Symptoms of Ovarian Cancer
In a postmenopausal woman presenting with bloating and abdominal fullness, you must recognize that persistent abdominal distension, difficulty eating/early satiety, pelvic or abdominal pain, and urinary symptoms (urgency or frequency) are the cardinal symptoms of ovarian cancer, particularly when these symptoms are new, persistent, and occur more than 12 days per month. 1
Key Presenting Symptoms
The most recent ESMO guidelines (2023) identify the following recognized symptoms of ovarian cancer 1:
- Abdominal/pelvic pain - a primary presenting complaint 1
- Abdominal distension - particularly when persistent rather than fluctuating 1, 2
- Bloating - though clinicians must distinguish between persistent distension (associated with malignancy) versus fluctuating bloating (not associated with ovarian cancer, OR 0.4) 2
- Difficulty eating or feeling full quickly (early satiety) - independently associated with ovarian cancer (OR 5.0) 1, 2
- Urinary symptoms including frequency or urgency 1
- Constipation or diarrhea 1
- Vaginal bleeding 1
- Fatigue 1
Advanced Disease Manifestations
In advanced ovarian cancer with ascites and abdominal masses, additional symptoms emerge 1:
- Nausea 1
- Anorexia/loss of appetite - independently associated with increased mortality (OR 3.2) 3, 2
- Dyspepsia 1
- Respiratory symptoms when disease extends into pleural cavities, producing effusions 1
Critical Diagnostic Features
The symptom pattern matters more than individual symptoms alone. Symptoms that are:
- New in onset 1
- Frequent (occurring >12 times per month) 1, 4
- Persistent rather than intermittent 2
- Progressive (OR 3.6 for malignancy) 2
These characteristics significantly increase the likelihood of underlying malignancy 1, 4.
Important Clinical Distinctions
Persistent versus fluctuating abdominal distension is a critical distinction. Women with ovarian cancer present with persistent abdominal distension (OR 5.2), while fluctuating distension is NOT associated with ovarian cancer 2. Although women frequently use the term "bloating," this represents two distinct clinical entities that must be differentiated 2.
Postmenopausal bleeding is independently associated with ovarian cancer (OR 9.2) and should prompt immediate evaluation 2.
Symptom Index Performance
Multiple symptoms occurring together worsen prognosis - each additional presenting symptom decreases survival (HR 1.20 per symptom) 3. Women presenting with symptoms listed in NICE guidelines have significantly worse survival (HR 1.48) compared to those without these symptoms 3. The modified Goff Index symptoms are associated with even worse survival (HR 1.68) 3.
Common Clinical Pitfalls
Do not dismiss vague abdominal symptoms in postmenopausal women. The majority of women with ovarian cancer present at advanced stage precisely because symptoms are often attributed to benign conditions 1.
Ovarian cancer is NOT a "silent disease." This outdated concept has been definitively refuted - recognizable symptom patterns exist before diagnosis 5, 4. The challenge is distinguishing malignant from benign causes of common symptoms 5, 4.
CA-125 elevation is present in only ~50% of early-stage (FIGO stage I) cases, though it is elevated in ~85% of advanced disease 1. Normal CA-125 does not exclude ovarian cancer, particularly in early stages 1.
Immediate Workup When Symptoms Present
When a postmenopausal woman presents with the symptom constellation described above 1, 6:
- Serum CA-125 measurement 1, 6
- Transvaginal and transabdominal ultrasound by an expert examiner 1, 6
- CT of thorax, abdomen, and pelvis for staging if malignancy suspected 1
- Consider CEA and CA 19-9 if mucinous histology suspected 1
Ultrasound-based diagnostic models (IOTA Simple Rules or IOTA ADNEX model) are superior to CA-125 alone for distinguishing benign from malignant ovarian tumors 1.