Ovarian Cancer Isn't Silent. We're Just Not Listening

Where Ovarian Cancer Really Begins

We used to think ovarian cancer started in the ovaries. We were wrong.

The deadliest form — high-grade serous carcinoma (HGSC) — usually begins in the fallopian tubes, not the ovaries themselves. Tiny precancerous lesions called STICs (serous tubal intraepithelial carcinomas) form at the fimbriated end of the fallopian tube, near the ovary.

These lesions can sit quietly for about 6.5 years, slowly evolving toward cancer – usually without symptoms or visible changes on imaging.

Slow to Start. Fast to Spread.

Once cancer cells spread from the fallopian tubes to the ovaries and peritoneal cavity, however, progression accelerates dramatically. The average time from ovarian involvement to metastases is just 2 years.

HGSC makes up 70% of all ovarian cancers and causes nearly 80% of ovarian cancer deaths.

This explains the apparent paradox of ovarian cancer: it seems to appear suddenly, yet women report symptoms for months before diagnosis.

Anatomical Barriers

The ovaries sit deep in the pelvis, cushioned by surrounding organs and tissue. Unlike breast tissue that can be palpated or skin that reveals visible changes, the ovaries operate in complete obscurity.

By the time a mass becomes large enough to detect during a routine pelvic exam, the cancer has often already spread. This creates a detection problem that has nothing to do with symptom awareness and everything to do with basic anatomy.

Barriers to Symptom Recognition

When symptoms do emerge, they're frustratingly nonspecific: bloating, pelvic discomfort, early satiety, urinary frequency.

It doesn't help that these same symptoms occur in countless benign conditions – irritable bowel syndrome, urinary tract infections, perimenopause, endometriosis. Doctors naturally pursue common diagnoses first, which is rational from a probability standpoint.

The failure occurs when symptoms persist despite treatment. When antibiotics don't resolve "UTI" symptoms. When dietary modifications don't improve "IBS." When "perimenopause" symptoms progressively worsen rather than stabilize.

But there's another factor at play beyond probability-based reasoning: documented gender bias in medical care. Research consistently shows that women's pain and symptoms are more likely to be attributed to psychological causes.

This systemic dismissiveness compounds the diagnostic challenge in ovarian cancer, where symptoms are already nonspecific. The combination of genuinely vague symptoms plus gender-based medical bias creates a perfect storm: women with ovarian cancer are less likely to be given access to medical evidence to support their convictions when they insist something is wrong.

Barriers in Ovarian Cancer Screening

Unfortunately, another reason why we don't hear as much about ovarian cancer as, say, breast or lung cancers, is because the standard screening tests for ovarian cancer don't work well enough to recommend their routine use.

The CA-125 blood test is "positive" in approximately 75% of ovarian cancer cases – but also in numerous benign conditions including endometriosis, fibroids, and menstruation. For postmenopausal women, levels above 35 U/mL are considered suspicious, but about 5% of healthy women exceed this threshold.

On the false negative side, up to 50% of women with early-stage ovarian cancer have completely normal CA-125 levels.

Transvaginal ultrasound can visualize the ovaries but struggles to distinguish between benign cysts and early malignancies. Combining CA-125 with ultrasound doesn't improve outcomes enough to justify routine screening.

This represents a genuine gap in cancer screening. For breast cancer, we have mammography. For colon cancer, we have colonoscopy. For ovarian cancer, we have symptom awareness and hope.

MRI: A Spot Solution

MRI doesn't solve the screening problem, but it addresses a specific diagnostic challenge: characterizing indeterminate ovarian masses.

Remember that part of the issue where ultrasounds cannot clearly reveal whether a growth is benign or malignant, resulting in prolonged medical exams resulting in false positives or false negatives? MRI with contrast provides superior characterization. Studies report sensitivity of 96% and specificity of 91% for distinguishing malignant from benign tumors.

MRI, which works by using magnetic fields and radio waves to create detailed soft tissue images, can use different sequences to reveal complementary information:

• T2-weighted imaging highlights fluid-filled structures, making cysts more visible.
• Diffusion-weighted imaging (DWI) tracks water movement in tissues, helping distinguish benign from malignant growths.
• Contrast enhancement patterns reveal tissue vascularity and structural characteristics.

Additional Genetic Risk Factor

Approximately 10-15% of ovarian cancers are linked to inherited BRCA1 or BRCA2 mutations.

These genes normally repair damaged DNA. When mutated, that repair system fails, allowing cancer-causing genetic errors to accumulate. The impact on ovarian cancer risk is substantial – BRCA1 mutations increase lifetime risk to 39-58%, while BRCA2 mutations increase it to 13-29%.

Women with Ashkenazi Jewish ancestry face higher mutation prevalence. If you have a family history of ovarian or breast cancer, genetic counseling is essential for informed risk assessment.

For BRCA mutation carriers, options include enhanced surveillance, prophylactic surgery to remove the ovaries and fallopian tubes, or both. These decisions require specialized counseling weighing individual risk tolerance, family planning considerations, and quality of life factors.

Practical Guidelines for Early Detection

For average-risk women:

• Know the four key symptoms: persistent bloating, abdominal or pelvic pain, early satiety, and urinary urgency or frequency. When these symptoms occur more than 12 times per month and represent a change from your baseline, pursue evaluation promptly.
• Document symptoms – when they started, frequency, severity, what makes them better or worse. Bring this documentation to your doctor.
• If initial treatment doesn't resolve symptoms or they return immediately after treatment, insist on further investigation, such as dedicated MRI with contrast, transvaginal ultrasound and CA-125 testing.

For high-risk women (BRCA mutations or strong family history):

• Genetic counseling to assess risk and discuss options.
• Enhanced surveillance protocols that may include CA-125 testing and transvaginal ultrasound every 6 months (or dedicated MRI with contrast)
• Consider prophylactic salpingo-oophorectomy (removal of ovaries and fallopian tubes) after completing childbearing, which reduces ovarian cancer risk by approximately 80%.

For everyone:

• Recognize that persistent symptoms deserve persistent investigation.
• If your doctor attributes symptoms to IBS, UTI, or stress without investigating further, and symptoms don't resolve with treatment, seek a second opinion or request referral to a gynecologist.

The Path Forward

Ovarian cancer detection remains challenging because the disease originates deep in the pelvis, spreads primarily through surface dissemination rather than forming discrete masses, and produces symptoms that mimic common benign conditions, compounded with social and technological underdevelopment in responsiveness.

No single technology or screening test solves these problems, but what does help is a proactive approach that combines symptom awareness, responsive medical evaluation, and targeted use of available diagnostic technologies based on individual risk factors.

The ceiling in ovarian cancer detection exists for both technological, medical, and social reasons. Breaking through requires patients who are supported in their self-advocacy when symptoms don't resolve and physicians who investigate thoroughly when symptoms don't match initial diagnoses.

Don't let ovarian cancer be silent. Speak up.