The EngagED Midwife
The EngagED Midwife
Silent Signals: Understanding Ovarian Clues
A stomach that feels “off” can be easy to brush aside—until it shouldn’t be. In this episode, Cara and Missi dig into the quiet warning signs of ovarian disease, separating the everyday from the rare but dangerous ovarian pathology. You’ll learn how to read the body’s cues using the BEAT mnemonic (Bloating, Early satiety, Abdominal/pelvic pain, Trouble with urination or bowels), what ultrasound reports actually mean, and why most ovarian cysts are benign even as we stay alert to red flags.
We walk through the physiology of the menstrual cycle—why ovulation naturally creates a cyst each month—and how that helps explain functional cysts that disappear on their own. Then we shift to the features that raise concern: septations, solid components, irregular borders, and blood flow on Doppler. We talk openly about the limits of CA125, the absence of a reliable screening test, and why surgical biopsy still anchors a definitive diagnosis.
We unpack how opportunistic salpingectomy at the time of hysterectomy or permanent sterilization can cut risk, and how combined oral contraceptives lower lifetime risk by suppressing ovulation. We also cover who needs genetic counseling—BRCA1/2, Lynch syndrome, and other familial cancer clues—and how to build smart follow-up plans that balance reassurance with action. Most ovarian findings are benign; the key is knowing when to watch and when to act. If this conversation helps you or a patient put a name to a nagging symptom, it’s done its job.
Welcome to the Engaged Midwife podcast. This is Missy.
SPEAKER_00:And this is Kara. We get to see each other really soon. I know. I'm excited for annual meeting and um seeing a bunch of midwives, but I'm most excited about seeing you.
SPEAKER_01:This too will this episode will come out after we've been at annual meeting. So I'm sure we have lots of things to share once we've been together for a few days.
SPEAKER_00:Yeah, absolutely. I think it's so fun to go to annual meeting during midwifery week. I think it's fun to see you. I think it's probably been since May, since I saw you, I guess. I don't know. I, you know, we talked and we see each other so much on Zoom, but there's nothing like being together. So I know, I know.
SPEAKER_01:So this topic that we're gonna like dive into today is something that we've kind of been spinning about for like five or six months where we're like, oh, we should really talk about this thing because it's really important. And there's some new stuff that came out. Um, and I have a story about a patient from maybe about a year ago um that I will share as we start to explore this. But today I think we're gonna talk about a topic that can be very scary. Um and as I always tell my students, it's scary because when things happen, they often happen in a very vague way. And people get diagnosed with bad bad outcomes, right? Because things get diagnosed late. And if you know what I'm talking about, I'm talking about ovarian pathology and ovarian masses, ovarian cysts, ovarian cancer. Um I think the reason it was it's scary to me as a midwife is because I know people who have had ovarian cancer and the lucky ones, right, were able to have aggressive treatment and be um and and be cancer free. But it's such a crazy disease, right? Because the symptoms are so vague. Yeah, um, you don't know necessarily that the symptoms are related to your ovaries and not just something else that's in your abdomen.
SPEAKER_00:Well, and as women, how many of us don't have like some bloating from time to time or some belly upset or things a little off? And so it's exactly what you're saying is things are so vague until they aren't, which is unfortunate.
SPEAKER_01:I have a a nurse of mine that was very young when she got diagnosed with colon cancer, and she had been in the ED two or three times over the course of like four months for intractable back pain, no bowel issue, no anything. And by the time she was diagnosed, she had stage four um colon cancer and she died. Yeah, yeah. Um terrible like maybe they found it in April and she died in July. I mean, it was seven. I think I feel the same way about these ovarian things because, like you said, I feel bloated. When don't I feel bloated? Um, I'm like, uh yeah, but with pretty good certainty, because I don't have any tubes, I feel really good about my chances of getting ovarian cancer. And that is going to be like a little asterisk because we'll come back to that. Yeah, we'll come back to that. And um as we work through all of the information, I think about cysts and masses. So do you want to get us started, Kara?
SPEAKER_00:Sure. I think I just want to say that um, you know, as you talked about, ovarian cancer can be quite scary because it is oftentimes found relatively late because it starts out so vague. But overwhelmingly, ovarian cysts are quite common and almost always are benign. Um, and so we're gonna spend a little bit of time talking about like the characteristics of the different types of masses and like what the workup should be and when you should be worried about warning signs. But I think that's one of the biggest takeaways of we all know people that have had ovarian cysts because they might have a functional luteal cyst or they might, you know, so many different things that can cause um ovarian cysts. And most of the time they resolve on their own, they don't need much um attention, they just require a little bit of follow-up and we go from there. But I think that's the main thing. I want to just make sure we put that as a key point here and we'll mention it again as we wrap up with a conclusion. But most of the time, most of the time, masses are benign. So that's good.
SPEAKER_01:I also love, and this is going to be on my nerdy side, talking about physiology of the ovary and what happens in the menstrual cycle. Because basically, I love saying to people, if you are ovulating, you have an ovarian cyst every single month. Yeah. Every month. It's just physiology. And that's why when we talk about functional cysts, they resolve quickly because your body is used to having a cyst and then letting it resolve. And so um, the physiology of like what our bodies can figure out is so fascinating to me around like ovulation and the menstrual cycle. And you and I have talked about the menstrual cycle a thousand times on the podcast, but it's just to me so interesting that like understand what your body is capable of doing, and then that gives you more insight about things like the functional invariances.
SPEAKER_00:Yeah. So just as a quick review, because Missy mentioned it, every month we usually have a dominant follicle that gets recruited. It's like, yay, it's your month. Yay, you, you're so good. And as that follicle grows, it's releasing estrogen, it progresses on, and we have a spike of lutinizing hormone. Um, and that triggers ovulation. And from ovulation, where that egg is released from the ovary, I always think of it. This dates how old I am as like kind of the Kool-Aid man busting through the wall. Um, as that egg busts through the wall of the ovary, um, that place where that egg came from forms the corpus luteum. And that corpus luteum releases progesterone until the pregnancy can be well established, placental attachment happens, and then the hormone development takes over from there. But the corpus luteum is progestational. It's trying to support early gestation, and it is a normal thing. The really cool thing about it is if it doesn't get the feedback that fertilization happened and that implantation has happened, it regresses. It has a set amount of um lifespan in that if it doesn't get that feedback, it dies. It's kind of apoptosis or kind of planned cell death, in that um it just regresses. Sometimes it has a little trouble regressing, and that can be a corpus luteum cyst or a follicular cyst. It could um, you know, just get a little large because it doesn't resolve on its own. And so that is most of the time what we're talking about when we think about those functional cysts or corpus luteum cysts, but generally it resolves. Your body takes care of it, it resorbs, it starts the whole cycle over again. Um, so that's what we're talking about when we're talking about those simple cysts generally.
SPEAKER_01:Should we give a little a little overview about the differences between simple cysts and malignant cysts since you I think that yeah, really set us up for that? So, like you were just saying, simple cysts, and um, these are really like characteristics of those different kinds of cysts. So, simple cysts are generally round or oval in shape. They are not solid. Um, and I think that's an important distinguishing piece when you think about solid tumors. Um, they have smooth or thin walls, they don't have blood flow to them, right? If you were to put like a Doppler on ultrasound on that, they have no um, they have no blood flow, they're not septated, um, and they have some acoustic enhancement on um ultrasound. And that means something to me because I'm ultrasound certified, but it has to do with what we see when we do um a pelvic ultrasound in terms of what you can and cannot see with a simple cyst versus a solid cyst. Um and on the other side of that, then malignant cysts. And I think this is important for you if you're reading an ultrasound report to sort of just understand these diagnostic things. And so these are non-hyperechoic solid areas. So hyperechoic, remember, an ultrasound means you cannot see through it. Like it's these are not um in terms of like what we see on the ultrasound and how they reflect the sound. Remember, ultrasound is sound based. Um, they are solid masses that have irregular walls. For me, this sounds so much about like when we're talking about skin things, like irregular borders, irregular walls.
SPEAKER_00:It makes me think of breast masses too, like if it's irregular, it's not smooth. Those are all concerning signs when we talk about breast masses as well. Correct.
SPEAKER_01:Um, they also have some like separation between the inner and the outer aspects of the cyst, um, which can also show blood flow, right? You put it, you put the ultrasound on there, you throw the Doppler on, you see blood flow in those areas. Um, oftentimes malignant cysts also have septations. So, especially if they have blood flow to them. Um, and so I think as you're considering simple versus malignant, or even simple versus concerning, those are the some of the characteristics that we're looking for.
SPEAKER_00:Yeah, I I always think complex septations, irregular shape, same, all those things that you mentioned. And it's the same as I mentioned with breast, breast tumors, that sort of thing. So interestingly, about 85 to 90 percent of ovarian cancer that's malignant is a type of epithelial ovarian carcinoma. And they can be like five different types, but epithelial we'll talk more about in just a second. But they could be high grade um cirrus carcinoma, low-grade serous, endometrioid carcinoma, clear cell, or mucinous. And the interesting thing about this is that epithelial tumors start from the epithelial cells that line the fallopian tubes and the ovaries. And so that is where abnormal cell development, cell growth happens in those epithelial cells. And again, that's the cells that line the fallopian tubes and line the ovaries, and that is where things can kind of go awry. There's other types of um cancerous tumors that can happen. They could be germ cell tumors or stromal tumors, but those are not nearly as common as the epithelial cell.
SPEAKER_01:Yeah, it's wild when you look when you think about the statistics about these things. Like up to 70% of um problematic ovarian cysts are, like you said, epithelial.
SPEAKER_00:Yeah, it's so wild. And you mentioned that you hinted at it earlier about fallopian tubes, but we've mentioned it here now that we think this the instigator of what we have always assumed was ovarian cancer could actually be a fallopian tube cause or an oviduct um kind of um origin. So those epithelial cells, sneaky darn tubes.
SPEAKER_01:Those darn sneaky tubes, they thought, oh, we're just gonna like hang out here and everybody's gonna think we're benign, but really we're the problem. Yeah. Yeah.
SPEAKER_00:They are. They are. It's kind of crazy.
SPEAKER_01:Cool, not cool. Um, but so, and as we talk about management, and and certainly we will get there, we will talk more about why now when we do tubules, we're not just doing like segments of tubes, and we're taking or doing in you know, an entire um salpingjectomy and taking the whole tube. There's a reason for that. And again, we're going to get there, I promise. We will. So, yeah, so I tell people this all the time. I'm like, it's they we think that it's really tube related, and we've been picking on ovaries this whole time, and we really think it's tubal. So, well, we've done a little physiology here. So let's talk some about big like red flag things and when to be worried. Um, here I will insert this story that I was saying about this person that I know who called me and she's like, you know, I was feeling bloated, right? This is the thing that you said, right? I was feeling bloated. I tried a bow regimen, I did all of these things. Um, and then my OB sent me for an ultrasound, and this is what it says. That she had a 17 centimeter. Now, for those of you who are midwives, think about 10 centimeters, almost double that 17 centimeter abdominal mass that they could not isolate to like where it was. And I was like, uh that's because it's so big, you probably don't know where it came from, right?
SPEAKER_00:Yeah, that's huge.
SPEAKER_01:It's huge. And I was like, gosh, I think I would have felt way more than bloated with something 17 centimeters. So I I knew some people at the hospital at the time and was like, let's get you in with this person. And she ended up having surgery. And um, and when they she sent me pictures when they took it out, and I was like, Holy crap, right? Um the pathology turned out to be okay. Um, but she grew this huge thing only, right? Yeah, your only complaint was bloating, 17 centimeters. Um I was I was pretty stressed when I saw the initial um ultrasound, right? Based on all of the things that we just talked about. Um, and she does need to do some follow-up. I do think that there were a couple of places that are like, I we don't think this is cancer, but we should still follow up, right? That has been like the key to my life recently is that sentence. I don't think it's cancer, but you know, it's definitely not normal either. I'm like, well, what lives between normal and cancer? That's what I'd like to know. What is the thing that lives between those two things?
SPEAKER_00:But yeah, and can we talk about how birads three and birads four is like just absolute crap?
SPEAKER_01:Yes, we need a we need an update on breast cancer, birads things because wow. Oh my gosh. Yeah. Um, so I think what we're saying is that most of the ovarian things that we see are harmless, but we do need to, we do need as practitioners to understand what signs and symptoms are things that people should call us for and things that we should be concerned about when they do when people do call, right?
SPEAKER_00:Yeah, absolutely. So there's a mnemonic that we can use um for the warning signs and things that should flag you to notify your own provider if you have these symptoms or things that we should be reviewing with people. But if we remember beat, B-E-A-T, those can be our warning signs. And you've mentioned one of them several times, so have I, bloating. Bloating is our B. Um, especially if it's new or it's persistent and it doesn't go away with dietary changes. Bloating is a very concerning sign. The next one is for E early satiety. So if you feel full when you're eating really quickly, you're not able to finish a meal, that sort of, and you're not, I should say, asterisk, you're not taking a GLP medication because that certainly will make you feel that way as well. Um, but you're bloated and you get full quickly while you're eating a meal. A is for abdominal or pelvic pain that again is new or persistent, or it's just getting worse. It's not improving in any way, then you would want to let someone know. And T is trouble with urination or bowel movements, and that could be changes in the frequency, it could be changes in the composition or the texture, um, the symptoms that go along with it. And in general, those beach or B-E-A-T signs are when they've been going on for two weeks or more, then we would be concerned, and those are red flags.
SPEAKER_01:Right. The other piece of this is how many women are just like, I'm bloated, it's been a few weeks, it's gonna get better, and we don't see them until six months later. So yeah, this is why ovarian cancer is as dangerous as it is in terms of progression.
SPEAKER_00:Now, I want to throw in a little bit here that is we we did mention that most cysts are not cancerous, but there are still also some warning signs about cysts, even when they are more simple, straightforward cysts and not ovarian cancer. Because if they are 17 centimeters, there are concerns that go along with that, even though it's not cancer. So if we have really large cysts and large is usually considered kind of over six centimeters, I would say I've heard most OBs that I um consult with, if it's around four to five centimeters, they're also concerned. They're like really thinking about like, do we need to do something about this cyst? Because what can happen is when they're really, really large, the weight of that cyst can cause that ovary to twist and you can get ovarian torsion. And that can obviously be an emergency. It can cut off the blood supply to the ovary, that sort of thing. You can also obviously have cyst rupture. Um that's not always like the worst thing, but it feels really icky. Um, people, when they have a cyst rupture, also whatever fluid was in that cyst, um, or if there may have been a hemorrhagic component to it, blood and fluid in the peritoneum is really irritating and can also cause quite a bit of discomfort. Um, and then larger cysts do have that concern about are they potentially a malignant, you know, do they have malignant potential? Is there something more that we need to watch out for? So if you have someone that has a cyst on ultrasound, the concerning things are the size greater than about four to five centimeters because the risk goes up greater that it could be something cancerous or more concerning, but also just could we end up with a torsion situation or um a cyst rupture?
SPEAKER_01:I also want to um add to this idea of like what's happening and how that gets complicated in the pelvis by saying the other reason that ovarian cancer can be problematic is think about everything that's in your gut, like everything that's in your abdomen, right? So uh ovarian cancer survivor that I know, she's like, Missy, I don't I literally have nothing in my gut, right? I had a hysterectomy, I had my tubes and my ovaries taken out, I had my bowel resected, I had my gallbladder taken out, I had my appendix taken out, I had um, they did a splenectomy, literally anything she didn't need that potentially that ovarian cancer had spread to or even started to spread to, there's like nothing left in her abdomen, just like a fellow person. So that, but that tracks, right? Basically, after what you just said about all of the dangers of what happens when these cysts get too big, like think about everything that's in the abdomen, right? There are things in the abdomen too you can't live without. You can't live without your liver, right? You I wouldn't consider your kidneys an abdominal organ necessarily, but where they are would also lend it themselves to easy metastasis for something that's in the abdomen. So um, all of those things become important.
SPEAKER_00:Yeah, I'm really fond of my colon still continuing to work and exit through my rectum. I mean, like any of those things, just think of all the important structures that are in our abdomen and pelvis.
SPEAKER_01:Yeah. I mean, I throwaway organs, right? But I'm like, they they can't necessarily just be throwaway organs. There's gotta be some purpose for those things somewhere along the line. I mean, we just can't get rid of all of like your appendix and your gallbladder, sure if they cause problems, but there are also, I think, um, complications that come along with not having a gallbladder, right?
SPEAKER_00:Well, that's what I was just gonna say. I think if you ask some people that have had their gallbladder removed, um, while they're glad not to have another gallbladder attack, there's a lot of other symptoms that go along with that in their lives.
SPEAKER_01:Yeah. So um I think we'll talk some more about like malignancies as we go on. But I do think like physiologically, think about how close of proximity things are, right? Yeah in the abdomen. So um, all right, what's next?
SPEAKER_00:Let's talk. Well, let's talk about what we would do if someone called us with concerns about these symptoms, or as we're doing, let's say, a well-person exam and we're asking them the different symptoms and we're doing our review of systems, and they mention that they've got some bloating or some, you know, bowel changes or that sort of thing. The really unfortunate thing about ovarian cancer is there is literally no screening test for it. We don't have a way that we just screen asymptomatic people for ovarian cancer. It isn't a thing. It doesn't exist or it hasn't, it hasn't historically existed. Um, and so it's really fascinating. Think about the very first manuscript I ever was able to publish, I did with my program director right as I was graduating from midwifery school. Shout out to Ginger Breed Love back in 2004. And we had an article in the Journal of Midwifery and Women's Health on ovarian cancer screening and this new available test that was going to be coming out, and it was being studied, and it was using proteomics or the proteins related to this type of cancer to detect it. And now, you know, we're 20 plus years later, and the test still doesn't completely fully exist. But I've been getting a lot of notices about that article being cited. So I'm thinking there's something right around the horizon that we're gonna have. But historically, what we would do if someone told us about these signs and symptoms is we might consider doing a pelvic exam or a bimanual exam. There's limited utilities, you know, in doing pelvic exams for asymptomatic people. But if someone has symptoms, there are components of the bin manual that can be really helpful to us. But definitely part of that screening is also going to be a pelvic ultrasound. And you mentioned having the ultrasound skills. I think knowing exactly what are those things that we would be worried about on our ultrasound reports. We don't have to do the imaging ourselves, although some people can, but knowing how to interpret the report and knowing what is concerning can be really helpful. The other test that is sometimes included here is a CA125. And a CA125 is a type of blood test that is a cancer marker, but it's not specific to ovarian cancer. And so that's why we can't just say, oh, we have this test that we can see if it's elevated and know that it's ovarian cancer. It's a it's a cancer marker that can be elevated for a multitude of reasons, but it can help us in our whole evaluation of pelvic ultrasound and a CA125.
SPEAKER_01:I also say when people ask about a CA 125, like it's a cancer marker, but it is not specific for ovaries as well.
SPEAKER_00:Well, and it's not even specific just for cancer. People that have endometriosis will have an elevated CA125 as well, which is really fascinating. You can see how this complicates the picture entirely.
SPEAKER_01:Yeah, I think it makes it much harder for us as as um as providers to really see um like what what do we do, what's next. But so when we see masses um or we get an ultrasound report back, it's like what's next, right? And I think we have to consider what's on the ultrasound and like you get you've gotten a lot of data. This is a test taking tip, right? I always say when we're working with students, um, is there an answer choice that allows you to get more data? Right? And so in this case, you've done the things, you've done the blood tests, you've done the ultrasound, you've done your physical exam, right? So what's next? Um, the very midwifery answer to something that looks like a simple fluid-filled cyst is very midwifery, watchful waiting. It is like we say this a lot, right? Watchful waiting. I said that to a student last night when we were looking at this patient who the nurse thought was hemorrhaging. I was like, we've done some interventions. Now we need to wait. Like, you gotta let your interventions work. So watchful waiting is a great midwifery answer, but it's also right in this case, right? Especially for a simple cyst.
SPEAKER_00:Also then small, yeah. If it's small and simple, fluid-filled, I I mean, I'm curious what you've heard what you've seen done, but I'm usually seeing them bring them back in like three months to re-image, um, unless there's a change in symptoms or something like that. And simple functional cysts should resolve in about six weeks.
SPEAKER_01:And if you think about physiology, that makes sense, right?
SPEAKER_00:Yeah. But a month is too short for follow-up. And so I've generally seen closer to like the three months because that gives you plenty of time for that resolution.
SPEAKER_01:The other good test taking tip that I give students is if you've tried something and you have worked somebody up and you have a lot of information and you don't know what to do, your next best step is to refer for someone who is smarter than you. And I'm not saying we're not smart. I'm saying that there are people who are smarter than us, which is our favorite, those are our favorite people, right? That are people who are smarter than us.
SPEAKER_00:Correct set.
SPEAKER_01:So for a more complex mass, this may be you need to refer patients out to gyne on gynecology oncology specialists for better evaluation. Because those are people who are experts, right, in that kind of pathology, um, and they can decide what's next.
SPEAKER_00:Yeah, absolutely. And just to remind everyone, you mentioned this earlier, those things that make us think of a complex ovarian cyst are if there's um multiple compartments or septations within the cyst, if it has an irregular boundary or border, um, if there's any solid areas within the cyst, um, or there's blood flow to that cyst. Those are all concerning. If there's a sighted in the abdomen, um, that seems pretty pronounced. Um sighted would not normally be an early sign, but those are all concerning for complex masses.
SPEAKER_01:So now that we've gotten to the big bad scary, which is what ovarian cancer is or looks like, I think the sort of epidemiology information is important here. So when we think about ovarian cancer, um I I I interestingly listen to these things. I heard it's breast cancer awareness month. We're in October, right? And they were, I was listening to some report about like how many women in the US will get diagnosed with breast cancer this year. And I was already like taking off on my fingers all the people that I know right now who have invasive breast cancer, and it's insane. But ovarian cancer numbers, around 20,000 new cases of ovarian cancer in the US in like in a calendar year. I think that sounds like a lot, but when you consider population, right? Yeah, it's not very bad. It's not that high. Um, and of now this is interesting, of the 20,000 women who will be diagnosed with ovarian cancer, we'll see about 12,000 deaths from ovarian cancer. So this again is the like high mortality rate of this type of malignancy because of the vagueness of how it gets diagnosed.
SPEAKER_00:Yeah. And if you take those numbers and think about it over a lifetime, your any woman, any person with ovaries has um an individual risk in their lifetime of about one in 91 of getting ovarian cancer. And those seem like pretty good odds. I mean, for other types of cancers, when we consider um, you know, the likelihood of breast cancer, certainly one in 91 sounds much, much better. So there are fewer cases. And then the lifetime chance of dying from ovarian cancer is about one in 143. So again, we're talking about small numbers, but can be quite catastrophic.
SPEAKER_01:Yeah. And when we talk about breast cancer, right, I think the statistic now is diagnostic, like getting diagnosed with breast cancer is like one in seven. So that gives you some perspective about ovarian cancer versus something like breast cancer.
SPEAKER_00:Yeah. The there's something else really cool about ovarian cancer in that diagnoses have been going down slowly over the Past few decades, which is awesome. Um, and they think that that might be because there's more oral contraceptive pill use, which is so cool.
SPEAKER_01:Oh, yeah, we're gonna talk about that here in a few minutes. I've got that like written down as a talking point about redu risk reduction, but let's um talk for a few minutes about ovarian cancer and then we'll get to risk reduction. So gene mutations are something that we know about, and we know that that's something that happens when you develop any kind of cancer, right? Um and what we're seeing in their research now is what are the factors that affect the gene mutations, right? Um a couple of things that we can think of in terms of pathophysiology. Everybody hates this word, but I love patho. Like I'm so, so, so nerdy. Um, is things like damage to the ovaries. Every time that we use our ovaries, right, when we ovulate, um, it can damage the ovaries. So that's one reason why, like over time, the more you ovulate across your lifetime, it can increase your risk.
SPEAKER_00:The other thing is Kool-Aid man is busting through the wall of your ovary.
SPEAKER_01:We're gonna have to put a graphic of the Kool-Aid man in this. So people who don't know it know it. Those damn millennials, they don't know what the Kool-Aid man does.
SPEAKER_00:It does sound damaging, though. I do have to admit, I think that that makes sense to me why there's increased risk. The more you ovulate, the more risk.
SPEAKER_01:Yes, and hold that thought because that's why we're gonna talk about risk reduction. But you know what else they don't know? They don't know about the hamburglar. Oh. Really? Like I I took a Cheeseburger, yes, from um from a kid the other day, and Bob called me the hamburglar. And I was like, they don't, that's lost on them. They have no idea who the hamburglar is. Well, so anyway. Um okay, so the other thing about why cancer is we talk about gene mutation, we talked about damage to the ovaries, inflammation, right? And aging. That's a complete sentence, right? Um, it may raise the risk of cancer. And I we talk a lot, you and I talked about cortisol in another um podcast episode, but inflammation certainly is a thing, right? That um can lead to cancer development over a lifetime.
SPEAKER_00:So it also makes sense that as you age, there is more opportunity for some abnormal cell growth, which is what cancer is, right, to have a chance to occur. So that's why the risk of cancer goes up as you age. One, just the aging process, more opportunity, but second, that inflammation aspect that you're talking about. And certainly there's more inflammation, says my almost 51-year-old body, um, compared to 20 years ago, 30 years ago, that kind of idea.
SPEAKER_01:Right. So we don't really know and what causes ovarian cancer. I think we've alluded to a lot of things, but risk factors for sure include things like we you just said, being older, any kind of gene mutation, early menarchy. So uh girls who have started their period before age 12. Um, also late menopause. Now, what to me that means is long exposure to ovulation, right? You've started menstruating before 12, you got to menopause after 52, 40 years of combined exposure to ovulation that should track about everything that we said, right? This should all be like a puzzle coming together now for you. Um, also, women who are noliperous have never had a baby, um, also have an increased risk. Niliparous women also have a risk of having breast cancer because of non-differentiated tissue in the breast. So um, if you continue, like you and I took time off from ovulating because we had babies, right?
SPEAKER_00:I have tried to prevent ovulation most of my life. I just want to be clear on that for a multitude of reasons.
SPEAKER_01:Correct, correct. But what I'm saying is, is like you've had five kids, you have taken off 50 months of ovulation, right? Yeah across your lifespan. Um, so endometriosis, also, which is an you know abnormal pathophysiology of the uterus, inflammation that can also be a risk factor for ovarian cancer. And then at least a less likely reason would be a history of radiation to the pelvis.
SPEAKER_00:Yeah. You've mentioned the um different types of gene mutations and that that is a risk factor. I just want to put a little info here. Certainly, if you have someone that you think has an increased risk of a gene mutation, genetic counseling, those are some really smart people that we want to make referrals to. Um, because there is a there is about 25% of ovarian cancers are thought to be linked to familial mutations. And there's a variety of them. But BRCA or BROCA, one or two, um, they're implicated in breast cancer, but they're also definitely implicated in ovarian cancer. There's Lynch syndrome, and then there's about uh 10 more other gene mutations that can be related to um Pewetz-Jager syndrome, there's a polyposis syndrome that is familial. Um, there's a couple of types of non-polyposis colon cancers that can also be linked to ovarian cancer risk. So if there's anything that you think in someone's family history of familial cancer syndromes, that would be worth sending them on to genetic counseling at a local cancer center, making sure that they get fully informed consent and understanding of um what risk they might have in their lifetime. Yeah. So we just talked a little bit.
SPEAKER_01:I alluded to risk reduction, right? For user and using all of the big words about gene mutations. Um so when I talked about early menarchy-late menopause and exposure to estrogen over a certain amount of your life, what is one way that we can decrease our exposure and our ovulatory risk? And that is contraception. Any kind of contraception that keeps us from ovulating, right? So one of the things that will not work is a copper IUD. A copper IUD does nothing to make sure you don't ovulate. Period. So we're talking about methods that prevent ovulation. So things like birth control pills, right? Um, oral contraceptives are a big like yes for decreasing ovarian risk. And the research has to do with how many years in your lifetime you are on a contraceptive. And so the risk drops after you've been on five years combined, right? In your lifetime, not five consecutive years. Just effectively shutting down your ovaries for five years will decrease your risk. That risk goes down again when you have been combined in your life on a contraceptive for 10 years. So for those of you who went on birth control at 16 and didn't come off of it until you're ready to have babies when you were 30, you got it. You've got your 10 years of contraceptive risk reduction. Um, it's important.
SPEAKER_00:Well, there's another way to reduce your risk of ovulating, and that is being pregnant. Go on and have baby.
SPEAKER_01:Now that's not a great reason to have a baby, isn't you? I think there's other ways. Correct. I agree with you. Um, so having babies breastfeeding, right? Yeah, those are those are ways. Contraceptives, like I said, IUD, but not a copper IUD, right? Not a copper IUD. Right. Um, and for those of us like me who had a hysterectomy, when I had my hysterectomy, my surgeon was like, I just took your tubes. And I was like, okay. And he was like, because we know that ovari, we know now that we think most ovarian cancer is actually tubal. And if we're taking out your uterus, we might as well take out your tubes. And that has nothing to do with your ovaries. We can leave your ovaries, they can work until they don't work, right? Which for me, I feel lucky I got like six extra years out of my ovaries post-hysterectomy in terms of estrogen and not being in menopause, but took my tubes. So I feel really good about that as a risk factor, as a, as a, as a thing. So if your patient needs a hysterectomy for some reason, I think good counseling is you don't need your tubes if you don't have your uterus, right? Let them take that as well.
SPEAKER_00:Well, and the question of, you know, whether or not to leave the ovaries, I feel like is obviously a conversation for the surgeon that's doing your surgery. But also, how close are you to menopause or not, or are you postmenopausal? Obviously, if um they're done, if they're done doing their job and they're just sitting there, then it may be worth getting them out because of the potential that could happen. So I think, you know, there's not a right or wrong answer. Everybody, you know, can have a very personalized decision, but the idea of removing the tubes is so important. And then thinking about whether or not to remove the ovaries. I think the conversation around permanent sterilization for women, though, and what do we do with the tubes is what's even more fascinating is that if you are done having babies and you are wanting to do a permanent sterilization, take those tubes. Don't just take a segment of them. Correct.
SPEAKER_01:Correct. So as we're starting to wrap up this, I would like to talk some about what you were saying earlier about screening and detection. And we know there's no effective routine screening test for ovarian cancer, right? Right. Why? Because of the things that we've talked about. Super vague symptoms, right? And then inaccurate testing, right? CA125 is not a super accurate or um specific test for ovarian cancer. And then a transvaginal ultrasound, an ultrasound, when I talk about what that is, is more of a screening than a diagnostic test. And if you don't remember screening versus diagnostic, we have a podcast episode on that. But that is a screening. And if you want a diagnostic, you need a biopsy of some sort. But honestly, there's not a there's not a way in the office that we can do a biopsy of something that's in somebody's pelvis that has to do with ovarian pathology.
SPEAKER_00:Absolutely. Yeah. I mean, you would need to have surgery and a biopsy to know for sure that this is something that is a malignancy. Absolutely. Correct.
SPEAKER_01:Um, so when we when we talk about this, I think it's important for women to hear us say um, if you're having symptoms for more than a few weeks, it's worth having somebody like going to see somebody and telling them about your symptoms.
SPEAKER_00:Yeah, absolutely. Absolutely.
SPEAKER_01:And if you have genetic predisposition, now I will say if you or your patients, if your patients have had BRCAT testing, because they have somebody in their family who has an estrogen-positive breast cancer and you have had bracketesting, they should be telling you that you have increased risk for gynecologic cancer, right? So that genetic predisposition, like a BRCA one or two mutation, may require that you have a more detailed sort of surveillance plan for ovarian pathology, right? That's just like if you have, you know, relatives who have colon cancer at a young age, right? You think about how often you need a colonoscopy, right? It's the same idea, right? You have a family member or more than one family member who has a, you know, a breast cancer or another gynecologic cancer. This the surveillance that you may need will maybe um on a more accelerated schedule.
SPEAKER_00:Yeah, absolutely. Absolutely. And I mentioned, you know, there is the hope that we're gonna have a better test soon. Um, there is still some predictors out there that there will be a test that's based on proteomics. So, again, looking at those proteins in cancer cells and being able to tell us who's at increased risk and who do we need again, then those more screening tests, diagnosis, that sort of thing, but we don't have it yet. And so really knowing the warning signs, knowing who needs appropriate follow-up, um, going from there is the best tools that we have. And I think education is key in that area as well.
SPEAKER_01:Yeah. Um, did I miss anything that you really we are you talked about beat, right? In terms of symptom-based detection. We talked about high-risk individuals with BRCA1 and two. Um, and what is sensitive and specific for ovarian cancer. So I think the the big takeaway for this is we know we don't have a screening test that is specific and sensitive for ovarian cancer, right? Yeah.
SPEAKER_00:Um, and I think that's what makes it scary. Yeah, absolutely. Absolutely. And, you know, the diagnosis rate versus the death rate is also scary. I mean, I think that I used to always think of ovarian cancer as being very similar to pancreatic cancer, um, that it was a catastrophic diagnosis and it was always too late. And I think the good news is that things have been improving. I think the really amazing news in your and my lifetime of practice as a midwife is that there are new discoveries in this idea of we can really reduce risk by salpingctomy, that we can really reduce risk um, you know, with the use of oral contraceptive pills. I think for so many years, um, my mom's generation was concerned about the health risks of the pills, not so much of like what are some of the health benefits, but a lot has changed. And I think the really exciting thing is that there's still more hope for change in the future as well.
SPEAKER_01:Yeah, and there's some new literature, and we will link some of this for you to look at in terms of, you know, that idea of taking people's tubes when they're, you know, done using them, essentially. Um, and that that salpinjectomy can decrease ovarian cancer risk by half, right? Um, but it's that's incredible. I know, right? Um, and there is a statement from ACOG about how we can that is a risk-reducing surgery. And so if somebody's already, you know, having surgery or once permanent sterilization, right? That that is a great way to reduce risk and prevent um future pregnancy. And so um, this article that I'm referencing is a clinical connection from Johns Hopkins, and we will link to it um in our um on our podcast page. But really, one of the quotes from this article is that we've never really been able to prevent ovarian cancer in any of our history, but we could choose to just eliminate an anatomic structure after we're done having babies that could prevent lethal cancer. And so that's kind of mind-blowing when you think about right. Like, gosh, a good example of this is pancreatic cancer is also super lethal, but we can't live without our pancreas. That's not something that's not a an organ that we can remove and live a normal life. Whereas like our fallopian tubes are something that certainly, when you're done with them at whatever point that may be, um, it's a great idea, it's a great option for risk reduction.
SPEAKER_00:So yeah. I've jokingly always said that I plan to take all my organs with me when I go, um, because I still have my tonsils and I still have my appendix and my gallbladder and all of the different things. But I do think it's just incredible to think that there is something that could be an option for people in the future of getting rid of an organ that could cause problems and especially lethal cancer.
SPEAKER_01:So try to kill you, right? Yeah. I said, like, oh, if my breasts try to kill me, I am certainly getting rid of them. Like, it is not worth keeping something that is trying to actively kill me.
SPEAKER_00:Yeah, I mean, we do have to think about the risks of surgeries and all of those different things, but I hear you. If there is something that is putting you at greater risk, it's it's worth knowing that there's options out there. Correct.
SPEAKER_01:So I think the key message in today's episode is really like listening to your body, listening to your patients who are listening to their body, right? Don't be afraid to go to your provider and say, I feel bloated. Maybe we're gonna tell you you need a bowel regimen, but maybe we're gonna say, hey, let's do a pelvic ultrasound just to be sure that there's nothing there. Right? Yeah. Maybe we're gonna say, let's do both of those things.
SPEAKER_00:Right, right. Yeah. I think the main thing is that if you've changed your diet and you've done a bowel regimen, or you know, you've like done some things to try to straighten up any problems that are going on. And it isn't getting better, or pain is getting worse, or your bloating's not improved. We want you to hear us say it doesn't need to be three months of that. Anything more than two weeks of persistent symptoms that aren't getting better, it's worth getting checked out. And so for us as providers, it's important to remember we do a lot of reassurance, we provide a lot of watchful waiting, but there's a time that we don't need to watch and wait and that we can take action and we might be able to improve outcomes by doing so.
SPEAKER_01:Yeah. So open communication with providers, reiterate that almost everything in the ovary is benign. Yeah. Benign until it's not. Yes. And then knowing the beat and knowing when you need to be concerned. I think these are all great takeaways for this episode.
SPEAKER_00:Yeah, I've learned a lot today. This has been good.
SPEAKER_01:Gosh, like now that we've talked about it, I'm like, oh, it feels so good that we've been talking about this, like doing this episode forever. And now we finally have gotten through it. So it's yeah, I think it's great information. I'm excited to share this.
SPEAKER_00:Yeah, absolutely. Well, happy midwifery week to everyone. If you're hearing this um after midwifery week, which you likely are, I hope you had a really great time celebrating with the midwives in your life and um celebrating yourselves.
SPEAKER_01:Well, thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again. Take care.