Management of Postmenopausal Woman with Family History of Ovarian Cancer
The correct answer is C: Counseling and education about ovarian cancer symptoms, along with referral for genetic counseling if she meets high-risk criteria—routine screening with pelvic ultrasound or CA125 is not recommended and causes more harm than benefit. 1, 2
Why Screening Is Not Recommended
Evidence Against Routine Screening
The USPSTF gives a Grade D recommendation (recommends against) screening for ovarian cancer in asymptomatic women, including those with a family history, because screening does not reduce ovarian cancer deaths. 1, 2
The PLCO trial of 78,216 women (17% with family history) demonstrated no mortality benefit from annual CA-125 and transvaginal ultrasound screening, with 118 deaths in the screened group versus 100 in controls (relative risk 1.18). 2
Even in women with a genetically defined risk or familial forms of ovarian cancer, screening is not recommended outside formal research trials. 3
Significant Harms from Screening
Approximately 10% of screened women receive false-positive results, with a positive predictive value of only 1-2%, meaning 98% of positive screening tests are false positives. 1, 2
For every 10,000 women screened annually, 300 women (using CA-125) or 350 women (using ultrasound) without cancer are recalled for further testing, causing significant anxiety. 3, 1
Unnecessary surgery is common: 20 women (CA-125) or 65 women (ultrasound) without cancer undergo surgery per 10,000 women screened annually. 3, 1
One-third of women with false-positive results undergo oophorectomy, resulting in a 20:1 ratio of surgeries to screen-detected cancers, with nearly 21 major complications per 100 surgical procedures performed for false-positive results. 2
Recommended Approach: Counseling and Risk Assessment
Symptom Education
Educate the patient about ovarian cancer symptoms to watch for, including abdominal or pelvic pain, unexplained weight loss, bloating or increased abdominal size, and early satiety. 1, 2
Emphasize that early-stage ovarian cancer is usually asymptomatic, so symptom awareness is for detecting disease that may develop, not for screening. 2
Genetic Counseling Referral Criteria
Refer for genetic counseling if she meets high-risk criteria: two or more first- or second-degree relatives with ovarian cancer, or a combination of breast and ovarian cancer in the family. 1, 2
For Ashkenazi Jewish women, one first-degree relative or two second-degree relatives on the same side with breast or ovarian cancer is sufficient for referral. 1, 2
Consider referral if her mother was diagnosed at a young age, there is additional family history of breast cancer, or there are other cancers suggesting Lynch syndrome. 1
Risk-Reducing Strategies to Discuss
Oral contraceptive use reduces ovarian cancer risk by approximately 50%. 1, 2
Other protective factors include pregnancy, breastfeeding, and bilateral tubal ligation. 1, 2
Risk-reducing bilateral salpingo-oophorectomy should only be discussed for confirmed genetic mutation carriers (BRCA1/BRCA2 or Lynch syndrome), not for family history alone. 1, 2
Important Caveats
If genetic counseling reveals a BRCA mutation, management changes entirely—these women may benefit from enhanced surveillance protocols or risk-reducing surgery, but this is a different clinical scenario than family history alone. 2
The single family history mentioned in this question does not automatically qualify as "high-risk" requiring genetic testing—you need to assess the complete family history details (number of relatives, ages at diagnosis, types of cancers). 1, 2
No medical organization recommends routine screening for ovarian cancer, even in women with family history, due to the lack of mortality benefit and significant potential for harm. 3, 1