What is the best approach for screening a postmenopausal woman with a family history of ovarian cancer, specifically a affected cousin, who presents asymptomatic with an unremarkable physical exam?

Counseling and Symptom Education is the Recommended Approach

For this postmenopausal woman with a family history of ovarian cancer (one affected cousin), the correct answer is C: Counseling and asking about ovarian cancer symptoms. The USPSTF gives a Grade D recommendation (recommends against) screening for ovarian cancer in asymptomatic women, even those with a family history, because screening does not reduce mortality and causes significant harms 1, 2.

Why Not Screen with Pelvic Ultrasound or CA-125?

The evidence is unequivocal that routine screening fails to save lives:

• No mortality benefit: The PLCO trial of 78,216 women (17% with family history of breast or ovarian cancer) showed no reduction in ovarian cancer deaths with annual CA-125 and transvaginal ultrasound screening (118 vs. 100 deaths; relative risk 1.18) 1, 2, 3
• High false-positive rates: Approximately 10% of screened women receive false-positive results, with only 1-2% of positive tests representing actual cancer 1, 2, 3
• Unnecessary surgeries: For every 10,000 women screened annually, 20-65 women without cancer undergo unnecessary surgery, with nearly 21 major complications per 100 surgical procedures 2, 3
• No stage shift: The PLCO trial found no significant shift toward earlier stage detection with screening 3

The Correct Approach: Counseling and Symptom Awareness

Focus on educating the patient about ovarian cancer symptoms and when to seek evaluation 2, 4:

• Key symptoms to discuss: Abdominal or pelvic pain, unexplained weight loss, bloating or increased abdominal size, and early satiety 2, 4
• Emphasize that early-stage disease is usually asymptomatic, so symptom awareness targets more advanced disease but is still the recommended approach over screening 2

Assess Need for Genetic Counseling

One affected cousin alone does not meet high-risk criteria, but you should assess the complete family history 1, 2:

• High-risk family history requiring genetic counseling referral: Two or more first- or second-degree relatives with ovarian cancer, or a combination of breast and ovarian cancer 1, 2, 5
• For Ashkenazi Jewish women: One first-degree relative or two second-degree relatives on the same side with breast or ovarian cancer 1, 2, 5
• If genetic counseling reveals BRCA1/BRCA2 or Lynch syndrome mutations, management changes entirely with consideration of risk-reducing bilateral salpingo-oophorectomy 2, 3, 5

Discuss Risk-Reduction Strategies

Counsel about proven protective factors 1, 2, 5:

• Oral contraceptive use: Reduces ovarian cancer risk by approximately 50% 2, 3, 5
• Other protective factors: Pregnancy, breastfeeding, and bilateral tubal ligation 1, 2, 5

Common Pitfall to Avoid

Do not order CA-125 or pelvic ultrasound as screening tests in this asymptomatic woman. While these tests may be appropriate for evaluating concerning symptoms, using them for screening in average-risk or moderately increased-risk women (like this patient with one affected cousin) leads to more harm than benefit through false-positives and unnecessary interventions 1, 2.

Why Not CEA (Option D)?

Carcinoembryonic antigen (CEA) has no role in ovarian cancer screening or diagnosis—it is a tumor marker for colorectal and other gastrointestinal malignancies, not ovarian cancer [@general medical knowledge@].