There’s nothing lighthearted about ovarian cancer.

Ovarian cancer is often referred to as a ‘silent killer’ because it is usually diagnosed at an advanced stage, when treatment is less likely to result in a complete cure and full recovery.

Why is a reproductive endocrinology and infertility (REI) specialist discussing ovarian cancer? While this disease most commonly affects postmenopausal women over the age of 60 who have completed childbearing, about 10% of cases occur in women under 45, during their reproductive years. This makes ovarian cancer a highly relevant concern within my field.

Although the exact causes of ovarian cancer remain unclear, in women of reproductive age, it is often linked to genetic mutations such as BRCA1, BRCA2, or Lynch syndrome. Other contributing factors may include conditions like endometriosis (particularly endometriomas, where endometrial tissue grows within the ovary), or a family history of ovarian, breast, or colorectal cancer, even in the absence of a confirmed genetic mutation.

There is a common misconception that fertility treatments cause ovarian cancer; however, this is not supported by evidence. It’s important to clarify that women undergoing fertility treatments often have underlying conditions such as endometriosis, which are independently associated with an increased risk of ovarian cancer. The link is one of association, not causation. In fact, ovarian cancer is occasionally first detected by reproductive endocrinology and infertility (REI) specialists during the course of evaluating or treating infertility.

If you have a strong family history of cancer, talk to your doctor about genetic counseling and start early surveillance.

So, how should we approach surveillance for ovarian cancer? Pelvic exams alone are limited in sensitivity and often cannot detect ovarian masses smaller than 5 cm, even in experienced hands. While serum markers such as CA-125, CA 19-9, CA 72-4, CA 15-3, HE4 (human epididymis protein 4), and CEA (carcinoembryonic antigen) are more specific to malignancy, they are not all specific to ovarian cancer and are typically only ordered after a mass has already been identified. These markers are not routinely used in serial testing for early detection.

In contrast, imaging, particularly transvaginal ultrasound with Doppler flow analysis, can detect even small ovarian abnormalities and raise early suspicion for malignancy. When performed regularly in reproductive-age women at risk, ultrasound may aid in detecting ovarian cancer in its earliest stages, when it remains confined to the ovary and before local or distant spread occurs.

Why, then, are physicians hesitant to adopt ultrasound for early ovarian cancer detection? First, from a financial standpoint, performing annual ultrasounds on all women of reproductive age is not cost-effective. Second, because ovarian cancer is relatively rare in this population, the low incidence reduces the test’s sensitivity and positive predictive value, ultimately limiting its effectiveness as a widespread screening tool.

Still, it is essential for physicians to recognize when an ovarian lesion displays features suggestive of malignancy. Two diagnostic tools have significantly advanced the role of ultrasound in evaluating ovarian conditions: the International Ovarian Tumor Analysis (IOTA) group, established in 1999, and the Ovarian-Adnexal Reporting and Data System (O-RADS), introduced in 2021. Both systems provide structured frameworks for assessing and scoring ultrasound characteristics of ovarian lesions, offering a more objective and standardized interpretation.

When an ultrasound-detected lesion raises suspicion for malignancy, further imaging, such as CT or MRI, can offer additional detail, help identify local or distant spread, and support initial staging to guide surgical planning.

As a reproductive endocrinologist, I feel a strong responsibility to support early detection during initial ultrasounds. Ongoing ultrasound surveillance empowers women to take an active role in advocating for their health.

September is Ovarian Cancer Awareness Month, but awareness should be year-round. Speak up about symptoms, intensify surveillance, support research, donate, or simply share this post, as every action counts.

Ovarian cancer may be elusive, but knowledge empowers, and imaging provides proof. Advocate for your health. Support the women in your life. Early detection saves lives, and awareness is the first step.