Ovarian Cancer Risk & Prevention

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're discussing ovarian cancer risk, prevention and awareness because ovarian cancer can be difficult to detect, knowing the signs, understanding your risk, and having the right conversations with your provider are incredibly important. Today, I'm joined by gynecologic oncologist, Dr. Kevin Elias. Thanks so much for joining me on the podcast, Dr. Elias.

Kevin Elias, MD:

Thank you very much for having me, Dr. Newlin.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role at Cleveland Clinic and your background?

Kevin Elias, MD:

Sure. So I came to Cleveland Clinic about two years ago. I was recruited here as the first incumbent of the Lilli and Seth Harris Endowed Chair for ovarian cancer research. And I came specifically to build up our ovarian cancer research program, particularly as revolves around laboratory work related to early detection and prevention.

Erica Newlin, MD:

Let's start with the big picture, why this is such an important topic and what makes ovarian cancer unique. Why is ovarian cancer often detected later than other cancers?

Kevin Elias, MD:

So ovarian cancer is going to affect about one in 70 women in her lifetime. Unlike other cancers, ovarian cancer typically doesn't start to have any symptoms until the disease is fairly advanced. We also don't have any screening or early detection strategies for ovarian cancer. So unfortunately, things like pap smears, ultrasounds, routine blood work don't pick up ovarian cancer in its earliest stages. And so by the time that someone actually presents for diagnosis, typically the disease has already spread well beyond the ovaries.

Erica Newlin, MD:

What are some of the most common symptoms women should be aware of or things that people should look out for?

Kevin Elias, MD:

So even though we talk about ovarian cancer being a disease that often doesn't become symptomatic until later, there are still important symptoms to look out for. Primarily those are persistent bloating, increases in the abdominal waistline. So if someone notices that they're eating less because they're getting full quickly, but their pants or their dress are going up a size, that's a concerning symptom that should be flagged. Changes in urinary frequency and pelvic pain should also prompt evaluation by gynecologist. Now, the majority of women who have those symptoms won't have ovarian cancer, but most women who end up having ovarian cancer have some of those symptoms.

Erica Newlin, MD:

And you've touched on this a little, but what do you wish more women recognized earlier?

Kevin Elias, MD:

So I wish that more women would recognize that if they're having what seem like persistent changes in either abdominal or pelvic symptoms, so we're not talking about, “I had a day or two of I felt a little bloated or full.” We're talking about more than half the days within a given month feeling these symptoms of persistent, bloating, feeling full easily, abdominal or pelvic discomfort, that they would get checked out by their OB/GYN and not chalk it up to, “oh, maybe I ate something,” “maybe I've got some food intolerances.” These sorts of persistent symptoms should be seen by an OB/GYN. Unfortunately, most women will see an OB/GYN as the third or fourth specialist when they have ovarian cancer. And so the time from symptom onset to diagnosis is actually between six and 12 months for most women.

Erica Newlin, MD:

I'm always surprised what women put up with often as symptoms before they seek care.

Kevin Elias, MD:

Well, it's easy to chalk them up to other things. I think particularly for women who are aware of ovarian cancer, there's a fear around ovarian cancer. And so you'd rather chalk it up to almost anything else. But there is a real difference in being able to diagnose women earlier in their symptom onset versus waiting that six to 12 months. That's oftentimes the difference between a disease which is amenable to surgery or to earlier intervention versus having a patient where we're really looking at trying chemotherapy first to try to get the disease to a point where it's even surgically manageable.

Erica Newlin, MD:

Let's shift a little and talk about ovarian cancer risk. What are some of the most common risk factors for ovarian cancer?

Kevin Elias, MD:

So the biggest risk factor by far is family history. And when we talk about family history, we're not just talking about family history of ovary cancer, but also other cancer types which can often track with ovary cancer. So breast cancer, colon cancer, uterine cancer, pancreatic cancer. Those are cancers that if they're clustering in a family could imply a hereditary syndrome. The most common ones being the BRCA1 and two genes, what we typically think of as hereditary breast and ovarian cancer syndrome. But also things like Lynch syndrome, which is more commonly associated with colon and uterine cancers, can also increase the risk of ovary cancer. There are also certain diseases that women might not think of being the risk for ovary cancer, for instance, early onset prostate cancer. So what often happens is you have few female relatives in the family, but maybe a lot of male relatives.

Kevin Elias, MD:

And if there are a lot of men in the family who have developed prostate cancer in their 40s and 50s, that should also prompt an evaluation for a potentially hereditary component.

Erica Newlin, MD:

What about age or reproductive history? Does that impact risk at all?

Kevin Elias, MD:

Absolutely. So the risk of ovary cancer certainly increases as women get older. The average age for diagnosis for ovarian cancer is 63, but there's a wide age spectrum. So I have patients who are teenagers all the way up to women in their 90s with ovarian cancer. So there's no age at which someone can't get ovarian cancer. Although certainly after menopause, that risk starts to go up quite significantly. As far as reproductive factors, yes. So as far as increasing the risk of ovarian cancer, women who have a history of endometriosis are at higher risk for ovary cancer, which I think is an often unrecognized risk factor for a lot of women, particularly women who have had endometriomas. So cysts in the ovary that had endometriosis in them are at higher risk for ovarian cancer. The other risk for ovarian cancer is women who have never been pregnant before.

Kevin Elias, MD:

Now there's a flip side to that. So anyone who has been pregnant has a lower risk of ovarian cancer. And many of the reproductive factors that we tend to think of as being risk factors for ovarian cancer, their converse are protective against ovarian cancer. So for each subsequent pregnancy that a woman has, it lowers her risk of ovarian cancer by about 10 to 15%. Breastfeeding also is protective against ovarian cancer. And for every additional month that a woman breastfeeds, it lowers her risk of ovarian cancer by additional 2%. And contraceptive pills are highly protective against ovarian cancer. So women who have ever taken birth control pills lower their risk of ovarian cancer by about 25%. And once you have use of oral contraceptive pills by more than five to 10 years, that risk goes down by about 50%. And that's also true for women who have genetic predispositions to ovarian cancer.

Kevin Elias, MD:

So one of the common myths that I hear is someone has a hereditary syndrome for ovarian cancer, like a BRCA1 or two gene and they've been counseled, "Oh, you shouldn't take birth control pills because it's going to increase your cancer risk." And the truth is that quite far from that, women who have a cancer syndrome who take birth control pills can cut their risk of ovarian cancer by at least half. And the relative people often think about, "Oh, is that going to increase my risk of breast cancer?" The tiny number of breast cancers, which might be in any way correlated to taking birth control pills is dwarfed by the huge number of ovarian and uterine cancers which are prevented by birth control pills. And particularly when you're talking about cancer deaths, the protective benefits from all causes of mortality go down by about 80% when you take birth control pills.

Kevin Elias, MD:

So while there's a statistically a very small measurable difference in breast cancer risks, those tend to be very early, highly curable breast cancers relative to the number of what would otherwise be fatal ovarian cancers or uterine cancers, which can be prevented by taking oral contraceptive pills.

Erica Newlin, MD:

Thanks for highlighting that. I hear that a lot in the office too as a fear of birth control. How does risk differ between someone who is considered average risk versus higher risk women?

Kevin Elias, MD:

So when we talk about average risk women, we're talking about that one in 70 lifetime risks. That's about a one to one and a half percent lifetime risk of ovary cancer. When we talk about high risk women, we can divide that up into degrees of risk. So the highest risk group would be women who have a BRCA1 mutation where we talk about a 40% lifetime risk of ovarian cancer. Now that's lifetime. And one thing that I do try to counsel people carefully about is the average age of ovarian cancer diagnosis for even women with a BRCA1 mutation is still around 50 to 53. So even though we recommend that women with genetic risk like BRCA1 start thinking about preventative surgery as early as 35, right now the guidelines are 35 to 40, that's really more than a decade earlier than we would expect them to potentially getting their cancers.

Kevin Elias, MD:

Other cancer syndromes, diseases really have a later onset, more like 45 to 50. And so we're really trying to push as many women as possible if they're thinking about surgical prevention. And my surgical prevention right now I'm talking about surgery to remove the tubes and ovaries. They should really try to push that as close to menopause as they safely can. So for genetic risk, 40% for BRCA1, about a 20% risk lifetime for BRCA2. Other cancer syndromes like the Lynch syndrome genes, more like the 10 to 15% risk. What's also important to know though is even if someone has had genetic testing that's entirely normal. If they have a first degree relative with ovarian cancer, they still have about a two to three fold lifetime increased risk of ovary cancer. So what does two to three fold mean? That means that if the average woman has about a one and a half percent risk of ovarian cancer, their risk is somewhere between three and 5%.

Kevin Elias, MD:

And right now there's a lot of discussion about what do we do with those individuals? It doesn't quite meet our threshold for saying that they should have surgical intervention as far as removing the tubes and ovaries, but it is a population where we should be thinking about other forms of prevention that could be birth control pills before menopause. And then increasingly we're talking about what's known as opportunistic salpingectomy. So these are women who would really benefit from having their fallopian tubes removed. Now why would you remove fallopian tubes for ovarian cancer? The reason is that we know now that about 80% of ovarian cancers actually begin in the fallopian tube and not on the ovary itself. And removing the fallopian tube in its entirety, not doing what we used to do as far as a tubal ligation when people say their tube's tied, what we really meant was taking out a small portion of the fallopian tube.

Kevin Elias, MD:

Now we recommend if someone's going to have permanent contraception, they should have the whole fallopian tube removed. And the reason being that you can cut that risk of ovarian cancer by almost 80% with removal of the whole fallopian tube. And so anybody who's having surgery for other reasons, whether it's a hysterectomy for benign indications or surgery on ovarian cysts and they're not desiring future fertility should think about having their fallopian tubes removed. Increasingly, we're even talking about having fallopian tubes removed if someone's having their gallbladder taken out or their appendix taken out. And so I do think it's worth women asking if they're going in for an elective surgical procedure, talking to their general surgeon or their colorectal surgeon to say, or a bariatric surgeon, "Would you be willing to remove the fallopian tubes or reach out to a gynecologist to do it during the same surgery?" Because there's very little downside to having the fallopian tubes removed.

Kevin Elias, MD:

It's a very quick, safe procedure. Doesn't affect hormonal function at all, but it has a tremendous benefit as far as reducing the risk of ovarian cancer.

Erica Newlin, MD:

If someone is worried about their own risk, how can they better understand what that risk might be?

Kevin Elias, MD:

So one thing is certainly talking to a genetic counselor, looking to see are there other diseases in the family that might suggest an increased risk of ovary cancer? And again, sometimes it's things that aren't related to the ovary at all. It's an uncle with prostate cancer and an aunt with breast cancer where as you start to map it all out, you say this could be a genetic syndrome. The second is really talking to their OB/GYN. “Should I be thinking about some sort of hormonal prevention for ovarian cancer?” Or if they're not thinking about getting pregnant in the future, thinking about some sort of permanent birth control, like having their tubes removed. Those can really reduce ovarian cancer risk quite a bit. And in particular, women who have these what I would call secondary risk factors, so not family history, but histories of endometriosis, they've never been pregnant.

Kevin Elias, MD:

Maybe they've had a family history, even if it's relatively remote of other cancer types. They might want to think about ways that they can reduce their ovarian cancer risk.

Erica Newlin, MD:

Once someone understands their risk, the next step is asking what can be done about it. So let's talk a little bit about prevention. We've touched on some prevention, but what about screening? That comes up a lot in the office. Is there any routine screening for ovarian cancer? How effective is that?

Kevin Elias, MD:

So right now there is no routine screening for ovarian cancer. Even for women that we know are high risk with a genetic predisposition to cancer, like a BRCA1 or BRCA2 mutation. We have not found that aggressive screening with either ultrasounds or blood work diagnoses these cancers earlier nor reduces the risks of dying from these cancers. And so it's not routinely recommended. What I will say is that for women who have any of those risk factors, being extremely attuned to symptoms is really important because if someone starts to develop pelvic discomfort, feeling full after they eat, bloating, we really do want to think about could this be an ovarian issue and do some sort of imaging to look at that. Now screening is my own personal interest. This is where my laboratory spends a lot of its time and work, is looking at are there strategies that we could use for early detection and prevention?

Kevin Elias, MD:

And really that falls into two camps. One is identifying more women who might benefit from either medication or surgical prevention of ovary cancer. So again, if you found that someone had an increased risk of ovary cancer, putting them on something like birth control pills, even if they're not thinking about having more children. So you even say someone who's 40 and they're not thinking about having another pregnancy, but they've got another 10 to 12 years before menopause. It's reasonable if you identify risk factors for ovarian cancer to put them on birth control to reduce their ovarian cancer risk. Or it could be surgical prevention, whether that's removal of the fallopian tubes or tubes and ovaries, particularly as someone's getting closer to menopause. The other thing that we're looking at increasingly is what's the potential to screen this population? So we have two clinical trials that are going on right now.

Kevin Elias, MD:

One is our study known as the microRNA detection study or the MiDe study, which is a nationwide clinical trial. So we have participants from all 50 states right now where we ask for individuals who either have a known genetic predisposition to cancer or just have a family history, even if they haven't had genetic testing yet, to be in an observational study where we look at serial blood collection. So once every six months uses mobile phlebotomy, someone comes to the house and draws a blood sample and we correlate it with their clinical history because we do have what we think is an emerging blood test for identifying early onset of ovary cancer, particularly among individuals who might be at elevated risk. And so the question becomes, to your point, you've been told that you're at risk, how will we monitor for that risk? So we're looking at blood samples over time in that population because we think that there are trends which can forecast, "Hey, you might be at risk for developing cancer two or three years from now.

Kevin Elias, MD:

Now is the time for us to intervene." The other study that we're going to be launching later this fall is what's called the ORBIT study. The ORBIT study is actually starting to return those results to patients for the first time because right now it's just been an observational study. We've been correlating what happens clinically with women with their blood profiles, but now we'll actually be returning those results to women and their care providers to say, "We think that your risk of getting ovarian cancer in the next couple years is this percent. What do we want to do about that? " Because these are really nuanced decisions. For some women, if I say that her risk of ovarian cancer is 10% in the next two years, they might view that as a really low risk. 90% sure I'm not going to get ovarian cancer. I don't want to do anything.

Kevin Elias, MD:

Other people might say 10% sounds like a lot to me. And that historically has been the threshold. We do think about intervention and someone might want to think about going on medication like a birth control pill or if they were amenable to it and a good candidate for it, something like a surgery to remove the fallopian tubes.

Erica Newlin, MD:

That’s all really exciting.

Kevin Elias, MD:

Yeah, it's going to be exciting because for the first time we're really empowering patients to make these decisions. And actually that's the purpose of the study is we want to see how clinicians and their patients use this information. Because we have a lot of theoretical ideas. I think it's easy for me as someone who works in this field every day. And I think even for OB/GYNs in general to think about how they would interpret that information. But we actually have very little data to say when we return results to patients about estimating their risk of ovary cancer, what do people do with that information? So I think it's important because for the first time we're going to be giving people time limited information as opposed to lifetime risk. What I've always struggled with is that to have a woman in my office who's 25 who's been newly diagnosed as a genetic carrier for a gene like BRCA1 to say, "Okay, between now and 60 years from now, there's a 40% risk you might get ovarian cancer." Is not nearly as helpful as saying, "You're not going to get ovarian cancer this year or next year." I'm 99% sure of that.

Kevin Elias, MD:

And to be able to continually update that metric, which is really the goal of the tests that we're developing through the MiDe and ORBIT studies.

Erica Newlin, MD:

Let's go back a little on prevention because I want to clarify about birth control and prevention. Is all birth control created equally when it comes to prevention or should someone be guided in a certain direction?

Kevin Elias, MD:

That’s a great question. No is the answer. They're not all created equal. When we talk about birth control for prevention, we're primarily talking about combined oral contraceptive pills. So these are traditional birth control pills that combine both estrogen and progesterone. And in particular, even when we look at combined oral contraceptive pills, it tends to be the slightly higher dose pills, higher dose as far as the estrogen component, not the ultra low dose pills. Because what we're really trying to do is prevent ovulation. As the estrogen dose and a pill gets lower, they become less effective at preventing ovulation. And progesterone only pills, while they're very effective at preventing contraception when taken very stringently, they primarily are acting on the uterus more than the ovary itself. So progestin-only methods of birth control, while they do offer some protection, are not quite the degree of protection you would get from a combined pill.

Kevin Elias, MD:

So whether that's a progestin only pill or progesterone IUD or a progesterone implant or progesterone shots, they have some degree of protection, but primarily protection against uterine cancer. Their protection against ovary cancer is actually much smaller.

Erica Newlin, MD:

So prevention is just one piece. Having the right care team is just as important. When should a patient talk to their provider about ovarian cancer concerns?

Kevin Elias, MD:

So I think it should be part of the general conversation you have during an annual visit. And it's also one of those things that's important to update frequently. These are the sorts of opportunities when you get together for Thanksgiving, for the holidays. Even though it can be a little bit of an awkward conversation around the Thanksgiving turkey day, I say, "Hey, has anyone had cancer recently?" That is the opportunity to be updating your family history. And we do recommend that as people get together for family events to try to get a sense of where the family history is because certainly as we all get older and our relatives get older, things crop up. And then when you meet with your OB/GYN for an annual visit to talk about, "Hey, this is what's new in my family history." Because we do expect that hopefully within the next couple years we're going to start offering some more of these expanded screening opportunities with the idea of really forecasting risk.

Kevin Elias, MD:

I think one of the misnomers with the whole screening and early detection paradigm as we've been very focused on the early detection side, meaning does this person have cancer in front of me right now? Because that's how we deal with things like mammograms and colonoscopies. Whereas what I really envision happening for ovarian cancer is we're going to be talking much more about risk, which is it's not important necessarily to know who has cancer at this moment. I'm really trying to understand who might have cancer right now and who might be getting cancer in the near future. It is one of the unique things about ovarian cancer, whereas the surgeries that we would do for say colon cancer or lung cancer can be quite drastic. For ovarian cancer, the surgeries that we can use to prevent disease when we have a high suspicion can be done with relatively low impact, particularly as we get closer to the menopausal years for patients.

Kevin Elias, MD:

I certainly don't want women to be having surgeries in their 20s and early 30s unless it's really indicated. But both as we get into women in their 50s who the hormonal benefits of retaining their tubes and ovaries might really start to dwindle as well as being able to push more women who don't need to have earlier surgery to having their surgeries closer to menopause rather than going through premature menopause unnecessarily. I think there's going to be a role for forecasting what the next two to three years look like for an individual for cancer risk rather than so narrowly focusing on is the cancer present or absent at this exact moment.

Erica Newlin, MD:

How is data looking right now in studies looking at opportunistic salpingectomy versus oophorectomy? Are we there yet?

Kevin Elias, MD:

So we have a couple pieces of information for it. So really when we talk about salpingectomy, we break them up into two different types. So we have opportunistic salpingectomy, which is women who are having their fallopian tubes out during surgery for otherwise non-cancer indications. So that could be because they want permanent birth control, they're having hysterectomy, they're having their gallbladder out. So that's truly opportunistic. The best data we have from that's really at a population level. So in British Columbia, they've been doing this now for a little bit more than a decade. And they have seen that their rates of ovarian cancer have gone down substantially in women who have elected to have their tubes out. In fact, they've had virtually no cancers in women who have had their fallopian tubes out over the last decade, which has been very encouraging at a population level.

Kevin Elias, MD:

On the high risk group, we talk about salpingectomy with interval oophorectomy. And so that's for individuals who have a genetic predisposition who would otherwise qualify for surgical prevention to ask, “could we take the fallopian tubes out now, get most of that protective benefit, and then perhaps wait to remove the ovaries until menopause or closer to menopause?” That is still technically considered within the realm of clinical trial. So it's still considered investigational, certainly when we're talking about individuals who have high risk genetic predispositions like BRCA1 and BRCA2, but it is being studied widely across the country through a couple different clinical trials. And so if someone knew that they had genetic predisposition like that and was interested in that approach, they're not randomized studies. They're again, observational studies. So women are choosing whether or not they want to have two procedures versus one, but there are opportunities to enroll in a study like that.

Kevin Elias, MD:

Now what we know so far is that quality of life for women who choose to have their fallopian tubes out now and keep their ovaries until later, quality of life is certainly better. Avoiding the surgical menopause and the side effects, both sexual side effects, mental health side effects, the effects on sleep, the effects on vascular motor symptoms, they're considerably better for women who choose to keep their ovaries and push removal of the ovaries until later. We haven't seen any signals yet that it's increasing their cancer risk, but it's going to be a few years yet until we know that for sure. So that is the purpose of these studies that are going on right now is to say, do you get the same degree of cancer protection? But the idea that we're still recommending that those women have their ovaries removed when they get to the upper ages of current recommendations so either 40 for BRCA1 carriers, 45 for BRCA2 carriers, or 50 for other types of genetic predisposition. Now again, for someone who doesn't fit into one of those kind of classic categories, but is say intermediate risk, intermediate risk meaning maybe you have a couple relatives who've had ovarian cancer, but there's no known gene in your family, or maybe you have something like a history of endometriosis and you're concerned about your ovarian cancer risk, it's still very reasonable. Anybody can choose to have her fallopian tubes out by simply saying she doesn't want to get pregnant. So it's always an option to look at that for those sort of intermediate groups.

Erica Newlin, MD:

And in patients who've had to have their ovaries removed for whatever reason or who've had a salpingectomy, does postmenopause hormone therapy affect their risk at all?

Kevin Elias, MD:

That's a really good question. So the answer is no. So we've looked extensively at women who are BRCA1 and BRCA2 carriers who go into surgical menopause and then subsequently go on to hormone replacement therapy. And we don't see any increased risk certainly of secondary say occult ovary cancers coming up later. We really don't see any increased risk of breast cancers either, and that's often been a concern for these women. And I think a lot of it has to do with the fact that if you're talking about hormone replacement therapy more through ages of natural menopause, we really don't see that as a huge increase in risk. That's primarily going to be true for women who are on estrogen only hormone replacement. And so who would that be? Those are usually women who have had a hysterectomy as well. So estrogen only hormone replacement not only doesn't increase the risk of breast cancer, it actually lowers the risk of breast cancer.

Kevin Elias, MD:

It's really the small increased risk of breast cancers we see are usually from progesterone combined with estrogen replacement therapy. And so it is worth talking other risk factors for uterine cancer as well or thinking about sometimes we'll do protection for the uterus with an IUD and then an estrogen only form of hormone replacement, like an estrogen only patch or pill, which kind of gives the best of both worlds. You're minimizing potentially the breast cancer risk while still getting the protective benefits of hormone replacement.

Erica Newlin, MD:

What does comprehensive care for ovarian cancer risk look like at the Cleveland Clinic?

Kevin Elias, MD:

So here we have our hereditary breast and ovarian cancer program, which does bring in our breast specialist for surgical and plastic surgery. So breast oncology surgery, plastic surgery, breast medical oncology, also brings in the genetic counselors and your gynecologic oncologist. Mental health and menopause professionals are also a big part of this. And fertility specialists, particularly for women who are thinking about future fertility. One thing that I really encourage individuals who might be thinking about having some sort of intervention for ovary cancer risk is recognizing that there is a correlation between earlier onset of menopause and ovarian cancer risk. Meaning that when we see women who have BRCA1 and two mutations, they actually go into menopause about five years earlier than women who don't have those mutations. And so that's really important if people are thinking about egg freezing or going through IVF, particularly if someone is interested in preconception genetic testing or pre-implantation genetic diagnosis.

Kevin Elias, MD:

IVF cycles are going to be much more successful the earlier someone goes through it or egg retrievals earlier someone goes through it. And unfortunately, if you're looking at someone who's 38, 39 with a BRCA mutation, their success with IVF is more akin to someone five years older. And so really those women should be thinking about fertility preserving options when they're in their early 30s. So that's one thing I think that's important. And that's the advantage of being in sort of a multidisciplinary kind of program. And so we really try to get all of those pieces at Cleveland Clinic available for patients as early as possible. So I always tell primary care providers or general OB/GYNs, don't be shy about sending women who are concerned about ovarian cancer risk to a GYN oncologist early. Yes, someone might be 10 years away from thinking they want anything done surgically, but there's a lot that we can talk about before then.

Kevin Elias, MD:

So we can be talking about what are your plans for future pregnancies? What are your thoughts about going on contraception? What are the opportunities for potentially staged surgical procedures for you and are you a candidate to get enrolled in one of these early clinical trials? So the ideal populations for that are really women in their 20s and early 30s. Once we see somebody who's in their late 40s or 50s, now we're really talking about, okay, you've reached the level where we're talking about interventions, but all of that prevention happens in the 10 to 15 years before then.

Erica Newlin, MD:

As we close, what advice do you have for women who want to be more proactive about their health?

Kevin Elias, MD:

In general, I think it's important that women should talk to their families. These are often awkward conversations, but it's really important to know. I think that it's important that we look at reproductive health as not just about fertility, but reproductive health is extending to other aspects of cancer prevention, the effects on reproductive risk factors for things like cardiovascular health. Hormones are not only about whether or not someone is trying to get pregnant or trying not to get pregnant. It's also about their effects on how it's going to affect their cancer risk, how it's going to affect their bone health, heart health, mental health, neurologic health. So making that part of a general conversation.

Erica Newlin, MD:

This has been such an important conversation, especially when it comes to taking a proactive approach to your health. Before we wrap up, let's leave our listeners with one final takeaway. What is one thing you want patients to remember about ovarian cancer prevention?

Kevin Elias, MD:

The primary thing about ovarian cancer prevention is having a conversation with your provider about whether or not you could be at risk and then identifying the opportunities to reduce that risk.

Erica Newlin, MD:

Dr. Elias, thank you so much for joining me on the podcast today. For more information and helpful resources on ovarian cancer, visit clevelandclinic.org/ovariancancer. That's clevelandclinic.org/ovariancancer. If you found this episode helpful, subscribe and share it with a friend. Remember, ovarian cancer prevention starts with simple, proactive choices that can reduce your risk and support your overall health.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.