Management of Postmenopausal Woman with Family History of Ovarian Cancer
The most appropriate next step is C: Counseling and asking about ovarian cancer symptoms, as routine screening with pelvic ultrasound or CA-125 does not reduce mortality and causes significant harm through false-positive results and unnecessary surgeries. 1
Guideline-Based Recommendation Against Screening
The USPSTF gives a Grade D recommendation (harms outweigh benefits) against screening for ovarian cancer in asymptomatic women, even those with a family history. 1 This recommendation is based on:
No mortality benefit: The PLCO trial of 78,216 women (17% with family history) showed no reduction in ovarian cancer deaths with annual CA-125 and transvaginal ultrasound screening (118 vs 100 deaths; relative risk 1.18). 1
Significant harms: Approximately 10% of screened women receive false-positive results, with a positive predictive value of only 1-2%. 1 One-third of women with false-positives undergo oophorectomy, resulting in a 20:1 ratio of surgeries to screen-detected cancers. 1
Major surgical complications: Nearly 21 major complications occur per 100 surgical procedures performed for false-positive results. 1
When to Consider Genetic Counseling
This patient should be evaluated for genetic counseling referral based on her family history details. 1 Referral criteria include:
Two or more first- or second-degree relatives with ovarian cancer or a combination of breast and ovarian cancer 1
For Ashkenazi Jewish women: One first-degree relative OR two second-degree relatives on the same side of the family with breast or ovarian cancer 1
The question states only "family history of ovarian cancer" without specifying the number or degree of relatives, so you must obtain this information during counseling. 1
Appropriate Counseling Content
Focus on symptom awareness rather than screening tests. 1 Educate the patient about:
Ovarian cancer symptoms: bloating, pelvic/abdominal pain, difficulty eating/early satiety, urinary urgency/frequency 2
The fact that early-stage disease is usually asymptomatic, and symptoms typically indicate advanced disease 2
Risk-reducing factors: oral contraceptive use (reduces risk by ~50%), pregnancy, breastfeeding, bilateral tubal ligation 1
Why Not Ultrasound or CA-125?
Option A (Pelvic ultrasound) and Option B (CA-125) are explicitly contraindicated by guidelines: 1
Both modalities have been studied extensively and show no mortality benefit even in women with family history 1
The British Journal of Cancer states that "routine population or individual screening programmes by ultrasound and/or CA125 assay is not indicated" for women without genetic mutations 1
Screening leads to more harm than benefit through false-positives, unnecessary surgeries, and complications 1
Important Caveats
If genetic counseling reveals she meets criteria for BRCA testing and is mutation-positive, management changes entirely. 1 Women with known BRCA mutations are excluded from the "do not screen" recommendation and should be managed differently, potentially including risk-reducing bilateral salpingo-oophorectomy. 1
The evidence for family history subgroups is limited. 1 While women with family history comprised 17% of the PLCO trial, outcomes were not separately reported for this subgroup, and the USPSTF found no reason to believe they would benefit from screening. 1