Ovarian cancer usually produces no symptoms until it is in an advanced stage. Very few women have it detected early on a routine pelvic exam or because it produced a symptom. In fact, almost 75% of women diagnosed with ovarian cancer have the disease at a very advanced stage.

At your annual checkup and Pap smear or when you have symptoms, your doctor will ask about your medical history and perform a physical exam, including a pelvic exam.

Tests may include:

• Pelvic exam —Your annual checkup includes a Pap smear to check for cervical cancer and a "bimanual" examination of your pelvic organs. Your doctor will look through a speculum and take a smear of cells from your cervix to be sent to a lab for testing. During the bimanual exam, the doctor will insert gloved fingers inside your vagina or rectum and will press on your lower abdomen with the other hand. With this method, the doctor can feel your reproductive organs and can detect abnormalities. This exam is much more accurate in non-obese women.

If the pelvic exam reveals abnormalities, or you have worrisome complaints, further tests may include:

• Imaging tests (ultrasound, CT scan, and MRI scan) —A transvaginal ultrasound can often be performed in your doctor's office and gives satisfactory images of the pelvic organs. It involves the use of a portable machine and a probe, which is inserted into your vagina. CT and MRI scanning require much bigger and more expensive machinery available only at hospitals and medical imaging centers.
• Lower GI series or barium enema —Although intended mainly for intestinal diagnosis, these images sometimes help diagnose problems in the nearby female reproductive organs. You should not eat or drink on the day of the exam. Before the procedure, you will take a laxative or have an enema to empty your bowels. In the x-ray suite, after preliminary x-rays, you will receive an enema of barium. This allows your lower bowel to be visible on an x-ray.
• Biopsy —Suspicious masses in your ovaries may require a biopsy to determine if they are cancerous. For a biopsy, a sample of tissue is removed and sent to a lab for testing. Pieces of the mass can often be taken through small incisions using a laparoscope—a thin, lighted telescope that looks inside your abdomen. In some cases, a surgeon may need to perform open surgery to reach the mass. The tissue sample is sent to the pathology lab to be examined for cancer cells.
• Blood tests—You may have blood tests for CA-125 assay (a tumor marker for epithelial ovarian cancer) or alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) for germ cell tumors. These tests may help with the diagnosis and with determining the success of treatments. The CA-125 assay is not as accurate as some other tumor markers. AFP and hCG are both useful for diagnosing and managing germ cell cancers, which are far less common cancers of the ovaries. Another blood test, called OVA1, may be used if a pelvic mass is found. By measuring certain protein levels in the blood, this test can identify whether the mass is cancerous.

If cancer is found, the prognosis and treatment depend on the location, size, and stage of the cancer, as well as your general health. Staging is a careful attempt to determine whether the cancer has spread and, if it has, what body parts are affected.

Additional tests to determine staging may include:

• Urine and blood tests
• Additional physical exams, including another pelvic exam in the operating room under anesthesia, which keeps you relaxed
• X-rays of other parts of the body, including lungs, bladder, kidneys, and lymph nodes
• Removal and examination of tissue from inside your abdomen during surgery for removal of the tumor

The following stages are used to classify cancer of the ovary:

• Stage I—cancer involves the ovary but has not spread
• Stage II—cancer has spread to nearby areas, but is still inside the pelvis
• Stage III—cancer has spread throughout the abdomen
• Stage IV—cancer has spread to other parts of the body

Beyond staging, a pathologist looks at the tumor through a microscope. The appearance of the cancer cells gives a good indication of how aggressive the cancer is. Grading the cancer adds to the staging information to help determine how best to treat you.