Ovarian Cancer Risk

Ovarian cancer is the deadliest gynecological cancer and affects up to 1 in 70 women in the US. Accordingly, many women are worried about what their risks are of having this kind of cancer. Currently, there are no screening tests for ovarian cancer, but women at high-risk should discuss with their health care providers what options are available to them to reduce their risk.
One of the main problems in diagnosing ovarian cancer are that so many of it’s symptoms are things that we all suffer from occasionally anyway. These include bloating, pelvic or abdominal pain, feeling full quickly, and urinary symptoms like urgency and frequency. The difference is that is normal to feel these symptoms for a day or two here or there, but if they persist almost daily for two to three weeks, you should certainly see your doctor.
The ways we can diagnose ovarian cancer may include a physical exam with a pelvic exam, a vaginal ultrasound, and sometimes a blood test for CA125. CA125 is not useful in all women and often has false positives in women who have not yet gone through menopause. This test is most useful when there is an abnormality on the exam or pelvic ultrasound, if a woman is post-menopausal, or if she is at very high risk of ovarian cancer based on other factors.
While ovarian cancer can affect any woman, there are four categories of risk.

• Average risk: the lifetime risk of developing ovarian cancer is 1 in 70. Women in this category do not have a family history of breast or ovarian cancers, never had problems getting pregnant, and have never taken hormone replacement therapy. For these women, the recommended screening for ovarian cancer is an annual gyn exam with pelvic exam.
• Slightly increased risk: the lifetime risk in this group is 1 in 20. Women in this category may have had problems getting pregnant or taken medications to help get pregnant, have a history of endometriosis, may have taken hormone replacement in menopause, or had breast cancer after age 40. The recommended screening in this group includes an annual gyn exam with pelvic exam. You may also want to discuss with your doctor ways to reduce your risks (see below).
• Moderately increased risk: a lifetime risk of 1 in 10. These women may have had a mother or sister with ovarian cancer, had breast cancer before age 40 or had breast cancer themselves with other members of their family with breast cancer as well, have a strong family history of breast cancer under age 50, have Ashkenazi Jewish heritage, or a close family relative with uterine or colon cancer under age 50. The recommendations for these women include genetic counseling and screening, and possibly testing for the BrCa mutation (a genetic predisposition to breast, ovarian, colon, or uterine cancers). These women should also have an annual gynecological exam with pelvic exam with close follow-up for any problems noted on the exam.
• Very increased risk: lifetime risk of up to 1 in 2. These women may be BrCa1 or BrCa2 positive (gene mutations that increase the risk of breast, ovarian, colon, and uterine cancer), or MLH1, MSH2, or MSH6 positive (gene mutations which increase the risk of colon, uterine, ovarian, and kidney cancers).

Women with the BrCa mutations should have a pelvic exam with a gynecologist 1-2 times a year. Some women will opt to have their ovaries and uterus removed (hysterectomy and bilateral salpingoophorectomy) once they have completed childbearing. Women who wish to avoid surgery should have a vaginal ultrasound and CA125 testing twice a year starting at age 30-35. They should also have an annual mammogram and breast MRI to check for breast cancer, starting at age 25-30.
Women with the MLH or MSH mutations should see their gynecologist 1-2 times a year, as well as have a vaginal ultrasound and CA125 test twice a year. They should also have an endometrial biopsy every year to check for endometrial or uterine cancer. Additionally, they should have colonoscopy every 1-2 years to screen for colon cancer, starting at age 20-25. Some women will also elect to have their uterus and ovaries removed when they have completed childbearing.
Reducing the risk of ovarian cancer can be discussed with your doctor. Birth control pills (and presumably the ring and patch) have been shown to reduce the risk of ovarian cancer by 50% in women who use it for more than 5 years. The longer this form of contraception is used, the more benefits. This is one of the simplest, most effective ways to reduce your risk of ovarian cancer.
For women at very high risk of developing ovarian cancer, removal of the ovaries is an option. Surprisingly, this does not completely eliminate the risk of ovarian cancer, but dose reduce it bu 85-90%. This can also reduce the risk of breast cancer by 40-70% in women who have the surgery before they go through menopause. Surgery is usually only recommended in women who have undergone genetic counseling and testing and have been shown to carry a genetic risk for cancers.
To learn more about ovarian cancer, check out the Women’s Cancer Network at http://www.wcn.org/ or the Gynecologic Cancer Foundation at http://www.thegcf.org/. To learn more about genetic counseling and testing, click on http://www.cancer.gov/cancer-topics/Genetic-Testingfor-Breast-and-Ovarian-Cancer-Risk.

Eating for Two

Eating right can be one of the best things you can do for yourself and your baby before and during your pregnancy. The foods you eat are the main source of nutrients for your growing baby.

If you are planning a pregnancy, see your doctor. She or he will discuss with you your diet, any vitamin supplements you might need (folic acid, for instance) as well as your overall health and how that might affect or be affected by a pregnancy.
A healthy diet is important even before you become pregnant. This helps you and your baby start out with the nutrients you will both need. There’s no magical formula for pregnancy nutrition. The basics of a well-balanced diet with plenty of whole-grains, fresh fruits and vegetables, and lean sources of protein remain the same. Of course, you also want to drink plenty of water – two to three liters a day!
You do need to eat more calories in pregnancy, but it may be less than you think. The number of calories recommended for a non-pregnant woman in 2000 a day. There is no recommended increase in the first trimester (up to about 12 weeks) and only about 300-350 calories more in the second trimester (12-26 weeks). This is equivalent to about a cup of yogurt and a small apple. In the third trimester (after about 26 weeks), the recommendation is about 400 extra calories a day.
Pregnant women also require more folic acid and iron. Folic acid helps prevent birth defects, preterm birth, and growth problems in the baby and iron prevents anemia in the mother. Fortified cereals are a great source of folic acid. Leafy green vegetables, citrus fruits, and dried beans and peas are also all good sources of folic acid. The recommended amount of folic acid in pregnancy is 800-1000mcg. A woman trying for pregnancy should start taking a prenatal vitamin or extra folic acid 3-6 months before she is ready to get pregnant. Some women with certain medical problems or a history of a baby with a birth defect may need more folic acid, so ask your provider if you are unsure.
Another important mineral is calcium, with a goal of 1200-1500mg a day. This is important to help build healthy bones in your growing baby as well to keep your bones strong during pregnancy and breastfeeding. Some studies suggest it might also help reduce the risk of other medical problems in pregnancy, like pre-eclampsia.
Prenatal vitamins are usually good sources of folic acid, iron, calcium, and other important vitamins and minerals, but check the labels and check with your doctor. Also, it’s best to avoid prenatal vitamins or formulations that include things like herbs or extracts since there is little evidence of the safety of these compounds and some have even been shown to cause cramping or problems in pregnancy (even ones that are “pregnancy” herbs!) Of course, the best place to get your vitamins and minerals is in your food.
DHA is an important supplement to help with healthy brain and eye development both in pregnancy and while nursing. DHA is one of the Omega 3 fatty acids and the best way to get enough is with a DHA supplement specifically designed for pregnancy. It’s best to avoid flaxseed oil (due to rare, but documented pregnancy complications) or fish sources (due to concerns about mercury levels).
Weight gain is to be expected in pregnancy, but how much you should gain depends on how much you weigh before you get pregnant. Women of a healthy weight should gain 25-35 pounds while women who are overweight should gain 15-25 pounds. Underweight women usually gain about 25-40 pounds in pregnancy. This increase in weight is needed for many components of your changing body and growing baby. As an example:

• Baby 7 ½ pounds
• Breast growth 2 pounds
• Maternal nutrition stores 7 pounds
• Placenta 1 ½ pounds
• Uterus growth 2 pounds
• Amniotic fluid 2 pounds
• Increase in blood volume 4 pounds
• Increase in body fluids 4 pounds

A few special concerns:

• Vegetarianism
  o If you are a vegetarian, it is safe to continue your diet in pregnancy. Some women choose to add lean meats or fish to help get enough protein and iron, but this is not strictly necessary if you can get enough of these in your diet or with the help of vitamins. Sometimes vegetarians need to take extra iron, vitamin B12, and vitamin D.
• Drinks
  o You should avoid alcohol in pregnancy because frequent use can cause birth defects and mental retardation. A few drinks before you knew you were pregnant rarely cause any problems.
  o Moderate caffeine intake is probably OK (1-2 cups of coffee, sodas, or teas). More than that has been shown to increase the risk of miscarriage. Caffeine also crosses the placenta.
  o Diet drinks and other foods with NutraSweet or Splenda is OK 1-2 servings a day. There is little data about the safety of these, and so it is probably best to reduce your exposure.
  o Avoid unpasteurized juices.
  o Read the labels on herbal teas. Many of the herbs used for teas, when taken in large or medicinal amounts, can potentially stimulate the uterus and induce miscarriage. These include anise, catnip, chamomile, comfrey, ephedra (or ma huang), European mistletoe, hibiscus, horehound, Labrador, lemongrass, licorice root, mugwort, pennyroyal, raspberry leaf, rosemary, sage, sassafras, stinging nettle leaf, vetiver, and yarrow. Also avoid Coca (or mate de coca), kava root, skullcap, valerian, woodruff, and lobelia. Mate tea can contain as much caffeine as coffee.
• Meats
  o Do not eat any raw meats. This includes sushi! The nori (seaweed) that sushi is wrapped in can also contain high levels of mercury, so avoid even vegetarian or cooked sushi.
  o Deli meats are probably OK as long as they are fresh. If they’ve been in the refrigerator for more than a few days, either throw them out or reheat them to steaming.
• Cheese
  o Do not eat unpasteurized or “raw” cheeses (this may include some imported, soft cheeses) – check the labels! Pasteurized soft cheeses are OK.
• Fish
  o Fish (including shellfish) is OK 1-2 servings a week. Avoid shark, swordfish, king mackerel, and tilefish. This is again due to the concern for mercury which is a neurotoxin in developing babies.