Ovarian Health
By M. Sara Rosenthal, PhD
WebMD Medical Reference from "The Gynecological Sourcebook"
Reference link: WebMD Ovarian Cancer
http://my.webmd.com/content/article/85/98742.htm
COMEDIENNE GILDA RADNER, who died of ovarian cancer, walked around with it for a long time before it was finally diagnosed. Feeling gassy and uncomfortable for months, she was told that her symptoms were gastrointestinal and not to worry. If only Radner had been educated as to the early warning signs of ovarian cancer, she might not have succumbed too early in life to this cancer.
In 2000, ovarian cancer struck approximately 23,000 women in the United States, and approximately fourteen thousand women previously diagnosed with the disease died of it. This places it fifth in order of the five leading cancers that are diagnosed in women in North America: breast, lung, colon, uterine corpus, and ovary. The only well-known risk factors for ovarian cancer are infertility and family history of ovarian cancer. There are conflicting studies showing that fertility drugs, as well as HRT, may also be a factor in ovarian cancer incidence. This chapter is designed to give you all the facts about ovarian health, including noncancerous conditions, as well as everything you need to know to catch ovarian cancer before it progresses to a later stage.
Ovarian Cysts
Abnormal bleeding and irregular periods can be caused by an ovarian cyst. This is a scary diagnosis, but ovarian cysts are very common and are not cancerous conditions. An ovarian cyst is a fluid-filled lump, just like a breast cyst, but it forms on the ovary. Often ovarian cysts don't even require surgery and just need to be monitored. An ultrasound can tell your doctor whether the cysts are benign.
Follicular Cysts
During normal ovulation, the follicle spits out the egg. When the follicle fails to do this, fluid, hormones, and other guck build up inside the unruptured follicle until a cyst develops. This kind of ovarian cyst is most common in women who are between the ages of twenty and forty. Some women are plagued by follicular cysts, which may keep forming. The symptoms of follicular cysts are different from symptoms of ovarian cancer. They include delayed periods, bleeding between periods, pelvic pain (constant dull ache or sharp jabbing), and cramping, but often there are no symptoms. A full pelvic exam is done first in investigating abnormal bleeding. Often follicular cysts are found in a bimanual exam. If your ovary is enlarged by more than two inches, it will immediately be investigated. Your doctor will order a blood test to see how well your ovary is producing hormones. Then he or she will perform an ultrasound scan to see the size and composition of the ovary. Just like an ultrasound can determine fluid-filled lumps in breasts, it can also determine fluid-filled lumps on the ovaries. In the United States sometimes a CAT scan or an MRI is done as well. Follicular cysts are always benign.
The next step in treating follicular cysts depends on your age and the size of the cyst. If you're menstruating regularly and the cyst is small, waiting it out may be the best course of action. However, since most follicular cysts resolve within one menstrual cycle, the first step is simply observation, eliminating the need for expensive tests and treatment. Most go away without rupturing, but these cysts may also rupture on their own. In either case, your menstrual cycle will get back in sync and return to normal. You'll then need to be reevaluated. If you're under thirty, you can be reevaluated in about two cycles (eight to ten weeks). If you're between the ages of thirty and forty, you should be reevaluated after only one cycle (about four to six weeks).
If you are experiencing a lot of pain, are over forty, or have a solid enlargement of the ovary, you'll need to be treated immediately. If the cyst persists after a second evaluation, you'll also need to be treated.
Treatment involves a laparoscopic procedure, which will tell the doctor more about the texture and size of your cyst. Depending on what is found, the cyst might be aspirated on the spot, at which point it will simply collapse and you'll be cured. But if the ovary is unusually large, the cyst is removed and your ovary biopsied via fine-needle aspiration. If no cancerous cells are found, once the cyst is removed, you'll also be cured. Sometimes a condition known as polycystic ovary disease can occur where a woman has numerous follicular cysts, which can be treated. This is also a major cause of infertility.
Corpus Luteum Cysts
After your egg is spit out by the follicle, which then turns yellow and becomes the corpus luteum (an empty shell that produces progesterone), the follicle doesn't shrink like it's supposed to. Instead, the little blood vessels that feed the follicular sac and bleed during ovulation continue to bleed into the empty sac and form a blood-filled cyst. This sounds dangerous, but it isn't. Corpus luteum cysts will often rupture and resolve on their own. If not, the diagnosis and treatment route is the same as for follicular cysts: the blood is aspirated during laparoscopy, and the ovary is biopsied. Sometimes, though, the ovary may be too large or the bleeding too severe. At this point, some doctors may opt to remove the ovary, but this is premature. The bleeding is caused by a stubborn blood vessel that can be tied off, which will stop the bleeding, allowing the cyst to be aspirated and the ovary to remain intact.
Dermoid Tumors
These are not cysts but common benign tumors (making up about 10 percent of benign ovarian tumors). Dermoid tumors are more common in young women but can occur throughout the reproductive years. Prepare yourself—these are really disgusting! What happens here is that the egg begins developing without being fertilized. So these growths develop hair, teeth, cartilage, and fat. Even surgeons are shocked by their appearance. The symptoms and diagnosis process for these tumors are the same as for follicular cysts, and an ultrasound test or even an x-ray can pinpoint dermoid tumors. Teeth often show up in the scans or x-rays!
Many surgeons will do laparoscopic surgery to remove the tumor and leave the ovary intact. Unfortunately, some doctors will just remove the ovary altogether. Because dermoid tumors can be removed while leaving the ovaries intact, your best bet is to seek out a doctor who will not remove the ovary. If you can't find one, contact the Hysterectomy Educational Resources and Services (HERS) Foundation, an organization that has lists of surgeons who perform alternative surgery to hysterectomy and oophorectomy.
Preventing Ovarian Cancer
Preventing ovarian cancer means, first, understanding your risk profile and going for regular pelvic exams. Second, know the symptoms. Seventy percent of all ovarian cancer is discovered in an advanced stage that does not respond well to treatment. However, if discovered early, it carries an 85 to 95 percent five-year survival rate.
The average woman has a one in seventy risk of developing ovarian cancer in her lifetime. The women at highest risk are those who never have a break from ovulation and who began their cycles earlier than the average twelve and a half years of age. On the flip side, if you had your first child after age thirty-five, you may also be at higher risk. Basically, having lots of kids starting at age twenty-five or younger and breast-feeding them (breast-feeding delays ovulation) will greatly reduce your chances of ovarian cancer. If you're having children beyond age thirty-five, breast-feeding also reduces your chances of ovarian cancer.
Not planning a life like this? Well, don't panic. We now know that oral contraceptives can also protect you from ovarian cancer because they give you a break from ovulation. The longer you are on an oral contraceptive, the greater your protection. A recent study reported a substantially reduced risk of ovarian cancer for women taking oral contraceptives who had a family history of ovarian cancer and who tested positive for the gene mutation linked to ovarian cancer (BRCA1 or BRCA2—the same mutation linked to premenopausal breast cancer). The risk of ovarian cancer decreased by 60 percent in high-risk groups with oral contraceptive use. In fact, oral contraceptives are now thought to be an ovarian cancer prevention drug for women who were previously considering a prophylactic oophorectomy (see further on).
Genetic Screening for Ovarian Cancer
When you're told you carry a gene for a particular cancer, it means that you have inherited a normal gene that is more vulnerable to attack by certain carcinogens, meaning that it can mutate. Cancers that are considered to be familial (inherited) are cancers that occur in first-degree relatives (parents, siblings, and children). Grandmothers, great-aunts, and paternal relatives are not as crucial in determining familial cancers. Genetic screening can find some of these vulnerable genes, but what does this information mean?
Familial ovarian cancer accounts for a significant percentage of all ovarian cancers. Several inherited genes can cause susceptibility to this cancer, including BRCA1 and BRCA2, also implicated in breast cancer. Women who have these genes are more susceptible to breast and ovarian cancer than those who don't.
If you are BRCA1 or BRCA2 positive, it's estimated, using data from high-risk families, that you are at very high risk of developing ovarian cancer if you have a family history of ovarian cancer. The problem with finding out whether you have a mutated gene that could cause cancer in your body is that it is not necessarily meaningful information. The stress that the information causes could be more damaging to you than the mutated gene. On the other hand, knowing you are vulnerable to certain cancers may help you to make certain decisions, such as going on oral contraceptives or even having a prophylactic oophorectomy.
A wider issue surrounding genetic testing is the fast-approaching future—a future where a long list of genetic information may be compiled about each person. And that means there may be a stigma attached to certain information getting out to people who may not understand what having a certain gene means and who may discriminate against you for having certain cancer genes. This is not an issue that you need to worry about today, but it may be one that will affect your children ten years from now. Now that the Human Genome Project is complete, many more cancer gene tests will be available.
The Downside of Genetic Testing
Testing for genetic mutations in presymptomatic women who come from high-risk families is producing a registry of confidential information that can perhaps be even more damaging to the future of the affected woman or families than the genetic mutation itself. Some of the following dilemmas regarding testing for the breast/ovarian cancer gene present themselves:
Who owns this information?
It is currently unclear whether a woman who tests positive for a cancer gene mutation can keep the information confidential.
How will this information be used?
The 1997 film Gattaca dramatizes the results of a genetically obsessed culture. In this film one's genetic makeup determines one's eligibility for education, employment, and social status, even though the film's protagonist makes it clear that "genoism" (a word in the film, which meant discrimination against people with genetic "defects" or mutations) is against the law. Gattaca shows us a world that is not so futuristic anymore—a world where every strand of hair or eyelash serves as one's genetic resume.
Insurance companies in the United States already practice a form of "genoism," with clauses that prevent people with preexisting conditions from receiving health care insurance. Could insurers in the near future require, for example, BRCA-positive women to undergo a prophylactic oophorectomy as a condition of coverage? Or would health insurance premiums simply become unaffordable for BRCA-positive women or even the families of these women?
As for denying employment to BRCA-positive women, while the Equal Employment Opportunity Commission considers genetic discrimination unethical under the 1990 Americans with Disabilities Act, its powers are limited. Given this, what would stop employers from requiring that BRCA-positive women undergo a prophylactic oophorectomy as a condition of hiring?
"BRCA Daughters": At what point does a mother tell her daughter that she is BRCA positive? At age twenty-one? At sixteen? At birth? While there are guidelines in place that prohibit genetic testing in girls under age eighteen, there is no way to enforce that a BRCA-positive woman withhold her own testing results from her daughter. The emotional impact of a daughter knowing that she may carry a "defect" may be an unfair burden. How will this information affect other decisions this daughter makes, ranging from career choices to contraception methods to childbearing?
Secondly, would BRCA screening become available prenatally? Would BRCA-positive pregnancies be terminated? In India, for example, little girls are aborted because they are viewed as economic burdens on families; in kind, little girls who grow up to be breast/ovarian cancer patients may be viewed as economic burdens.
Is Getting Tested Harmful?
Well, it can be, depending on how you're interpreting the news or who is interpreting it for you. If you have inadequate genetic counseling (which happens a lot!), critics of genetic testing state that misunderstood genetic information can do enormous damage. It's important to consider the following before deciding to get tested:
Testing negative:
Testing negative is never a "true negative," since the test is not an accurate prediction of one's future health. Some women mistakenly interpret a negative result to mean that they will never develop any form of ovarian cancer. If other women in your family are being tested at the same time, the women in the family who test negative may suffer from survivor's guilt if other women test positive.
Testing positive:
On the flip side, testing positive is not necessarily a guarantee of ovarian cancer, although there is certainly a greater likelihood of a BRCA-positive woman developing ovarian cancer. The issue of harm should be examined, in the context of whether a still-healthy, presymptomatic woman should sacrifice her emotional health. Women who test positive are more likely to suffer from anxiety, depression, and hopelessness; strained relationships with family members; and even employment and insurance discrimination.
Harmful interventions:
Right now, women who test positive for an ovarian cancer gene are recommended for prophylactic oophorectomies, meaning that they will require hormone replacement therapy (HRT) for life, which has now been shown to be potentially harmful as a long-term therapy. This prophylactic surgery asks women to sacrifice their health before showing symptoms of a disease.
Prophylactic Oophorectomy
A prophylactic oophorectomy means removing the ovaries to prevent disease—in this case, ovarian cancer. Women whose mother or sister(s) had ovarian cancer are three times more likely to develop ovarian cancer themselves. Women who have witnessed family members die from ovarian cancer are particularly fearful that they will suffer the same fate and often request prophylactic oophorectomy before it is even recommended. However, the complications that can follow this procedure because of surgical menopause are not always discussed in great enough detail. And in light of changing guidelines regarding HRT, many women considering prophylactic oophorectomy may have to weigh other risks with the perceived benefits. For more on menopausal symptoms and HRT, please see Part IV of this book.
Ovarian Cancer Symptoms
The symptoms of ovarian cancer are very different than they are for ovarian cysts, comprising more general signs of ill health, such as gas, bloating, and flulike symptoms. Occasionally, vaginal bleeding or even masculine hair growth might be a sign, but these are rare. Sharp abdominal pain or a continuous dull ache could be a symptom of ovarian cancer but usually points to a cyst. Menstrual irregularities are also not a common symptom.
The following are the official signs of early ovarian cancer:
discomfort in the lower abdomen
painless swelling or bloating in the lower abdomen
a feeling of fullness (even after a light meal)
loss of appetite
gas and indigestion that can't otherwise be explained
nausea
weight loss
frequent urination
constipation
pain during sexual intercourse
Typically, most women with early ovarian cancer won't notice symptoms unless they're on the lookout. Noticeable symptoms occur when the cancer has spread to the abdominal cavity, causing abdominal fullness and early satiety (a sensation of fullness after eating only a small amount). Many women will be sent off to a gastroenterologist to investigate motility disorders, hiatal hernia, or gallbladder disease.
Early ovarian cancer is usually caught by a doctor during a routine pelvic examination where he or she finds an enlarged ovary or mass (in a premenopausal woman) or can actually feel the ovary (in a postmenopausal woman—the ovary shouldn't be "feelable" at this stage). Enlarged lymph nodes around the pelvic region are sometimes a clue as well. In rare cases, brain tumors are the first sign of ovarian cancer. This is why it's so important to have regular pelvic exams. Your doctor can feel for enlarged ovaries or masses by inserting two gloved fingers inside the vagina and simultaneously feeling the outside of your abdomen with the other hand (something akin to fitting your duvet into its cover with your fingers).
Let's invent a rule from now on: if you are over fifty and notice three of the aforementioned symptoms for ovarian cancer, go to your doctor without delay and ask him or her to feel for an enlarged ovary or mass. If this doesn't reveal anything, ask to have a transvaginal pelvic ultrasound to rule out ovarian cancer. When it comes to this kind of deadly cancer, better safe than sorry. If your doctor gives you a hard time, say that you don't want to be another ovarian cancer statistic, and then blame what may be perceived as overcautiousness on this book.
When the Abdominal Pain Is Caused by the Fallopian Tubes
A rare problem, known as fallopian tube torsion, can cause almost the exact symptoms as ovarian cancer: gastrointestinal symptoms, such as nausea and vomiting, and urinary frequency and urgency with voiding difficulties. This may need to be ruled out if no mass is found when you present with ovarian cancer symptoms.
Women who are at risk for ovarian cancer tend to have one or more of the following characteristics:
- They have a family history of ovarian, uterine, breast, or colon cancer.
- They are between fifty-five and sixty-four years of age.
- They have never been pregnant. (In this case, the risk is twice as likely.)
- They have been diagnosed with breast, intestinal, or rectal cancer. (This appears to increase the risk of developing ovarian cancer.)
- They have been on fertility drugs but have not conceived. (Fertility drugs cause your ovaries to "superovulate.")
- They are exposed to environmental toxins (including in the workplace).
- They experience irregular or no menstrual cycles, ovarian malfunctions, ovarian tumors, or ovarian cysts or have polycystic ovary disease or Turner's syndrome (a genetic disorder).
- They consume a high-fat diet, low in vitamin A.
- They have hypertension or diabetes.
- They are Caucasian or of northern European descent.
- They are living in an industrialized country.
Ultrasound Screening
If you are in a high-risk category for ovarian cancer, once you reach forty, you should request an initial pelvic ultrasound to measure the size of your ovaries, even if you've already had a hysterectomy. Have blood tests done to obtain a baseline reading of your hormone levels. Then go back once a year for a comparative ultrasound and blood test. Any readings or results that veer too far from your first baseline reading can be investigated before it's too late. Canadian researchers have now developed a blood test that can detect ovarian cancer at an early and treatable stage. The test measures the levels of lysoPC, which is significantly increased in women with ovarian cancer. Ask your doctor about the availability of this test.
Unfortunately, ultrasound is not an effective screening method for women who are not in a high-risk group, but you can request it if you notice symptoms. The gastrointestinal-like symptoms of ovarian cancer are simply too vague for mass ultrasound screening to be routinely recommended. However, keep in mind that ultrasound or CA-125 can produce false positive or false negative results.
The CA-125 screening test can find cancer cell "sheddings" in 80 percent of patients with advanced ovarian cancer. In fact, it is 99.9 percent specific in postmenopausal women, but only 50 percent specific in premenopausal women. The problem is that it doesn't always find ovarian cancer, but it does find other cancers, such as breast, lung, and gastrointestinal cancers. It also can test positive for benign conditions, such as benign cysts and endometriosis, simple menstruation, and pregnancy. Exploration laparotomy is often necessary to diagnose ovarian cancer.
What to Eat
Adopting a diet that is low in animal fats and free of pesticides will reduce your exposure to excess estrogen and may help to reduce your risk of ovarian cancer, since it is seen in women who consume higher fat diets. You can also make extra estrogen when your liver is not functioning well or you have other nutritional deficiencies or bowel problems.
Taking all the B vitamins in doses of 50 to 100 mg a day as well as an additional 200 mg of B6 a day can help improve liver function. Choline, methionine, and inositol also improve the breakdown of estrogen in the liver. Bitter greens such as endive, escarole, dandelion greens, and radicchio also stimulate liver function. Swedish bitters are another very helpful tonic to stimulate liver action and improve digestion. Supplements such as evening of primrose oil, vitamin E, vitamin C, and bioflavonoids may also help.
If you have an ovarian cyst, you can use diet to help dissolve the cyst. The following are reported to be helpful:
- raw vegetables
- red raspberry leaf tea
- cayenne pepper
- yarrow infusions
- chickweed in a tincture
- Flower Power
To maintain the reproductive system and overall ovarian health, you can use essential oils as a daily tonic in a bath.
Natural Progesterone
Natural progesterone can help to balance out excess estrogen in the body. Excess estrogen in the body causes, among other things, increased body fat. Natural progesterone can help to counterbalance excess estrogen.
How to Move
Aerobic activity can help to burn fat and hence reduce the estrogen in your body. Practicing daily exercises is also helpful.
Copyright © 2003 by M. Sara Rosenthal, PhD. All rights reserved. From "The Gynecological Sourcebook", by arrangement with Contemporary Books, The McGraw-Hill Companies.
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