About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Most common in postmenopausal women. Peak incidence age 60–65. 5-year survival ~45% overall (75% if stage I)
- Majority are epithelial (90%): high-grade serous most common subtype
- Symptoms vague: persistent bloating, early satiety, pelvic/abdominal pain, urinary frequency — especially if >12 times/month
- Diagnosis pathway: CA-125 in primary care → if ≥35 IU/mL → pelvic USS → if abnormal → 2WW referral
- RMI (Risk of Malignancy Index) >250 → manage at specialist gynaecological oncology centre
- Treatment: primary debulking surgery + adjuvant carboplatin/paclitaxel chemotherapy. BRCA testing for all
Overview
Ovarian cancer is the most common cause of death from gynaecological malignancy in the UK. Approximately 90% are epithelial in origin, with high-grade serous carcinoma being the most common and aggressive subtype. The remaining 10% include germ cell tumours (more common in young women), sex cord-stromal tumours (granulosa cell, Sertoli-Leydig), and metastatic disease (Krukenberg tumours from GI primaries). Ovarian cancer typically presents late because early-stage disease produces few symptoms, and there is no effective screening programme for the general population. BRCA1 and BRCA2 mutations significantly increase lifetime risk.
Epidemiology
Ovarian cancer is the 6th most common cancer in UK women, with approximately 7,500 new cases per year. Peak incidence is at age 60–65. Lifetime risk is approximately 1.3% (1 in 70), rising to 40–60% with BRCA1 mutation and 10–30% with BRCA2 mutation. Risk factors include increasing age, nulliparity, early menarche, late menopause, family history (BRCA1/2, Lynch syndrome), HRT use (small increased risk), and obesity. Protective factors include COCP use (reduces risk by ~50% after 5 years), multiparity, breastfeeding, and tubal ligation.
Clinical Features
Symptoms
Persistent abdominal distension/bloating — especially if >12 times per month
Feeling full quickly (early satiety) and/or loss of appetite
Pelvic or abdominal pain — persistent or frequent
Increased urinary urgency and/or frequency
Unexplained weight loss or fatigue
Change in bowel habit
New-onset IBS symptoms in women >50 — IBS rarely presents for the first time at this age
Signs
Ascites — shifting dullness, fluid thrill
Pelvic or abdominal mass — fixed, irregular, may be bilateral
Pleural effusion (Meigs syndrome: ovarian tumour + ascites + pleural effusion)
Cachexia in advanced disease
Sister Mary Joseph nodule — umbilical metastasis (rare)
Investigations
First-line
Serum CA-125First-line in primary care if symptoms suggest ovarian cancer. ≥35 IU/mL → arrange USS. Note: also elevated in endometriosis, PID, menstruation, liver disease, pregnancy
Pelvic USS (TVUSS)If CA-125 ≥35 → USS to assess ovarian morphology. Complex, solid, bilateral → high suspicion
RMI (Risk of Malignancy Index)USS score (0–3) × menopausal status (1 or 3) × CA-125. RMI >250 → refer to specialist centre
Second-line
CT chest/abdomen/pelvisStaging — assess for peritoneal disease, omental cake, lymphadenopathy, hepatic/pulmonary metastases
Histological diagnosisImage-guided biopsy (percutaneous or laparoscopic) or at primary surgery
Specialist
BRCA1/BRCA2 genetic testingOffer to ALL women with high-grade serous ovarian cancer — guides treatment (PARP inhibitors) and informs family risk
HE4, ROMA scoreAdditional markers used in some centres alongside CA-125 to improve specificity
1
Primary care pathway
- Measure CA-125 if persistent/frequent symptoms (especially in women ≥50)
- CA-125 ≥35 → arrange USS
- If USS abnormal → calculate RMI. If RMI >250 → 2-week wait referral to specialist gynaecological oncology centre
- If USS normal but symptoms persist → safety-net and re-evaluate. Consider other diagnoses
2
Surgery
- Primary debulking surgery: total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and maximal cytoreduction (aim for no residual disease)
- Surgical staging: peritoneal biopsies, pelvic/para-aortic lymph node sampling, appendicectomy (mucinous tumours)
- Neoadjuvant chemotherapy (NACT): if disease too extensive for primary surgery → 3 cycles chemo → interval debulking surgery → 3 further cycles
3
Chemotherapy
- Adjuvant: 6 cycles of carboplatin + paclitaxel (first-line standard)
- PARP inhibitors (olaparib, niraparib): maintenance therapy after platinum-based chemo in BRCA-mutated or HRD-positive tumours — significantly improves PFS
- Bevacizumab (anti-VEGF): may be added in advanced disease
4
Follow-up and family
- Serial CA-125 monitoring
- BRCA testing and genetic counselling for all high-grade serous cases
- Risk-reducing salpingo-oophorectomy offered to BRCA carriers after completion of family (by age 35–40 for BRCA1, 40–45 for BRCA2)
- Psychological support and palliative care as appropriate
Complications
- Bowel obstruction: From peritoneal disease — common in advanced/recurrent ovarian cancer
- Ascites: Requiring repeated paracentesis — impacts quality of life
- VTE: High thrombotic risk — prophylaxis essential perioperatively
- Chemotherapy toxicity: Neutropenia, neuropathy, nephrotoxicity, ototoxicity (cisplatin), alopecia
- Recurrence: Majority recur — platinum-sensitive if >6 months after last platinum; platinum-resistant if <6 months
UKMLA Exam Tips
- 1CA-125 ≥35 + abnormal USS + postmenopausal = high suspicion. Calculate RMI
- 2Persistent bloating, early satiety, pelvic pain, urinary frequency in women ≥50 → measure CA-125. Key NICE pathway
- 3New IBS symptoms in women >50 → think ovarian cancer, not IBS (IBS rarely presents de novo at this age)
- 4BRCA1/2 testing for ALL high-grade serous ovarian cancer — guides PARP inhibitor use
- 5Krukenberg tumour = signet ring cell metastasis to ovary from GI primary (typically gastric)
- 6COCP use for ≥5 years reduces ovarian cancer risk by ~50%
- 7High-grade serous = most common and most aggressive subtype
practicetest your knowledge on ovarian cancerApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
open q-bank