may dismiss them as unimportant or misdiagnose them.
If you have any of the listed symptoms consistently – every day for a few weeks – or if you feel that something is not right in your pelvic or abdominal area, it’s important to speak to a doctor. Keeping up with your annual check-ups and screenings may also help to detect ovarian cancer at an early stage.
Ovarian cancer has three main types: epithelial, germ cell, and sex cord-stromal. Germ cell tumors are rare, and typically diagnosed in woman under the age of 30. Sex cord-stromal tumors are the least common ovarian tumor type, and often found early and are rarely malignant. They are more common in African- American women.
Epithelial tumors account for around 80% of all ovarian cancers. They can be divided into five subtypes. Each subtype can be categorized as Type I or Type II.
Sub-types of epithelial tumors
Characteristics: Less fatal than Type II; generally fewer symptoms; slow growth; originating in ovary
- Low-grade serous
- Clear cell carcinoma
Characteristics: More often fatal; often diagnosed late; linked to genetic mutations; originating in fallopian tube
- High-grade serous
High-grade serous epithelial ovarian cancer is the most common kind. High-grade cancers tend to grow and spread more quickly. More than 70% of all epithelial cancers are of this type and 90% of serous cancers are classified high-grade. It is often found late when the cancer is advanced.
Low-grade serous are less common – around 10% of serous cancers are of this type. Low-grade serous cancer has different causes, responds to treatments differently, and has a different effect on your health and body to high-grade serous epithelial cancers.
Mucinous cancer is rare. It can be benign, borderline malignant or malignant.
Endometrioid is the 2nd most common type of epithelial ovarian cancer Most cases of endometrioid ovarian cancer are diagnosed at an early stage and are low grade. Some women have endometrioid ovarian cancer and womb cancer at the same time.
Clear cell carcinoma accounts for between 6 -10% of ovarian cancers in the US. In countries like Japan and Korea, this type of ovarian cancer is much more common.
What is the cause of ovarian cancer?
We don’t know for sure what causes ovarian cancer but there are known risk factors associated with epithelial ovarian cancer. Less is known about the risk factors for the other ovarian cancers.
What is a risk factor?
A risk factor is anything that may affects your chance of developing a disease, or the disease coming back after treatment. A risk factor for ovarian cancer makes it more likely that you will develop the disease, or that it will come back after treatment. But it’s important to understand that a risk factor doesn’t mean you will definitely develop ovarian cancer – and some people who do develop the disease had no obvious risk factors.
Risk factors for epithelial ovarian cancer
Factors that lower the risk:
- Pregnancy and childbirth before age of 26
- Birth control (‘the pill’ in particular)
- Hysterectomy (removal of the womb and ovaries) in women with higher risk of ovarian cancer and those with endometriosis and fibroids
Factors that increase the risk:
- BRCA1 mutation carrier
- BRCA2 mutation carrier
- Family history of ovarian, breast or colorectal cancer
- The risk is 5% for a woman with a family history, compared to 1.6% average lifetime risk for a woman without a family history
- Having children later or not having children
- A 2009 study found that obesity was associated with an almost 80 percent higher risk of ovarian cancer in women 50 to 71 who had not taken hormones after menopause.
- Older age
- Long-term hormone replacement therapy (HRT) after menopause
Data from the American Cancer Society, 2023
The lifetime risk that any woman in the general population will develop ovarian cancer is about 1.6% To express this another way, out of every 100 women in the general population, between 1-2 will develop ovarian cancer in their life. Risk factors increases that chance.
Family history/genetic link
Having a close relative who has had breast cancer or ovarian cancer increases a woman’s risk of ovarian cancer. You may read the term Hereditary Breast and Ovarian Cancer Syndrome (HBOC), which is sometimes used to refer to this genetic link between family members.
The gene mutations involved in this genetic link are principally BRCA1, BRCA2 tumor suppressing genes and the MMR gene. A mutation in these genes can increase a woman’s risk of developing ovarian cancer from 1.6% to 40%, 18% and 10% respectively. If you have a close family member who has or had breast or ovarian cancer, tell your doctor, even if you do not have symptoms. He or she can do a genetic test to find out if you are more at risk of developing the cancer.
Some people have a higher genetic risk of ovarian cancer because of their ethnicity. Women from Ashkenazi Jewish, Polish, Icelandic, or Pakistani ethnic backgrounds should also be offered a genetic test.
Non-modifiable risk factors are those you can’t change. They include gene mutations, a family history of ovarian or breast cancer or your age. Many of the risk factors associated with ovarian cancer are non-modifiable. But while you can’t change your genetic make-up or your ethnicity, you can find out whether you are in a risk group with genetic testing. 20% of ovarian cancers are caused by genetic factors.
Surgery. Surgical prevention options are very successful in reducing ovarian cancer risk in women who are BRAC mutation carriers, but they are not appropriate procedures for everybody.
We now know that 70% of ovarian cancers begin in the fallopian tubes. If you do not plan to have any (more) children, it is possible to have surgery to remove your ovaries and/or your fallopian tubes which can reduce your risk of developing ovarian cancer. Removing your ovaries as well as your fallopian tubes is called a ‘bilateral salpingo-oophorectomy’. The removal of the ovaries will trigger menopause (which comes with its own challenges), so if this is unacceptable to you, it is possible to remove just the fallopian tubes.
Tubal ligation (the medical term for ‘’getting your tubes tied’’) is where your fallopian tubes are cut, tied or blocked. The procedure is often done as a form of permanent contraception, but it is also another option for women to reduce their risk of ovarian cancer. The risk reduction is similar to taken oral contraceptives for a number of years and may be suitable for women who know they do not wish to have any (more) children.
Modifiable risk factors are those you can do something about, such as smoking, obesity or your diet.
For many years there was a lack of evidence linking ovarian cancer risk and diet, but new research published in 2023 says that there is, in fact, a measurable link between a diet of ultra-high-processed food and developing – and dying of- ovarian cancer.
Ultra-high-processed food contains artificial colors or flavors, sweeteners, emulsifiers, and other additives and includes foods like boxed meals, hot dogs and burgers, pastries, doughnuts and cookies, sauces, dips and chips. It’s not clear exactly why this kind of food might increase the risks of ovarian – and breast – cancer, but there’s some evidence that certain food additives and chemicals may be negatively affecting female hormones.
What we also know is that a poor diet – one loaded with ultra-high-processed foods – has a relationship with increased weight, and obesity is also a modifiable risk factor for many diseases, including ovarian cancer.
If you are overweight or obese, try to reduce your portion sizes and what proportion of your diet is ultra-high processed food. In the US, 60% of a person’s daily calories come from these foods. Even small reductions can make a difference to your weight.
Because many ovarian cancers do not have obvious symptoms they are frequently diagnosed late. Keeping up with your pelvic health checks are important. And speak to your doctor if you notice any of the symptoms outlined above. These can include changes in your period (if you still have them), changes in how often you pee or poop or any pain or sensations of fullness in your abdomen after eating. Even a reduction in your appetite is worth mentioning to your doctor.
Some people have a higher genetic risk of ovarian cancer: if you are having a consultation about any symptom, tell your doctor if you have an Ashkenazi Jewish, Polish, Icelandic, or Pakistani ethnic background.
Physical examination – when you have a pelvic exam, your doctor or gynaecologist will feel the ovaries and uterus for their size and shape. While this can find other gynaecologic cancers, it is not so successful at finding ovarian cancer.
Blood tests – are not yet so useful for diagnosing ovarian cancer, though they will give a picture of your overall health and can be helpful when used in addition to other methods.
Biomarkers – A biomarker of cancer is anything (often a protein) produced by the body in response to cancer. Usually, a marker is found in a blood or urine sample or body tissue. A marker (often called a biomarker) can give important information about what treatment will be more appropriate for an individual and whether a treatment is working.
Your doctor may be looking for a biomarker of cancer, the CA125 tumor marker, but this is not so reliable when on its own. While CA 125 is raised in 80% of advanced epithelial ovarian cancers, it often seems normal when an ovarian tumor is at an early stage. Also, some other conditions of the womb and ovaries also produce CA125. It is also raised when a woman is pregnant.
Another marker, the ‘human epididymis protein 4’ is also used before starting treatment for epithelial ovarian cancer and after treatment, to monitor how successful the treatment has been. Both markers used with transvaginal ultrasound may be useful to diagnose some ovarian cancers, but they cannot find them all.
Different markers relate to germ cell tumors and stromal tumors.
Transvaginal ultrasound – Transvaginal ultrasound uses sound waves to look at the uterus (womb), fallopian tubes and ovaries. The doctor uses a tool called an ultrasound wand, which is inserted into the vagina. It uses sound waves to give an image of your organs, which is viewed on a computer screen. Depending on where you live, the test can be done by your gynaecologist in their office, meaning a hospital visit isn’t necessary. While it’s useful as it can help to see an ovarian tumor, ultrasound cannot distinguish between benign or malignant tumors.
Computer Tomography (CT) scan – A CT scan is a form of radiography. It can see larger tumors and is also used to perform a biopsy to see if a cancer has spread (metastasis). For this, a CT-guided needle biopsy is done.
Laparoscopy – Laparoscopy is a kind of surgical investigation known as ‘minimally invasive’. It is often performed as a day hospital procedure and should take 1-2 hours. A few small incisions are made in your lower abdomen and a tiny camera is put through. The images of your ovaries and other gynaecological organs are displayed on a video monitor. You will be given a general anaesthetic for this procedure so will be asleep when it’s done.
This technique is also sometimes used to perform a biopsy and for understanding how advanced the cancer is, after is has been diagnosed (staging).
Tissue biopsy is the most effective method of diagnosing ovarian cancer. For ovarian cancer, biopsies are usually done during a surgical procedure called a laparotomy. This involves one large cut in your abdomen. During the procedure, a biopsy is taken, and the tissue sample is tested. If cancer is found, the surgeon will remove it.
Depending on where the cancer is, and if it has spread, it may be necessary to remove your fallopian tubes and your uterus, as well as your ovaries, during the laparotomy. This is called a hysterectomy. This will be explained to you before your go into the operating room and you will need to give your consent.
Staging is a description of how large the tumor is, if and where it has spread, and what other parts of the body are affected. This information comes from tissue biopsy. Knowing the stage of the cancer can help your healthcare team decide whether to begin treatment and what treatment may be beneficial for you.
The 2 systems used for staging ovarian cancer are the FIGO (International Federation of Gynecology and Obstetrics) system and the AJCC (American Joint Committee on Cancer). Staging is complex and more detailed information can be found on the website of the American Cancer Society.
Ovarian cancer stages range from stage I (1) through IV (4), with stage 1 being an early-stage and stage 4 a cancer that has spread to other parts of your body. Most ovarian cancers are stage 3 when they are found.
Unlike many other cancers, the vague, non-specific symptoms of ovarian cancer mean that screening is very difficult. In the past, the tumor marker CA125 was used as a screening method for ovarian cancer but it is not reliable and is no-longer a recommended method. It is used instead to monitor changes to the cancer after treatment.
Keeping up with your pelvic health checks, speaking to your doctor if you experience symptoms that seem unusual for you or last longer than usual, and asking for a genetic test if you fall into a risk group. This is particularly important if you have a close relative who has had breast cancer or ovarian cancer, or you have an ethnic background that increases your risk.
If you have ovarian cancer, treatment options include surgery, chemotherapy or newer drugs called targeted therapies. Which treatment is best for you depends on the size and stage of your cancer and which type of ovarian tumor you have, though most women will have surgery and chemotherapy.
Debulking Surgery – When ovarian cancer has spread into the surrounding tissue of the abdomen, surgeons will generally perform a procedure called debulking surgery. The aim is to remove as much of the cancer as possible, and to leave no tumor larger than 1cm in size.
During debulking surgery, the surgeon may decide it is necessary to remove other gynaecological organs or parts of other organs. This is called cytoreduction. This may include a part of your colon, a part of your small intestine or a part of your bladder. This may sound frightening, but in many cases the surgeon can repair the organ and any discomfort should be temporary. The decision to remove other organs or parts of organs is made if the cancer has spread.
You will need to give consent to this before surgery, and your healthcare team should explain this possibility to you and be available to answer your questions. It can be a frightening time, but to maximise the chance of recovery, it’s important to understand that all cancerous tissue is removed at this time.
Unfortunately, it is not always possible to remove all affected tissue and there are many reasons why a surgeon may decide it is not an appropriate thing to do. Often a laparoscopy is done first to make sure that debulking surgery will be useful.
For low-grade (Stage 1) tumors, if you want to have children, it may be possible to remove only the affected ovary and fallopian tube. This may also be possible if you have stomal or germ cell tumor. You should be able to discuss this with the surgeon before the procedure.
Neoadjuvant therapy – Advanced epithelial ovarian cancer can sometimes be treated with neoadjuvant therapy before surgery. ‘Neoadjuvant’ means a treatment or procedure given before the main treatment. The objective is to shrink the tumors before surgery. Whether neoadjuvant therapy is offered to you depends on many factors, including how advanced your tumor is, your state of health or whether your hospital think it has any benefits.
The same kind of chemotherapy drugs are used for neoadjuvant therapy and the chemotherapy that a woman will receive after surgery.
Chemotherapy – Most women diagnosed with ovarian cancer will receive either …
- Surgery followed by 6 cycles of intravenous (IV) chemotherapy or
- 3 cycles of neoadjuvant chemotherapy, followed by surgery and 3 more chemotherapy cycles.
Standard chemotherapy drugs are paclitaxel and carboplatin, though other drugs are also used.
Mostly, you receive chemotherapy either intravenously (directly into a vein) or sometimes orally (as a tablet).
Targeted therapies – Targeted therapies are also used to treat ovarian cancer. These newer drugs work by ‘targeting’ the proteins that cause cancer cells to grow and divide. There are many different types but for ovarian cancer, so-called PARP inhibitors have shown promising results. There are many different PARP inhibitor drugs, but all are generally used with chemotherapy. Olaparib (Lynparza), rucaparib (Rubraca), and niraparib (Zejula) are some of the most common PARP inhibitors. Research is on-going to find out how best to use these drugs. The downside is that they are expensive.
Radiation therapy – Radiation therapy is rarely used for ovarian cancer as surgery and chemotherapy are more effective.
Many women with ovarian cancer, particularly if the cancer was discovered early, respond well to treatment.
Sadly, many ovarian cancers are advanced when they are first discovered, and treatment may not be successful. And for some women, the cancer reoccurs (this is often called a relapse). Treatment is available and will usually be chemotherapy again (second-line treatment) or in some cases, surgery. Surgery at this stage may well be palliative. Palliative means it is done to reduce pain and not to cure.
Tests and follow-ups – after treatment should include regular (every 2-4 months) pelvic examinations and physical examinations. Blood tests should also be done regularly. Your doctor may propose imaging such as a CT or MRI exam.
Self-care – It is very important to remain aware of any changes in your body and report them to your doctor if they concern you or are recurrent (happening 12 times a month every month.) Changes might include feeling bloated or suddenly having constipation that doesn’t get better or diarrhoea. You might feel pain in your abdomen or your lower back that keeps coming back or lose or put on weight unexpectedly.
Support – Having a strong support system, including family, friends, and healthcare providers, can make a significant difference in the journey of battling ovarian cancer. It’s essential to stay informed about your condition, ask questions, and actively participate in your treatment decisions.
You may prefer to talk to someone outside of your family about your concerns, such as your specialist nurse, primary care physician, or a religious or spiritual leader. If you prefer to talk to someone you don’t know, but who understands what you are going through, your healthcare team may be able to refer you to a counselor. Some cancer charities offer free telephone or online support, too.
Sharing – Finding others in a similar situation to you can be an important source of psychological support. Your specialist nurse may know of local support or patient advocacy groups that you can go to. Groups like this can be a huge help for some people.
With online forums and patient groups, finding other people with the same condition as you is easier than it used to be. A lot of people prefer to make contact online because it’s anonymous Always remember that you are not alone, and there are resources and organizations like the Tigerlily Foundation available to provide guidance and support.
Side effects of chemotherapy
Chemotherapy targets cancer cells, but it also affects the healthy cells in your body, and this causes side effects. There are many different side effects of chemotherapy, some are temporary, others last longer. Some side effects may appear long after treatment has finished. Many cancer associations have detailed information on the side effects and how to manage them.
The side effects of chemotherapy can impact your closest relationships and can have an immediate impact on intimacy with a partner. Some of the side effects include:
- Fatigue. Extreme tiredness that makes you struggle with your day-to-day activities, including your sexual life. Nearly everybody receiving chemotherapy will experience fatigue.
- Body image. Chemotherapy can cause a temporary loss of head and body hair, eyebrows, eyelashes and pubic hair. You may feel unattractive, and your self-confidence may be low.
- Infections. Chemotherapy affects your body’s immune system, and you are more likely to develop infections, including vaginal thrush.. You may feel anxious about this, and you may want to avoid intimacy as a result.
- Nausea. Chemotherapy can make you feel nauseous; you may also be physically sick. In addition, you may experience stomach aches and diarrhoea.
Side effects of surgery
There is an emotional impact as well as physical impact after surgery to remove a woman’s gynaecological organs.
In younger women, the removal of both ovaries triggers an immediate surgical menopause. Surgical menopause means that the menopause is caused by the surgery. Symptoms of the menopause can begin very quickly. The rapid onset of the menopause can be very distressing for many women, particularly as they are also dealing with worries about the cancer.
Symptoms of the menopause include hot flushes and night sweats, difficulty sleeping, brain fog, mood changes, joint and muscle pain, vaginal dryness and urinary symptoms. Many of these symptoms have an impact on a women’s desire for intimacy.
Your healthcare team should discuss ways to manage these symptoms before you have treatment and put in place an individualised plan, guided by your medical history. There are an increasing number of dedicated menopause websites where you can find advice and suggestions of therapies and approaches to relieve some of the symptoms of menopause.
Fertility loss after treatment can be devastating for some women and their partners and counselling is often offered to women in this position. Always ask about your fertility options if future pregnancy is important for you. However, you need to understand that even if fertility preservation is possible, it may be time consuming or may not be appropriate for you if your cancer could spread quickly.
Effects of a hysterectomy. A hysterectomy, which is the removal of the uterus, can lead to a loss of sexual pleasure as some women feel the uterus muscles contract strongly during orgasm. A hysterectomy can also result in a shortening of the vagina which can result in sex feeling different or difficulty getting aroused or to orgasm.
Navigating intimate relationships
Cancer has a profound effect on relationships. Stronger relationships tend to survive a cancer diagnosis, though the changing family dynamics and the impact on finances and job security are a heavy burden for many people. Many partners say they feel helpless or powerless to make things better and instigating intimacy after treatment can seem impossible out of fear of getting it wrong or of hurting or being hurt. The avoidance of intimacy is often the result.
Keeping lines of communication open is key, though it isn’t always easy. Some people find they cannot cope with what has happened and the impact of what has happened on the relationship and so they emotionally withdraw. Having a support network is essential – for both parties.
An invaluable piece of advice after cancer treatment is to find new ways of expressing intimacy. Cuddling, touching, stroking– anything that you would only do with your partner can count as being intimate.
One source of help and support that many women and their partners find extremely helpful is relationship therapy. Even if you and your partner had good lines of communication before your cancer, you may need the extra help that a therapist can give. Relationship therapy can be very helpful to reestablish the connection and the trust between partners.
Myth: Ovarian cancer is particularly common in premenopausal women
Fact: Ovarian cancer is more frequently diagnosed in women between the ages of 55-64. The risk increases with age.
Myth: There are no risk factors for ovarian cancer
Fact: There are both modifiable and non-modifiable risk factors. Modifiable risk factors are things you can do something about. They include smoking, your diet and being overweight.
Myth: A PAP smear can detect ovarian cancer
Fact: A PAP smear can detect cervical cancer, but it cannot detect ovarian cancer. There is no specific examination to find ovarian cancer in its earliest stages.
Myth: Ovarian cancer is a symptomless disease
Fact: While it is true that many of the symptoms of ovarian cancer are non-specific – which means they can be symptoms of other conditions too –many women notice signs such as a sensation of fullness or pressure in the abdomen, swelling or bloating, constipation, needing to pee urgently, or pain in the pelvic area. Women are encouraged to see their doctor if they have changes like these that occur every day for a few weeks.
Myth: Ovarian cancer cannot be successfully treated
Fact: When ovarian cancer is caught early, it has a good prognosis, with a 5-year survival rate of 92.4%. Even some-stage ovarian cancers can have good treatment outcomes. Treatment options, particularly in the area of targeted therapies are improving all the time.
We hope this content provided education and guidance. Remember to stay informed, make educated choices early, and have a good relationship with your health care team – whether or not you’re dealing with a health issue.