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Referral and warning signs
When to refer
Refer urgently to Gynaecologist/Gynae-Oncologist if: Pelvic mass suspected on examination or imaging. Elevated CA-125 (especially postmenopausal). Ascites of unknown origin. Persistent unexplained abdominal/pelvic symptoms.
Red flags
- Palpable pelvic or abdominal mass
- Ascites
- Persistent bloating, early satiety, pelvic/abdominal pain (especially postmenopausal)
- Elevated CA-125 (interpret with caution)
- Unexplained weight loss
Signs and symptoms
- Often vague and non-specific in early stages.
- Persistent abdominal bloating or swelling.
- Pelvic or abdominal pain/discomfort.
- Difficulty eating or feeling full quickly (early satiety).
- Urinary symptoms (frequency, urgency).
- Change in bowel habits.
- Fatigue, back pain, pain during intercourse (dyspareunia).
- Abnormal vaginal bleeding (less common).
- Weight loss (late sign).
- Palpable pelvic or abdominal mass.
- Ascites (fluid in abdomen - often indicates advanced disease).
Risk factors
- Increasing age (most common post-menopause).
- Family history of ovarian, breast, or colorectal cancer.
- Inherited genetic mutations (BRCA1, BRCA2, Lynch syndrome).
- Nulliparity (never given birth).
- Early menarche / Late menopause.
- Endometriosis.
- Obesity.
- Hormone replacement therapy (possibly).
- (Protective factors: Oral contraceptive use, tubal ligation, hysterectomy, breastfeeding).
Diagnosis
Clinical assessment
Suspect in women (especially postmenopausal) presenting with persistent, vague abdominal/pelvic symptoms (bloating, pain, early satiety, urinary changes). Pelvic examination may reveal adnexal mass or ascites.
Investigations
- Pelvic Ultrasound (Transvaginal and Transabdominal): Initial imaging test. Assess ovarian morphology (size, cysts, solid areas, papillary projections), rule out other pelvic pathology, detect ascites.
- CA-125 Blood Test: Tumour marker. Often elevated in epithelial ovarian cancer, but non-specific (can be raised in benign conditions like endometriosis, fibroids, PID, pregnancy, cirrhosis, pancreatitis). More useful in postmenopausal women and for monitoring treatment response.
- Other Tumour Markers (if germ cell/stromal tumour suspected): AFP, hCG, LDH, Inhibin.
- CT Scan (Abdomen/Pelvis +/- Chest): Staging - assess extent of disease, peritoneal spread, lymph nodes, distant metastases.
- Histopathology: Definitive diagnosis requires tissue. Usually obtained during exploratory laparotomy/laparoscopy with surgical staging (hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node sampling, peritoneal biopsies/washings). Biopsy may be done percutaneously/laparoscopically if metastatic/unresectable.
Diagnostic criteria
Histopathological confirmation from surgical specimen or biopsy.
Management
Non-pharmacological management
- Referral to specialized Gynae-Oncology centre.
- Management depends on stage, histology, patient fitness.
- Surgery: Comprehensive surgical staging +/- cytoreductive ('debulking') surgery aiming to remove all visible tumour is crucial.
- Supportive care, management of complications (ascites drainage, bowel obstruction management).
Pharmacological treatment
- Chemotherapy: Mainstay of treatment, especially for epithelial ovarian cancer. Usually platinum-based (Carboplatin) + Taxane (Paclitaxel) combination chemotherapy, given intravenously, typically post-operatively (adjuvant) or sometimes pre-operatively (neoadjuvant).
- Targeted Therapy (e.g., PARP inhibitors like Olaparib): For maintenance therapy in patients with BRCA mutations or platinum-sensitive recurrence.
- Anti-angiogenic therapy (Bevacizumab): Can be added to chemotherapy in some settings.
- Hormonal therapy (limited role).
- Pain management, antiemetics.
Monitoring
Monitor CA-125 levels (if initially elevated). Monitor treatment toxicity. Imaging (CT) to assess response/recurrence. Long-term follow-up.
Complications
- Ascites
- Bowel obstruction
- Pleural effusion
- Thromboembolism
- Malnutrition
- Treatment-related side effects (chemo toxicity, surgical morbidity)
- Recurrence
Prevention
- Oral contraceptive use reduces risk.
- Prophylactic salpingo-oophorectomy (removal of ovaries/tubes) in high-risk women (e.g., BRCA carriers).
- Tubal ligation may offer some protection.
Patient education
- Explain diagnosis, stage, and implications.
- Discuss treatment plan (surgery, chemotherapy).
- Potential side effects of treatment.
- Importance of follow-up and monitoring.
- Genetic counseling if family history/mutations suspected.
- Support resources.
Uganda-specific notes
Often presents at late stage. Diagnosis requires ultrasound, CA-125, and specialist gynae-oncology services (surgery, pathology, chemotherapy) available mainly at UCI/referral centres.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 12, Section 12.3.2 (Listed under Adult Cancers)