Welcome to the Speaking of Women's Health podcast.

I'm your host, dr Holly Thacker, the Executive Director of Speaking of Women's Health, and I'm back in the Sunflower House for a new episode of the Speaking of Women's Health podcast, and it's September 2025, and September is Ovarian Cancer Awareness Month.

Cancer of the ovary strikes fear into most all women, and it's actually the second most common gynecologic malignancy and when found in an early stage, it can be cured up to 90 to 95% of the time.

I have many ovarian cancer survivors in my practice.

Your risk of ovarian cancer gets higher if there is a family history, like in a mother or a sister or even a daughter.

Unfortunately, ovarian cancer is hard to detect and there's no screening test, and many cases of ovarian cancer are found after the cancer has spread to other organs, and in these cases the cancer is much harder to treat and to cure.

So you might ask what causes ovarian cancer?

Well, we don't know, but we do know it can increase the risk.

Certainly there is hereditary types of ovarian cancer, meaning it can run in the family, and so you really want to know your family history, your biological family history mother, sister, daughter.

The risk gets higher the more relatives that you have with ovarian cancer and you can have an increased risk for ovarian cancer on the father's side, the paternal side.

So it is important to know your father and his blood relatives history.

If you have a family history of other types of cancers, like colorectal cancer, breast cancer, that can be associated with an increased risk of ovarian cancer, because these cancers can be caused by an inherited mutation or change in certain genes that cause a family cancer syndrome.

That can increase the risk of ovarian cancer.

That can increase the risk of ovarian cancer.

Women who have never been pregnant or if they have their first full-term pregnancy after age 35, or who were never able to carry a pregnancy to term, also have a higher risk of ovarian cancer.

If you're over the age of 50, the likelihood of developing ovarian cancer increases with age.

Like most cancers, if you carry the BRCA gene, mutations in BRCA1 and BRCA2 are responsible for most, but not all, of the inherited ovarian cancers.

For most but not all of the inherited ovarian cancers, mutations in BRCA1 and 2 are about 10 times more common in those who have an Ashkenazi Jewish descent than those in just the general United States population.

The lifetime ovarian cancer risk for women with BRCA1 is estimated to be between 35% and 70%, which means if 100 women have BRCA1, there's going to be 35 to 70 of them who would get ovarian cancer.

For women with BRCA2 mutation, the risk has been estimated between 10% and 30% by age 70.

Estimated between 10 and 30% by age 70.

And these mutations increase the risk for primary peritoneal carcinoma and fallopian tube carcinoma.

In comparison, the average population, the ovarian cancer risk for females is less than 2%.

Now, if you haven't heard the prior podcast that I did with a medical breast specialist, dr Holly Peterson, on big gene mutations, intermediate gene mutations and lesser gene mutations, that's a really good podcast to go back and listen to.

Also, at the beginning of season three in January, I did an interesting podcast with genetic counselor Ryan Noss on the GINA law.

So if you or a loved one has a genetic mutation and you have offspring, that's really critically important to understand the GINA law and perhaps the best time for testing Now.

Other risk factors for ovarian cancer is being overweight or having a very high BMI.

Obesity has been linked to a higher risk of developing many cancers, including uterine or endometrial cancer.

The current information available for ovarian cancer and obesity is not as clear Obese women that have a body mass index of at least 30, which is considered obese, most likely have a higher risk of developing ovarian cancer, but not necessarily the most aggressive types, like the high grade serous cancers.

Obesity may also negatively affect the overall survival of a woman with ovarian cancer, just like with any medical condition metabolic syndrome, diabetes, hypertension, sleep apnea all of these things tend to compound when there's too much visceral body fat.

Now, talcum powder has been linked to ovarian cancer.

And, importantly, what are some of the things that you can do to lower your risk of ovarian cancer?

If you don't yet have ovarian cancer, if you've got women in your life that you're concerned about, certainly, studies show that women who have children and who breastfeed, as well as who use hormonal contraceptives like estrogen, progesterone pills, patches or a vaginal ring, are much less likely to develop ovarian cancer, because these factors decrease the number of times that a woman ovulates, and studies suggest if you reduce ovulation, you can reduce the risk of ovarian cancer.

So, pregnancy and breastfeeding Women who have been pregnant and carried the baby to term before age 26 have a lower risk of ovarian cancer than women who have not, and that's true with breast cancer, especially under the age of 18 to 20.

And breastfeeding may lower the ovarian cancer risk further because it stops ovulation many times for several months Not always, and usually once solids are introduced, by six months, there is ovulation.

Now, interestingly, women who've used hormonal contraceptives.

So we're not talking about the IUD, we're not talking about the diaphragm or spermicides.

We're talking about using something that has an estrogen and a progestin in it that inhibits ovulation, and this risk is lower the longer the time pills are used and it continues for several years after the pill is stopped.

Now other forms of birth control, like tubal ligation, especially complete removal of the tube, salpingectomy dramatically reduces the risk of ovarian cancer.

In fact, in women at high risk for ovarian cancer but who are still just a little too young to lose their ovaries, many times they'll undergo complete salpingectomy.

Many times they'll undergo complete salpingectomy.

Maybe use of certain intrauterine devices may be associated with slightly lower risk of ovarian cancer, but not as consistently and the data is not as robust as with hormonal contraceptives.

So incessant ovulation isn't really what the body was designed to do.

Incessant ovulation isn't really what the body was designed to do.

Now, if you have a hysterectomy and you remove the uterus but leave the ovaries, but take out the tubes.

This also does reduce ovarian cancer.

Menopause itself does not cause ovarian cancer, and neither does taking menopausal hormone therapy.

Now what are the symptoms of getting ovarian cancer?

Well, early on there may be very few symptoms.

The first sign may be a slightly enlarged ovary.

The ovaries are located deep within your pelvic cavity, so a lot of times swelling is not noticed until it's more advanced.

Women typically seek care when they notice abdominal swelling due to fluid that accumulates in the abdomen.

Some women may notice urinary changes such as increased frequency or discomfort with urination.

Now, most urinary frequency and pain with urination is from bladder infections or other bladder problems, but one always has to think about ovarian cancer.

Symptoms of more advanced ovarian cancer include a swollen abdomen caused by buildup of fluids produced by the tumor, lower abdominal and leg pain, a sudden weight loss or weight gain, nausea, swelling in the legs and change in bowel or bladder function.

Also, women with ovarian cancer may complain of abdominal bloating, gas, heartburn, intolerance to certain foods or what we call early satiety, kind of getting filled up a little too fast.

When these symptoms occur, many times the tumor has spread outside the ovary.

Tumor has spread outside the ovary and unfortunately, despite a lot of common urban myths, there is no reliable screening test for ovarian cancer.

So we're getting down to how can you protect yourself from getting ovarian cancer?

And you have been listening to the Speaking of Women's Health podcast.

I'm your host, dr Holly Thacker, in the Sunflower House in September of 2025.

September is Ovarian Cancer Awareness Month and we're talking about how one can protect themselves from ovarian cancer and it's not easy, but there are steps that you can do to be proactive.

Get a regular pelvic exam.

If you have any irregular vaginal bleeding or abdominal pain or discharge, you need to bring it to your women's health clinician's attention.

You also need to bring it to your healthcare team's attention if there's a close family member, like a mother, sister or daughter or grandmother, with ovarian cancer.

Discuss your risk factors with your physician.

Do not use talcum powder on or near the vulva or vagina.

Eat a heart.

Healthy whole food diet healthy whole food diet.

And if you're not planning pregnancy or breastfeeding, talk to your healthcare clinician about extended use of hormonal contraception to reduce the risk of ovarian cancer.

Make sure you tune into our future podcast with nurse practitioner Dana Leslie, where we're going to talk about how we profile different types of hormonal contraceptives and just contraception in general, depending on the woman's profile.

And then if you have the BRCA gene or a strong family history, you may need to be referred for genetic counseling.

And even if your genetic counseling is negative, if there is a strong family history of ovarian cancer, you may want to consider removal of the tubes and the ovaries after completing your family after age 40.

Removing the ovaries before age 40, even with estrogen therapy, does still confer some increase in neurologic problems.

So ideally we like women to make it to age 40.

Now there is a survival advantage to keeping your ovaries up to age 65, unless there's BRCA gene, diseased ovaries or a family history of ovarian cancer and it's kind of an individual decision.

And so if a woman is over 65, especially if she knows she's going to take a systemic or vaginal estrogen, post hysterectomy and oophorectomy, estrogen post hysterectomy and oophorectomy I usually recommend, if they're in there and you're over 65 or you don't know what your family history is, to go ahead and take the ovaries.

But under that age 65, even if you're in menopause, there's still substances that the ovaries make.

So we don't go around just doing ovary removal on all women who are past childbearing.

Now for some women and also it depends on the family history of the onset of breast and ovarian cancer, but sometimes with BRCA1, it's recommended to even take the ovaries and tubes before the age of 40.

Now if you're going to undergo removal of ovaries and tubes and you're not planning to have in vitro fertilization to carry a pregnancy, I usually will recommend that the uterus be taken out at the same time, because then you can just give estrogen, and estrogen alone reduces breast cancer.

Now it does take a little bit longer surgery and of course, each case is unique and you need to speak to your gynecologic oncology surgeon.

And this podcast is not medical advice.

It's just giving you information to empower you to be strong and be healthy and be in charge.

But I have a number of women post ovary and uterus removal.

Some of them have had abnormal PAPs that progress, or fibroids or adenomyosis, which is the lining of the uterus growing into the muscle, and they already have a diseased uterus and they already know they want to be on hormone therapy.

And keeping the uterus in means that we have to use progestin or progesterone or something to prevent any stimulation of the lining of the uterus and we have to be a lot more stingy with the menopausal hormones and castrated women, ie women who've had their ovaries removed and are castrated, have no estrogen, no ovarian hormones, tend to have more intense menopausal symptoms, particularly if they're younger, and I've even had women who've had benign ovarian tumors removed for struma ovarii, which produce extra androgens, and they never had a hot flash in their life.

And then at age 72, after both ovaries are removed, they have terrible hot flashes because the ovarian tumor was producing testosterone which got converted to estrogen and body fat.

So they never were estrogen deficient until they had their ovarian tumors removed.

So some ovarian tumors are hormone producing, many are cancers of varying degrees, some very aggressive, some not as much.

And then there is a class of ovarian tumors called dermoid tumors, where the ovary cells differentiate into other types of tissue.

There may be cartilage or hair or even teeth in the tumor, and usually these are removed just based on size or bulk symptoms.

But sometimes they're observed.

So what are the stages of ovarian cancer?

If you're diagnosed with ovarian cancer, the first thing the physician usually likes to try to figure out is how far it's gone, if it's spread.

This medical term is called staging.

The stage of a cancer describes how much cancer is in the body.

It helps determine how serious the cancer is, how best to treat it, and doctors also usually use the cancer stage when talking about general survival statistics.

So ovarian cancer stages range from stage one through four.

As a rule, the lower the number, the less the cancer has spread, and the higher the number like stage four usually means it's spread more and it's metastatic.

Although each woman's ovarian cancer experience is unique, cancers with similar stages tend to have similar outlooks and many times are treated in much the same way.

Now the goals of surgery for ovarian cancer is to take tissue samples to get the diagnosis and the stage To stage the cancer.

Samples of tissues are taken from different parts of the pelvis and abdomen and examined in the lab, and the factors to stage or classify ovarian cancer include the size of the tumor, which is T.

Has the cancer spread outside the ovary or the fallopian tube?

Has the cancer reached nearby pelvic organs like the uterus or bladder?

Has the cancer spread to lymph nodes?

N.

Has the cancer spread in the pelvis or around the aorta, which is the main artery that runs from the heart down through the back of the abdomen and pelvis?

These are called para-aortic lymph nodes.

And then, finally, has there been spread or metastasis to distant sites, which is labeled M.

So usually the tumor gets a T, n and an M rating.

Has the cancer spread around the lungs, which can cause fluid, or to distant organs like the liver or bones?

Sometimes, if surgery is not possible right away, the cancer will be given a clinical stage instead of anatomic surgical stage, and this is based on the physical exam, the biopsy and then the imaging test.

So, moving on to treating ovarian cancer, most women suspected of having ovarian cancer usually will have a mass on either exam, ultrasound or CAT scan, which is computed tomography CT scan.

Any woman with a new mass should undergo a preoperative workup, including blood tests for CA-125 and a CAT scan, if not previously done, and the main treatments for ovarian cancer usually involve a combination of both surgery and chemotherapy.

Chemotherapy is strong medicine given through an intravenous line to help kill the cancer cells.

Unfortunately, chemotherapy many times can kill off regular cells, especially fast-growing cells, like in the GI tract, the skin, the hair.

Sometimes debulking surgeries perform before chemo and other times it happens afterwards.

So your individual treatment plan depends on a lot of different factors, including your overall health, your personal preferences, whether you want to plan to have children if you haven't had children already.

Age alone is not a determining factor, since several studies have shown that older women can tolerate the ovarian cancer treatments just as well.

So it's important to discuss all of your treatment options, including goals and side effects, with your team to make the decision that best fits your needs.

It's a scary time.

It's important to write down your questions and to get answers to anything that you're not sure about, and some people, especially if time permits, may want to seek a second opinion to give them more information and feel more confident about the treatment plan you choose.

Many women feel very confident with their expert gynecologic oncologist and want to get right to treatment.

Local treatments.

Some are local, meaning they treat the tumor without affecting the rest of the body, so local treatments include general pelvic surgery as well as localized radiation therapy.

Surgery for ovarian cancer is complex.

In most cases, the surgical treatment involves removal of the uterus, both ovaries, the fallopian tubes, nearby lymph nodes and the omentum, which is the fatty apron attached to the large intestine.

The surgeon will remove as much of the tumor as possible, and this is a medical process known as quote debulking.

The procedure can be done in the traditional manner through an open incision in the abdomen.

In certain cases it's done laparoscopically, through a very small incision using a laparoscope.

The ability to perform comprehensive staging and removal of the largest bulk of the tumor has been shown to be best performed by a specialist in gynecologic oncology, so that's someone who's gone through medical school and then an OBGYN residency and then a surgical fellowship in GYN oncology.

In young women with low-grade tumors who still want to have children, sometimes only the diseased ovary is removed, with the remaining ovary watched closely for signs of cancer through imaging labs and physical exam.

If the tumor has spread throughout the abdominal cavity, women sometimes require removal of part of the intestines to remove as much a visible tumor as possible.

And removing the intestines, especially if it's the lower ileum, can affect B12 absorption and can come along with other concerns.

Systemic treatments Some of the drugs or medications used to treat ovarian cancer are systemic therapies because they can reach the cancer cells almost anywhere in the body.

They can be given by mouth or put directly into the bloodstream, and they may include chemotherapy, hormone therapy, targeted drug therapy and immunotherapy.

Chemotherapy following surgery chemotherapy is used to treat cancer cells left behind and the microscopic disease that may be elsewhere in the body.

So most women with ovarian cancer will have chemotherapy unless their tumor is so low grade and only occurs within the ovaries with cells that do not look at all aggressive or worrisome under the microscope.

Typically two drugs are given in combination and the most common approach is to give carboplatinum and Paxlatol intravenously every three weeks for six to eight treatments, so that can be 24 weeks or almost six months.

Many times a port is inserted so that the veins aren't used up and that can be accessed right through the port.

So there's a lot of innovations in both surgery and chemotherapy that are Cleveland Clinic OBGYN Institute and our gynecologic oncologist team offers.

Now egg freezing may be considered because it can extend fertility.

So when young women are facing life-saving but fertility damaging treatment for cancer that's not just of the ovary but also breast, colon cancer or other common ones to rapidly freeze eggs and preserve the egg for future use can be done.

Much the way that men bank sperm, egg freezing is a spinoff of in vitro fertilization.

Now, before starting chemotherapy, patients are given fertility shots to increase their production of eggs, and the eggs are retrieved or harvested as if they were undergoing IVF.

So sometimes, if the woman does not have a partner, the eggs can be frozen rather than being fertilized.

But if there is a partner, it's always much more ideal to fertilize those eggs and freeze the embryos, as the defrost and viability rate is much higher with frozen embryos than frozen eggs.

Early detection embryos than frozen eggs.

Early detection being able to find ovarian cancer early could certainly help our cure rates.

So this is an intense area of research.

One method being tested is looking at the pattern of proteins in the blood called protonomics, to see if we can find proteins that may tip us off to this.

What's new on ovarian cancer research?

Scientists continue to study the genes responsible for familial ovarian cancer, and the research is beginning to yield clues about how these genes normally work and how disrupting their action can lead to cancer.

This information eventually is expected to lead to new drugs for preventing or treating familial ovarian cancer.

Research in this area has already led to better ways to detect high-risk genes and assess a woman's ovarian cancer risk.

Assess a woman's ovarian cancer risk and a better understanding of how genetics and hormonal factors, such as hormonal contraceptive use and their interactions, may lead to better ways for us to prevent ovarian cancer, which is really the most ideal thing to do Now.

There are several other gynecologic cancers that we do want to be able to focus on, just in general.

Cervical cancer is cancer at the opening of the cervix.

It's usually caused from the human papillomavirus.

If you didn't hear my prior podcast with Dr Sharon Sutherland on cervical cancer awareness month, that's one to really pay attention to, and certainly if you have HPV, getting yearly pap smears is important.

If you don't and you're over age 30, you should have a pap and an HPV.

I'm not a big fan of only doing just HPV testing without the pap, but for some women that don't have healthcare access or don't want to come in and be seen for a pap, there are some self-collection HPV tests.

Now a lot of women are told they don't need one for every five years.

I think that's a little bit long and I think ideally to do a pap every three to four years as opposed to waiting to five, because I see otherwise responsible women in my practice all the time who, five years somehow has become seven years.

It's really really ridiculous and it is very treatable, especially if caught early, and endometrial or uterine cancer is another cancer that is um potentially completely curable if caught early.

So if you're over 40 and you have abnormal vaginal bleeding, even if you're under 40 and have a family history or have a high BMI or have diabetes, it needs to be evaluated.

And getting an endometrial sampling in the office for a lot of women isn't too much more than a pap smear, and so early diagnosis for cervical and uterine cancer are more successful so far than with ovarian cancer.

I have a lot of women come in and say oh well, I heard you can get an ultrasound and a CA-125.

And really they've been looked at and they're not screening tests.

I wish they were.

So your exams and paying attention to symptoms and knowing your family history.

You know many cancers like breast cancer and colon cancer and pancreas cancer and cervical cancer.

There's been some benefits with adequate vitamin D.

So I am always talking about vitamin D, which is not a vitamin, it's a pro-sterile hormone and if you haven't listened to my third podcast in season one, it's all about vitamin D and the research keeps rolling in and it's cheap and it's safe and it's available and sometimes non-expensive.

Old, uh, kind of established things don't always get the attention maybe that they should than you know higher profile, more expensive therapies or tests.

So I really want to thank our listeners for listening to our Speaking of Women's Health podcast.

Don't miss a future one, so be sure to hit subscribe or follow wherever you listen to podcast Apple podcasts, spotify, tune in, amazon music wherever you listen.

Thanks again and I'll see you next time in the sunflower house.

Remember be strong, be healthy and be in charge.