What is the best initial screening approach for an asymptomatic postmenopausal woman with a family history of ovarian cancer?

Counseling and Symptom Education is the Recommended Approach

For an asymptomatic postmenopausal woman with a family history of ovarian cancer (one cousin), the best management is counseling about ovarian cancer symptoms and risk factors (Option C), not screening with pelvic ultrasound or CA-125. 1, 2

Why Screening is Not Recommended

Strong Evidence Against Routine 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, due to no mortality benefit and significant harms. 1, 2

• The PLCO trial of 78,216 women (17% with family history) demonstrated no reduction in ovarian cancer deaths with annual CA-125 and transvaginal ultrasound screening, with 118 versus 100 deaths (relative risk 1.18). 1

• The ACR Appropriateness Criteria (2025) confirms that results of published literature are inadequate to recommend transvaginal ultrasound for ovarian cancer screening in postmenopausal patients without high-risk factors. 3

Significant Harms from Screening

• False-positive rate is extremely high: approximately 10% of screened women receive false-positive results, with a positive predictive value of only 1-2%. 1, 2

• Unnecessary surgeries are common: one-third of women with false-positives undergo oophorectomy, resulting in a 20:1 ratio of surgeries to screen-detected cancers. 1

• In the PLCO trial, 1,080 women underwent surgery with oophorectomy for false-positive results, and 163 (15%) experienced major complications—nearly 21 major complications per 100 surgical procedures. 3, 1

What Constitutes High-Risk Family History

This Patient Does NOT Meet High-Risk Criteria

• High-risk family history is defined as: two or more first- or second-degree relatives with ovarian cancer, OR a combination of breast and ovarian cancer in the family, OR being Ashkenazi Jewish with one first-degree relative (or two second-degree relatives on the same side) with breast or ovarian cancer. 1, 2

• One cousin with ovarian cancer does not meet high-risk criteria for genetic testing or altered management. 1, 2

• Only 5-10% of ovarian cancer patients have a significant family history warranting genetic evaluation. 1

Appropriate Management Strategy

Counseling and Education (Option C)

• Educate about ovarian cancer symptoms: abdominal or pelvic pain, unexplained weight loss, bloating or increased abdominal size, and early satiety. 2

• Emphasize that early-stage disease is usually asymptomatic, so symptom awareness is critical for prompt evaluation if symptoms develop. 1

• Discuss risk-reducing factors: oral contraceptive use reduces ovarian cancer risk by approximately 50%, and other protective factors include pregnancy, breastfeeding, and bilateral tubal ligation. 1, 2

When to Consider Genetic Counseling

• Refer for genetic counseling if additional family history details reveal: multiple affected relatives, young age at diagnosis, Ashkenazi Jewish ancestry, or other cancers suggesting Lynch syndrome. 2, 4

• If genetic counseling reveals a BRCA mutation, management changes entirely, potentially including risk-reducing bilateral salpingo-oophorectomy and enhanced surveillance. 4

Why Other Options Are Incorrect

Pelvic Ultrasound (Option A)

• No relevant literature supports transabdominal pelvic ultrasound for screening in this population. 3

• Even transvaginal ultrasound has not demonstrated mortality benefit and leads to excessive false-positives (specificity 98.2%, but PPV only 2.8-5.3% for invasive cancers). 5

CA-125 (Option B)

• CA-125 alone has poor specificity (96%) and very low PPV (13%) for ovarian cancer screening. 6

• False-positive CA-125 results are common due to benign conditions: endometriosis, adenomyosis, pelvic inflammatory disease, menstruation, and uterine fibroids. 3

• Even combined CA-125 and ultrasound screening achieved only 40% PPV in high-risk women, and failed to prevent diagnosis of advanced-stage disease. 6

CEA (Option D)

• Carcinoembryonic antigen (CEA) is not a marker for ovarian cancer and has no role in ovarian cancer screening or diagnosis. 3

Critical Pitfall to Avoid

Do not order screening tests (ultrasound or CA-125) based solely on family history of one second-degree relative. This leads to unnecessary anxiety, false-positive results, and potentially harmful surgeries without any demonstrated mortality benefit. The appropriate action is counseling about symptoms and risk factors, with genetic counseling referral only if additional high-risk features are identified. 1, 2