Early Ovarian Cancer Symptoms and Fertility-Sparing Surgery

The early symptoms of ovarian cancer are vague: bloating, gastritis and feeling full after small meals. When these last more than two weeks and do not settle with medication, they need investigation, starting with an ultrasound. Because the disease rarely causes specific symptoms early, about 75% of ovarian cancers are diagnosed at an advanced stage, which is why it is called the silent killer.

Dr. Punyashree R M, a consultant gynaecological oncosurgeon and robotic surgeon at Fortis Hospital, CG Road, Bangalore, sets out the tumour types, the risk factors that can be modified, the symptoms and tests that catch the disease earlier, and how surgery, chemotherapy and fertility preservation are combined. The other gynaecological cancers are covered in the complete guide to gynaecological cancers.

Types of ovarian cancer

Ovarian malignancies are either primary tumours arising from the ovary or metastatic tumours that have spread to the ovary from elsewhere. Primary tumours fall into three families:

The distinction matters because it changes the tumour markers requested, the operation offered and, above all, whether fertility can be preserved.

Ovarian cancer causes and risk factors

Age is the most common risk factor, and most cases arise from sporadic rather than inherited mutations.

The incessant ovulation theory

Each time an egg is released, the surface of the ovary is injured and then repaired. The incessant ovulation theory holds that a lifetime of uninterrupted ovulation means many cycles of injury and repair, and with them more chances for a mutation to arise. That is why factors that increase the number of ovulations raise the risk: nulliparity, early menarche and late menopause.

Other causes

• Sporadic mutations: in Dr. Punyashree's figures, about 85% of cases arise from spontaneous mutations.
• Genetic and familial tendency: 5 to 15% of cases.
• Exogenous hormones: subfertility treatment and hormone replacement therapy can change ovarian cells.
• Age: the most common risk factor.
• Lifestyle and gynaecological history: smoking, obesity and endometriosis.

Why family history must be taken in detail

Dr. Punyashree urges every woman to know her family history: which relatives had cancer, whether first, second or third degree, which cancer, at what age, and whether anyone had more than one cancer. That history can point to an inherited mutation, which can then be tested for in the next generation so that risk-reducing procedures can be offered to carriers.

How the risk of ovarian cancer can be reduced

Tying or removing the fallopian tubes lowers the risk of ovarian cancer. The other protective factors are multiparity, breastfeeding, hysterectomy and oral contraceptive pills. Long-term use of combined oral contraceptives roughly halves the risk of ovarian cancer.

The fallopian tube connection

The fallopian tube is now recognised as the site where many ovarian cancers, particularly high-grade serous cancers, actually begin: abnormal cells start in the tube and spill onto the ovary. This explains why tubal ligation lowers the risk of ovarian cancer.

It also underpins a practice Dr. Punyashree recommends: opportunistic salpingectomy. When a woman in her forties who does not want further children undergoes a myomectomy or a hysterectomy, the surgeon can remove both fallopian tubes while leaving the ovaries in place. The ovaries continue to function, and the tissue from which many ovarian cancers arise is gone.

Early symptoms of ovarian cancer: the two-week rule

Bloating, gastritis or early satiety that lasts more than two weeks and does not improve with medication needs investigation. That is Dr. Punyashree's rule, and the reason is simple: these vague symptoms, when they persist, can be caused by ovarian cancer. The most common early symptoms are:

• Bloating
• Gastritis or indigestion
• Early satiety, feeling full after eating little

As the disease advances, symptoms become more specific:

• Persistent pelvic or abdominal pain
• Abdominal distension from ascites (fluid in the abdomen) or from the mass itself
• Frequent urination or constipation, from pressure on the bladder and rectum
• Acid reflux
• Breathlessness, if a pleural effusion develops
• Weight loss and extreme tiredness
• Back pain and pain during intercourse

Menstrual disturbance is a specific clue. Granulosa cell tumours secrete oestrogen and can cause postmenopausal bleeding in older women or heavy menstrual bleeding in women of reproductive age.

On examination, the clinician may find a hard mass arising from the pelvis or an adnexal mass on vaginal examination, ascites, or a pleural effusion on auscultation. Rarely, an enlarged inguinal lymph node is present. The supraclavicular lymph nodes should always be examined.

How ovarian cancer is diagnosed

Imaging

Ultrasound comes first. The next step depends on what it shows:

• A mass confined to one ovary within the pelvis: MRI with contrast is the best modality to characterise the lesion.
• Ascites, omental stranding or bilateral tumours: a higher level of imaging is needed, either CT of the thorax, abdomen and pelvis, or PET-CT.

A chest X-ray is always obtained to look for pleural effusion.

Tumour markers by age and tumour type

Tumour markers are blood proteins that some tumours release in raised amounts. The basic panel is CA-125, CEA and CA 19-9. The panel then changes with the patient:

• Adolescents, young adults and women of reproductive age: add alpha-fetoprotein (AFP) and beta-hCG to rule out germ cell tumours.
• Heavy menstrual bleeding with an ovarian mass, or a thickened endometrium with an adnexal mass: suspect a granulosa cell tumour and request inhibin.

Ovarian cancer treatment

Ovarian cancer is treated mainly with surgery and chemotherapy, and the operation depends on the stage and on whether the woman wants to preserve fertility.

Early stage disease

Finding ovarian cancer at an early stage is rare, and it is the best outcome a patient can have. For a woman who has completed her family, the operation is a complete surgical staging: hysterectomy with removal of both ovaries and tubes (bilateral salpingo-oophorectomy), total omentectomy (removal of the omentum, the fatty apron of tissue that hangs over the bowel), pelvic and para-aortic lymph node dissection, peritoneal cytology and peritoneal biopsies.

Advanced disease: primary or interval surgery

For advanced disease, the choice depends on the patient's performance status:

• Primary cytoreductive surgery: removing all visible disease at the outset, or
• Neoadjuvant chemotherapy followed by interval debulking surgery: shrinking the disease with chemotherapy first, then operating.

When the surgeon can achieve complete cytoreduction (CC-0, or R0, meaning no visible disease remains), Dr. Punyashree's team also offers HIPEC, hyperthermic intraperitoneal chemotherapy, in which heated chemotherapy is circulated through the abdomen in the same sitting. Adjuvant chemotherapy follows. In her account, this approach improves five-year overall survival and reduces recurrence. In international guidelines, HIPEC is an option mainly at interval surgery after neoadjuvant chemotherapy for stage III disease, based on the OVHIPEC-1 trial.

Radiotherapy has little role in ovarian cancer. Chemotherapy with paclitaxel and carboplatin is the standard treatment for epithelial ovarian cancer. The cost of cancer surgery for women travelling for treatment is set out on the cancer surgery cost page.

Fertility-sparing surgery for ovarian cancer: who qualifies

Fertility-sparing surgery is an option in early ovarian cancer in young women, but only after several conditions are met. In Dr. Punyashree's practice:

1. The woman wants to preserve fertility.
2. The disease is early, ideally stage IA: confined to one ovary, with no peritoneal deposits and no malignant cells in any ascites.
3. The other ovary is confirmed clear. Imaging can miss surface deposits, so the team may perform a diagnostic laparoscopy and biopsy the other ovary. Even when imaging shows disease confined to one ovary, this assessment is made before deciding.
4. The tumour type is favourable. Germ cell tumours, sex cord-stromal tumours and epithelial tumours are weighed differently.

Germ cell tumours are the clearest case. These tumours, common in young women, are highly chemosensitive and, in her words, melt with chemotherapy, so her team always offers fertility-sparing surgery for them. The operation removes the affected ovary and the lymph nodes on that side, with an infracolic omentectomy, peritoneal biopsies and cytology, and a biopsy of the other ovary to establish the stage. Chemotherapy follows for most tumours beyond stage IA; low-risk stage IA tumours, such as stage IA dysgerminoma, can be managed by surveillance alone. If the tumour burden is not reduced, chemotherapy alone may not suffice, and both surgery and chemotherapy may be needed.

For other tumour types, the patient is told plainly about the complications and risks of not undergoing complete staging, and the decision is tailored to her.

Egg freezing before chemotherapy

Because chemotherapy can suppress ovarian function, Dr. Punyashree's team always tells patients about egg freezing (oocyte cryopreservation) before adjuvant treatment begins. The team works with a fertility specialist, explaining the planned chemotherapy, so that eggs can be frozen until treatment is complete. The aim is an informed choice made by the patient before fertility-sparing therapy is offered.

Ovarian cancer follow-up and prognosis

After treatment, follow-up runs on a fixed schedule:

• Every three months for the first two years
• Every six months for the next three years
• Once a year after five years

Each visit combines the history, a clinical examination and tumour markers. Based on these, the team decides whether a simple ultrasound is enough or a higher imaging modality is needed.

Five-year survival depends on the stage at diagnosis, the patient's age and performance status, and the tumour type. Since stage is the factor that early recognition can change, the two-week rule for persistent bloating and gastritis is one of the most practical tools a primary care doctor has.

Her answer to a question from Ethiopia on fertility-sparing surgery is on the Live Discussion page. Endometrial cancer, which shares risk factors such as nulliparity and early menarche, is covered in endometrial cancer and the 4 mm endometrial thickness rule. Dr. Punyashree's profile is at Dr. Punyashree R M.