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Ovarian cancer

Ovarian cancer: symptoms to recognise and the GP pathway in Australia

By Dr HB Lo, FACRRM

- Reviewed 8 August 2026
- 9 min read

Ovarian cancer kills approximately 1,000 Australians annually; over 70% are diagnosed at advanced stage. No effective population screening exists — CA-125 and ultrasound did not reduce mortality in the UKCTOCS trial. Recognise the symptom cluster: abdominal bloating, early satiety, pelvic pain, or urinary frequency more than 12 times per month in a woman aged 50 or older. Combine CA-125 and transvaginal ultrasound as the Risk of Malignancy Index (RMI) — an RMI ≥250 warrants gynaecological oncology review within two weeks.

Medicare funds BRCA testing with appropriate family history.

Ovarian cancer is Australia’s most lethal gynaecological malignancy. AIHW 2024 data records approximately 1,815 new diagnoses and 1,030 deaths per year, with a five-year survival rate of 46% — a figure that has improved only slowly, because more than 70% of cases present at FIGO stage III or IV, when cure is rare. No mass-screening programme exists. The GP remains the single most important clinician positioned to shorten the diagnostic delay.

This article covers how ovarian cancer presents, how to investigate a pelvic mass, the Risk of Malignancy Index, family history assessment, and the Australian referral pathway.

- Core clinical — the AU general-practice framework

Why ovarian cancer is diagnosed late The dominant histological subtype — high-grade serous carcinoma (HGSC), accounting for approximately 75% of cases — spreads rapidly along peritoneal surfaces before any single symptom becomes specific enough to prompt investigation. Research since 2007 (Crum, Clin Med Res) has established that HGSC originates from the fallopian tube fimbria via a precursor lesion (serous tubal intra-epithelial carcinoma, STIC), not from the ovarian surface epithelium as previously believed. By the time a palpable pelvic mass forms or CA-125 rises significantly, peritoneal spread has usually already occurred. The symptom cluster to recognise The Goff Symptom Index (JAMA 2004) — Validated In Multiple General Practice Cohorts — Identifies Four Symptoms That Are Significantly More Common In Women With Ovarian Cancer Than In Those With Benign Causes

- Abdominal bloating or distension (the most GP-recognisable symptom; “my clothes don’t fit anymore” is a useful prompt).
- Early satiety or loss of appetite.
- Pelvic or abdominal pain.
- Urinary frequency or urgency (from mass effect on the bladder).

Threshold for investigation: symptoms occurring more than 12 times per month, present for at least three weeks, and representing a change from baseline — particularly in a woman aged 50 or older. A woman aged 35–49 with the same persistent cluster also warrants workup; the threshold for investigation should never be comfort-driven waiting in the presence of a new persistent symptom pattern. Additional features to ask about: unintentional weight loss, change in bowel habit (constipation or narrow stools from rectosigmoid mass effect), postmenopausal vaginal bleeding (also prompts investigation for endometrial cancer), fatigue, and dyspareunia.

Examination

- Weight, BMI, and any weight change.
- Abdominal assessment: distension, palpable mass, ascites (shifting dullness, fluid wave), Sister Mary Joseph nodule (umbilical nodule — late sign of peritoneal metastasis).
- Bimanual pelvic examination: adnexal mass, mobility, consistency, fixed mass or pouch of Douglas nodularity; speculum examination to assess for cervical lesion.
- Lymph nodes: supraclavicular (Virchow node — Troisier sign), inguinal.
- Pleural effusion: dullness at the lung base (right-sided more common).

Initial investigations First-line

- Serum CA-125 (MBS item 66659) — note that up to 50% of early-stage ovarian cancers have a normal CA-125, and CA-125 is elevated in fibroids, endometriosis, peritonitis, pregnancy, and menstruation, reducing its specificity in premenopausal women. Do not use a normal CA-125 to reassure when symptoms persist.
- Transvaginal ultrasound (TVUSS) (MBS item 55070) — the report should characterise morphology using the IOTA Simple Rules: five malignant (“M”) features (irregular solid tumour, ascites, ≥4 papillary structures, irregular multilocular-solid mass >10 cm, strong Doppler signal) versus five benign (“B”) features.

Calculate The Risk Of Malignancy Index (RMI) Jacobs BJOG 1990: RMI = CA-125 (U/mL) × menopausal score × ultrasound score

- Menopausal score: 1 (premenopausal) or 3 (postmenopausal).
- Ultrasound score: 1 (0–1 morphological features) or 3 (≥2 features).

RMI score Interpretation Action ≥250 High risk of malignancy Urgent 2-week referral to gynaecological oncology 200–249 Intermediate Gynaecology referral with high clinical suspicion Lower risk — benign more likely Repeat TVUSS in 6 weeks; refer if unchanged or worsening Additional tumour markers in women under 40: AFP, β-hCG, LDH, inhibin, CA 19-9, and CEA — to investigate germ-cell and sex-cord stromal tumours, which present in younger women and have distinct markers.

Other bloods: FBC, UEC, LFTs, albumin, CRP.

Differentials to consider

Differential Distinguishing feature Functional or haemorrhagic ovarian cyst Premenopausal; resolves on repeat TVUSS in 6–12 weeks Endometrioma Premenopausal; chronic dysmenorrhoea; ground-glass appearance on TVUSS Uterine fibroid (pedunculated) Continuous with uterus on TVUSS; hypoechoic Irritable bowel syndrome Bloating with bowel-habit correlation; normal pelvic TVUSS and normal CA-125 Endometrial cancer Postmenopausal bleeding; thickened endometrium on TVUSS Appendix mucocele Right-sided mass; may mimic ovarian Diverticular abscess Left iliac fossa mass with fever; bowel-habit change

- Family history and BRCA assessment

Why hereditary risk matters Approximately 10–15% of high-grade serous carcinomas carry a germline BRCA1 or BRCA2 pathogenic variant. Kuchenbaecker JAMA 2017 — the largest BRCA lifetime risk study to date — defines the risk precisely: BRCA1 carriers face a 44% lifetime ovarian cancer risk; BRCA2 carriers face 17% . Lynch syndrome (MLH1, MSH2, MSH6 variants) confers a 4–14% lifetime ovarian cancer risk.

Who to test from general practice

GPs can order BRCA1/2 testing under MBS items 73296 and 73297 when any of the following apply:

- A first-degree relative with a known pathogenic BRCA variant.
- Personal or family history of breast cancer diagnosed before age 50.




- Triple-negative breast cancer.
- Male breast cancer in the family.
- Ovarian cancer at any age in a first- or second-degree relative.
- Ashkenazi Jewish heritage with a relevant cancer history.

Pre-test genetic counselling is recommended (referring to a Family Cancer Clinic or a GP trained in genomics per RACGP genomics resources). Risk-reducing surgery for BRCA carriers

Domchek PROSE study (JAMA 2010) demonstrated that risk-reducing bilateral salpingo-oophorectomy in BRCA1/2 carriers reduces ovarian cancer risk by approximately 80% and breast cancer risk by approximately 50% in premenopausal women. Finch JCO 2014 confirmed that the ovarian cancer mortality benefit is significant. Recommended timing: BRCA1 carriers: 35–40 years, after childbearing is complete; BRCA2 carriers: 40–45 years .

Management of BRCA-positive women is through a Family Cancer Clinic (eviQ) in consultation with a gynaecological oncologist.

- No population screening — and why

The question patients most often ask is whether a blood test can “check for” ovarian cancer. The answer is important to communicate clearly. The UKCTOCS trial (Menon Lancet 2021) — enrolling over 202,000 women and following them for 16 years — is the definitive evidence. Neither annual CA-125 with multimodal interpretation nor annual CA-125 plus transvaginal ultrasound reduced ovarian cancer mortality compared with no screening, despite modest stage-shifting in screened groups. Overdiagnosis and unnecessary surgery for benign lesions occurred in screened women.

Cochrane 2018 and the USPSTF 2018 evidence review reach the same conclusion.

Cancer Australia 2023 and RACGP therefore recommend against routine screening of asymptomatic average-risk women. CA-125 is appropriate for symptomatic workup, not annual screening.

- Australian operations

Referral pathway
- Urgent 2-week referral to gynaecological oncology: RMI ≥250; postmenopausal woman with any adnexal mass + elevated CA-125; ascites without clear benign cause.
- Gynaecology referral (within 4 weeks): premenopausal persistent adnexal mass on TVUSS that does not resolve on 6-week repeat; intermediate RMI 200–249.
- Family Cancer Clinic referral: confirmed BRCA1/2 variant; strong family history meeting eviQ criteria.

Opportunistic salpingectomy RANZCOG C-Gyn 25 (2024) recommends that opportunistic salpingectomy — removal of the fallopian tubes at the time of planned hysterectomy or laparoscopic sterilisation — be discussed with all average-risk patients. The fallopian tube fimbrial origin of HGSC means that removing the tubes removes the most common cancer origin site while preserving ovarian hormonal function. This is currently the most practical population-level risk-reduction strategy available for average-risk women.

MBS

- CA-125: item 66659 (rebatable when ovarian cancer is clinically suspected).
- Transvaginal ultrasound: item 55070.
- CT chest/abdomen/pelvis for staging: items 56412 and 56407.
- BRCA1/2 germline testing: items 73296 and 73297.

First Nations women AIHW 2024 data shows comparable age-standardised incidence of ovarian cancer in Aboriginal and Torres Strait Islander women compared with non-Indigenous women, but higher stage at presentation and lower five-year survival — driven by later presentation, access barriers, and comorbidity.

The ATSI Health Assessment (MBS item 715) provides a structured opportunity to screen for persistent symptoms in a culturally safe setting. Family cancer clinic outreach services are available in some states; coordinate with state cancer services.

- Special populations

Premenopausal women. CA-125 is substantially less specific in premenopausal women — elevated in endometriosis, fibroids, PID, and during menstruation. A single mildly elevated CA-125 in a premenopausal woman with a simple cyst on TVUSS should not trigger an urgent referral in isolation; calculate the RMI (menopausal score = 1, which substantially reduces the RMI compared with the same result in a postmenopausal woman) and plan repeat TVUSS in 6 weeks. Young women under 40. Germ-cell tumours (dysgerminoma, yolk-sac tumour, teratoma) and sex-cord stromal tumours (granulosa cell, Sertoli-Leydig) present at younger ages. These tumours have distinct tumour markers (AFP, β-hCG, LDH, inhibin) and are highly chemo-sensitive with excellent outcomes when detected early. Any adnexal mass in a woman under 40 warrants marker assessment.

Endometriosis. Long-standing endometriomata carry a small but real risk of transformation to endometrioid or clear-cell ovarian carcinoma. Unexplained change in character of an endometrioma — growth, loss of ground-glass appearance, solid component — warrants repeat assessment, CA-125, and gynaecology referral.

Cancer survivorship. Women completing ovarian cancer treatment — cytoreductive surgery, carboplatin/paclitaxel chemotherapy, and where eligible PARP inhibitor maintenance — require ongoing shared care. GP roles include managing treatment side effects (peripheral neuropathy, fatigue, anaemia, menopausal symptoms after oophorectomy), monitoring for recurrence, and supporting psychological wellbeing. Cancer Australia’s Australian Cancer Plan 2024 sets survivorship planning as a national priority.

When to escalate

- Persistent symptom cluster in a woman ≥50 (bloating, early satiety, pelvic pain, urinary frequency ≥12×/month) — initiate CA-125 + TVUSS without delay.
- RMI ≥250 — urgent 2-week referral to gynaecological oncology; do not wait for repeat investigations.
- Postmenopausal woman with any adnexal mass + elevated CA-125 — urgent referral regardless of RMI.
- Ascites of uncertain cause — CT staging and urgent referral.
- New persistent unilateral parotid or groin lymphadenopathy in a known ovarian cancer patient — recurrence assessment.
- BRCA1/2 variant confirmed — Family Cancer Clinic for risk management and surgical planning.
- Abnormal vaginal bleeding in a postmenopausal woman — endometrial and ovarian workup concurrently.

What this article is and is not This is general health information based on current Australian guidelines — Cancer Australia 2023, RANZCOG C-Gyn 25, RACGP,



and eviQ — written to help patients and carers understand how ovarian cancer is detected, investigated, and managed in Australian general practice. It is not personal medical advice. Decisions about investigation, referral, genetic testing, or surgery require individual assessment by your GP, gynaecologist, or specialist.

For Australian patient information and support: Ovarian Cancer Australia, HealthDirect — Ovarian cancer, Cancer Australia.

For mental health support during cancer care: Cancer Council 13 11 20, Lifeline 13 11 14, Beyond Blue 1300 22 4636.

Sources cited

- Cancer Australia — Ovarian cancer guidelines 2023
- AIHW — Cancer data in Australia 2024
- RACGP — Genomics in general practice: ovarian cancer
- Therapeutic Guidelines (eTG)
- RANZCOG — Opportunistic salpingectomy C-Gyn 25 (2024)
- eviQ — Risk management for BRCA1/2 carriers
- Ovarian Cancer Australia
- HealthDirect — Ovarian cancer
- MBS — CA-125 item 66659
- MBS — BRCA1/2 items 73296/73297
- Menon U et al. — UKCTOCS (Lancet 2021)
- Kuchenbaecker KB et al. — BRCA1/2 risks (JAMA 2017)
- Goff BA et al. — Ovarian cancer symptom index (JAMA 2004)
- Domchek SM et al. — PROSE study (JAMA 2010)
- Jacobs IJ — Risk of Malignancy Index (BJOG 1990)

Frequently asked questions
- What are the early warning signs of ovarian cancer? Ovarian cancer rarely causes distinctive early symptoms, which is why most cases are diagnosed late. The most recognised symptom cluster — validated in the Goff symptom index — is persistent abdominal bloating, early satiety or loss of appetite, and pelvic or abdominal pain, occurring more than 12 times per month and present for three weeks or more. Other symptoms include urinary frequency or urgency, unintentional weight loss, change in bowel habits, and abnormal vaginal bleeding in postmenopausal women. A new persistent symptom cluster in a woman aged 50 or older warrants prompt investigation, not watchful waiting.
- Is there a screening test for ovarian cancer? No effective population screening test exists. The largest trial — UKCTOCS, following over 200,000 women for 16 years — found that annual CA-125 blood tests combined with transvaginal ultrasound did not reduce ovarian cancer deaths, despite detecting some cancers at an earlier stage. As a result, Cancer Australia and the RACGP do not recommend routine screening of asymptomatic average-risk women. However, women with a BRCA1 or BRCA2 gene variant or a strong family history are offered specialist surveillance and risk-reducing surgery through Family Cancer Clinics — a different situation to population screening.
- What is the BRCA gene and should I be tested? BRCA1 and BRCA2 are genes that normally help repair DNA. When they carry a pathogenic variant (commonly called a BRCA 'mutation'), the lifetime risk of ovarian cancer rises to 39–44% for BRCA1 and 11–17% for BRCA2, compared with about 1.5% in the general population. Your GP can order a Medicare-funded BRCA blood test (MBS items 73296/73297) if you have a family history of ovarian cancer at any age, breast cancer before age 50, triple-negative breast cancer, male breast cancer, or are of Ashkenazi Jewish heritage with a relevant family history. A positive result is managed through a Family Cancer Clinic.
- What is the Risk of Malignancy Index and what does a high score mean? The Risk of Malignancy Index (RMI) is a scoring tool that combines your CA-125 blood test result, your menopausal status, and the appearance of the mass on ultrasound. A score of 250 or above strongly suggests ovarian cancer and triggers an urgent referral to a gynaecological oncology team for assessment within two weeks — this is the national standard in Australia. A score below 200 is more likely to represent a benign cause such as an endometrioma or a simple cyst, and a planned repeat ultrasound in six weeks is often appropriate. Your GP or gynaecologist will calculate this score for you.
- What is opportunistic salpingectomy and why is it recommended? Opportunistic salpingectomy is the removal of the fallopian tubes at the same time as another planned gynaecological operation — usually a hysterectomy or a sterilisation procedure. Research now shows that most high-grade serous ovarian cancers (the most common and aggressive type) actually start in the fallopian tube fimbria, not in the ovary itself. Removing the tubes removes this primary cancer origin site without causing surgical menopause (the ovaries are preserved). RANZCOG and Cancer Australia both recommend discussing opportunistic salpingectomy with patients who are undergoing pelvic surgery, as it reduces future ovarian cancer risk with minimal added surgical time.

Source quality Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.
- T1 AU primary 10 sources
- Cancer Australia — Ovarian cancer guidelines 2023
- AIHW — Cancer data in Australia 2024
- RACGP — Genomics in general practice: ovarian cancer and BRCA
- Therapeutic Guidelines (eTG) — Oncology: gynaecological
- RANZCOG — Opportunistic salpingectomy at hysterectomy (C-Gyn 25, 2024)
- eviQ — Risk management for women with BRCA1/2 variants
- Ovarian Cancer Australia — patient information
- HealthDirect — Ovarian cancer
- MBS Online — CA-125 item 66659
- MBS Online — BRCA items 73296/73297
- T3 Named-author reconstruction 5 sources
- Menon U et al. — UKCTOCS final mortality results (Lancet 2021)
- Kuchenbaecker KB et al. — Risks for BRCA1/2 mutation carriers (JAMA 2017)
- Goff BA et al. — Ovarian cancer symptom index validated in general practice cohorts (JAMA 2004)
- Domchek SM et al. — Risk-reducing surgery in BRCA1/2 carriers — PROSE (JAMA 2010)
- Jacobs IJ — Risk of Malignancy Index (BJOG 1990)

Where to next
- The Tiredness Workup — if tiredness is part of your picture: a free tool that helps you prepare for a thorough GP conversation. No card, no sign-up to start.
- Patient tools — free, private tools for preparing questions, decoding results, and mapping decisions with your GP.
- Work with me — The Workup membership: the weekly member-deep work-up, the 12-week pathway, and the monthly live call.

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📌 Ovarian cancer: symptoms to recognise and the GP pathway in Australia (Trópico de Cáncer)
🏢 Dr Hb Lo
📍 Trópico de Cáncer